Evaluation of Dyspnea and Fatigue Among the COPD Patients

Hatice Tel, Zeynep Bilgiç and Zübeyde Zorlu
Cumhuriyet University, Health Sciences Faculty,
Department of Nursing, Sivas
Turkey
1. Introduction
Chronic diseases are diseases of long duration and generally slow progression. Chronic
diseases, such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes, are
by far the leading cause of mortality in the world, representing 63% of all deaths (World
Health Organization(WHO), 2010a). Rapid improvements in health and longevity are
dramatically changing the burden of illness throughout the world. In developed countries
changes in lifestyle and improvements in the treatment of major causes of mortality have
aged the population and increased the prevalence of chronic diseases. Poor countries that
have achieved gains in life expectancy are also experiencing an increase in chronic disease
(Davis et al.,1999). According to Centers for Disease Control and Prevention (CDC) more
than 1.7 million Americans die of a chronic disease in 2005. Chronic disabling conditions
cause major limitations in activity for more than one of every 10 Americans, or 25 million
people (CDC, 2005). In Turkey, chronic diseases accounted for 79% of all deaths in
2002(WHO, 2010b). Notification to national reports, 305.467 dies of total 430.459 was related
to chronic diseases in Turkey (Turkey Health Ministry National Burden of Illness Report
2004).
Chronic obstructive pulmonary disease (COPD) is one of the important chronic diseases.
COPD is characterized by airflow obstruction with related symptoms such as chronic cough,
exertion dyspnea, expectoration, and wheeze. (Edelman et al., 1992; Mannino, 2003). COPD
is a highly prevalent, usually progressive illness associated with disability and early death
(WHO, 2008). COPD is a major cause of chronic morbidity and mortality throughout the
world. It is a growing cause of morbidity and mortality worldwide (Mannino, 2003;
Mannino & Braman, 2007; Tatlıcıoğlu, 2000). According to the World Health Organization,
80 million people worldwide have moderate to severe COPD. More than 3 million people
died of COPD in 2005, which is approximately 5% of all deaths worldwide (WHO, 2008).
COPD is currently the fifth leading cause of death and disease burden globally (O’Donnell
et al., 2008). In the Turkey, COPD is the third leading cause of death. Although there has
been significant decrease in other mortality causes; there has been an increase by 163 % in
COPD mortality (Turkish Thorasic Society, 2010). COPD will be third leading cause of death
globally by 2020(WHO, 2008). COPD is the tenth leading disease burden, expressed in
disability-adjusted life-years (DALYs), and causes about 2% of the burden of disease
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worldwide. Overall, COPD was estimated to have resulted in more than 26 million DALYs
in 2000 (Lopez et al., 2006).
COPD characterised by progressive airflow obstruction which is mainly irreversible. COPD
is associated with significant comorbidities and extrapulmonary manifestations (Baghai-
Ravary et al., 2009). Living with COPD can be challenging, as the disease dramatically
impacts patients’ daily life. When disease symptoms especially dsypnea affects the
performance of daily activities, the potential exist for important changes to occure in
individual’s overall quality of life (Meek et al., 2001). COPD is associated with increased risk
for anxiety, depression, and other mental health disorders (Dowson et al., 2004; Singer et al.,
2001). Psychiatric disorders are at least three times higher in COPD patients compared to the
general population (Laurin et al., 2007). As the disease progresses, any kind of physical
activity or social interaction may prove difficult. COPD is a significant disease which affects
the individual physically, emotionally, and socially and leads to an increase in the social
support needs of the patients (Aras & Tel, 2009).
Dyspnea and fatigue are occurred many chronic disease. COPD, congestive heart failure,
and fluid build-up in renal failure can cause dyspnea. (Ramasamy et al.,2006). Fatigue is
almost a universal complaint in patients with autoimmune deficiency syndrome (AIDS),
congestive heart failure, myocardial infarction, and progressive neurologic disorders such as
multiple sclerosis, and autoimmune diseases such as rheumatoid arthritis, and dialysis
patients receiving either hemodialysis or peritoneal dialysis, and cancer (Appels & Mulder,
1988; Brunier & Graydon, 1996; O’Brain & Pheifer, 1993; Tel et al., 2011).
Dyspnea and fatigue are the two most common symptoms experienced by patients with
COPD (Meek & Lareau, 2003; Oh et al., 2004; Tel, 1998). The most important complaint of
patients with COPD is dyspnea. Dyspnea is identified as a perception or observation of
abnormal and disturbing sensation of breathing. Dyspnea is the perception and experience
of labored, uncomfortable breathing, and may produce secondary physiological, emotional,
cognitive, and behavioral responses (American Thorasic Society, 1999).
Another accompanying important symptom of dyspnea is fatigue in COPD. Fatigue is an
unpleasant subjective symptom that prevents individuals from performing his functions
and using his normal capacity, affects whole body and changes from a slight exhaustion to
unbearable fatigue (Swain, 2000). Fatigue is poorly understood and believed to have a
significant subjective component strongly associated with dyspnea, although the nature of
the relationship remains unclear. Fatigue has been defined as “the multidimensional
sensation of tiredness that the individual experiences when perceiving the reduced capacity
to function normally” and it often varies with respect to daily pattern, triggers or
contributing factors, and responsiveness to interventions (Kapella et al., 2006). In contrast
with a prevalence rate of 18.3%–25% in the general population (Lewko et al., 2009;
Pawlikowska et al., 1994) fatigue is “almost always” experienced by 43%–58% of persons
with COPD ( Kinsman et al., 1983; Walke et al.,2007).
Fatigue was reported by patients with COPD as the second most important symptom of
COPD, after dyspnea (Blinderman et al., 2009; Janson-Bjerklie et al., 1986; Walke et al., 2007).
Peters et al. (2010) found that fifty percent of patients with COPD had abnormal fatigue.
Guyatt et al. (1987) report that fatigue ranks second to dyspnea as a symptom contributor to
decreased quality of life in COPD patients.
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Dyspnea and fatigue are a subjective experinces that can only be measured from the
patient’s perceptions, because every person have different thresholds for noticing, reporting,
and rating the severity of these symptoms (Victorson et al., 2009). In severel studies were
found out that there is a significant correlation between dyspnea, fatigue and physical
activity and that fatigue levels increase when dyspnea intensifies and physical activity levels
reduce (Breslin et al., 1998; Theander & Unosson, 2004; Woo, 2000a). Individuals with COPD
undergo a high amount of activity restriction and dependency due to dyspnea or fatigue or
both symptoms (Akbal, 2003; Woo, 2000b; Yıldırım, 2006). McCarley (2003) explored that
there was a moderate correlation between dyspnea and fatigue experienced by the patients
with COPD. Reishtein (2005) reported that there was a moderately negative correlation
between dyspnea, fatigue and functional capacity among COPD patients. It is reported that
there is a complicated correlation in COPD between fatigue and other disease-related
symptoms such as dyspnea, anxiety, depressed emotions and sleep quality (Kapella et al.
2006). Breslin et al. (1998) suggested that physical dimensions of fatigue correlated with an
increase in the severity of pulmonary impairment and reduction in exercise tolerance.
1.1 Assessment of dyspnea and fatigue
Because dyspnea and fatigue are subjective symptoms, they are assessed through the use of
standardized symptom reports or questionnaires (Guyatt et al., 1993; Victorson et al., 2009).
Implementation of many interventions to patients with COPD, measurement and evaluation
of dyspnea and fatigue is very important part of this patients care. The two purposes of
measuring dyspnea are to differentiate between patients who have less dyspnea and those
who have more dyspnea (discriminate), and to determine whether dyspnea has changed
over time and/or as a result of treatment (evaluate) (Mahler, 2006). For the most part,
questionnaires used to measure dyspnea as an outcome of pulmonary rehabilitation are
evaluative instruments and each of this instruments measure different aspect of dyspnea
(Meek & Lareau, 2003; Meek, 2004).
The Medical Research Council Scale (MRC); The MRC categorizes the individual based on
whether dyspnea is associated with specific tasks and situations (ATS, 1999; Meek, 2004).
Patients are assigned to one of five grades, based on their difficulty with mobility, from
Grade 1, "never troubled by breathlessness except on strenuous activity," to Grade 5, "too
breathless to leave the house or breathless after undressing." The MRC does not uniquely
measure dyspnea, since the level of dyspnea is evaluated related to activities. The MRC, is
easy to administer and is useful for general screening and categorizing of patients (ATS,
1999; Mahler, 2006).
The Oxygen Cost Diagram (OCD); This scale was developed in an effort to match a range of
tasks with the occurrence of dyspnea (ATS, 1999). The OCD is a 100-mm vertical visual
analog scale with 13 activities listed at various points along the line corresponding to
increasing oxygen requirements for their completion, ranging from sleeping (at the bottom)
to brisk walking uphill (at the top) (McGavin et al.,1978).
The Basaline Dyspnea Index(BDI); BDI is a rater evaluation of dyspnea associated with
activities (Mahler et al.,1984). The rating includes the magnitude of the task and the effort
required to perform the task. Each category is rated on a 0 to 4 grade and summated for a
total score. The BDI also has a transitional score, the transitional dyspnea index (TDI), that
measures the change in dyspnea associated with activities following an intervention. (Foglio
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et al., 1999; Meek & Lareau, 2003). The most widely used multidimensional instruments
include the Baseline (BDI) and Transition (TDI) Dyspnea Indices , which consider three
components (functional impairment, magnitude of task, and magnitude of effort) (ATS,
1999; Mahler et al.,1984).
The University Of San Diego Shortness Of Breath Questionnaire (SOBQ); The University
of San Diego Shortness Of Breath Questionnaire (SOBQ) is a 24-item measure that assesses
self-reported shortness of breath while performing a variety of activities of daily living
(Eakin et al.,1998). Patients are asked to rate their dyspnea associated with the 21 different
activity, from 0 = "not at all" to 5 = "maximally or unable to do because of breathlessness."
Three additional questions about limitations due to shortness of breath, fear of harm from
overexertion, and fear of shortness of breath are included for a total of 24 items. [Eakin et al
1998; Ries et al., 1995).
The Borg Scale; The Borg scale a category-ratio scale, is commonly used to evaluate the
effects of exercise on dyspnea. The original and modified scales have ratio properties
ranging from 0 = nothing at all to 10 = very, very severe, with descriptors from 0 to 10. The
Borg scale has been used in pulmonary rehabilitation programs to evaluate dyspnea before,
during, and after progressive exercise (Foglio et al.,1999).
The Visual Analog Scale (VAS); The VAS is usually a 100 mm line anchored at either end
with descriptors, such as "none" to "very severe." When used to measure dyspnea, these
anchors are qualified to read "no shortness of breath" to "maximum shortness of breath," or
some similar variation (Gift, 1989). The VAS can be used to quantify a number of aspects of
symptoms besides the sensation of dyspnea, such as effort and distress with dyspnea. The
visual analogic scales and the Borg scale are the simplest tools available; both are completed
by the patient, and allow a follow-up of the impact of treatment on dyspnea ( Janssens et al.,
2000).
The Chronic Respiratory Questionnaire (CRQ); The Chronic Respiratory Questionnaire
(CRQ), a 20-item, disease-specific, quality-of-life questionnaire (ATS,1999; Guyatt et
al.,1987), has been used extensively in pulmonary rehabilitation settings. The CRQ consists
of four domains (dyspnea, fatigue, emotional function, and mastery), rated on a seven-point
scale. The dyspnea component of the CRQ asks patients to identify five activities of
importance to them. These same activities are rated with 1 = most dyspnea and 7 = least
dyspnea, before and after a pulmonary rehabilitation program. (Meek, 2004). The CRQ has a
fatigue subscale consisting of five items, scored on a 7-point scale. The CRQ fatigue domain
is reliable, valid with the same clinically important differences as the other components. To
determine the outcomes of pulmonary rehabilitation, it is safe to say that the CRQ is the
most widely used and tested instrument that measures both dyspnea and fatigue (Meek &
Lareau, 2003).
The Pulmonary Functional Status Scale (PFSS); The Pulmonary Functional Status Scale
(PFSS) is a 53-item, self-administered questionnaire measuring physical, mental, and social
function. The dyspnea subscale evaluates dyspnea related to activities, as well as dyspnea
independent of activities(Weaver et al.,1998).
The Pulmonary Functional Status And Dyspnea Questionnaire (PFSDQ); The Pulmonary
Functional Status And Dyspnea Questionnaire (PFSDQ) is a 164-item, self-administered
questionnaire that evaluates dyspnea and activity levels. The pulmonary functional status
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and dyspnea questionnaire-modified version (PFSDQ-M), measure dyspnea, fatigue, and
activity levels (Lareau et al.,1994). PFSDQ-M has been used to measure fatigue in COPD
patients (Meek et al. 2001). The PFSDQ-M comprises three domains: influence of dyspnea on
ADLs, influence of fatigue on ADLs and change experienced by the patient in ADLs. The
patient reports to what degree dyspnea and fatigue affect 10 specific ADL items, assigning a
score from 0 to 10 for each activity as follows: 0 (no interference); 1-3 (mild); 4-6 (moderate);
7-9 (severe); and 10 (extremely severe). Higher values on the scale indicate greater ADL
limitation. The five general questions in the dyspnea and fatigue domains are informative
and qualitative, and the answers are not calculated in the questionnaire score (Lareau et
al.,1998).
The St George’s Respiratory Questionnaire (SGRQ); The Saint George Respiratory
Questionnaire (SGRQ) is the best-known and most frequently used disease-specific health
related quality of life (HRQL) questionnaire for respiratory diseases (ATS,1999; Jones et
al.,1992). The SGRQ is a standardized, self-administered questionnaire for measuring
impaired health and perceived HRQL in airways disease. It contains 50 items, divided into
three domains: Symptoms, Activity and Impacts. A score is calculated for each domain and
a total score, including all items, is also calculated. Each item has an empirically derived
weight. Low scores indicate a better HRQL(Jones et al.,1992; Ståhl et al. 2005).
Multidimentional Fatigue Inventory (MFI); The MFI consists of 5 subscales: general
fatigue; physical fatigue; reduced activity; reduced motivation; and mental fatigue. Each
subscale has 4 items with a 5-point Likert scale (1 -no, that is not true, 5 - Yes, that is true),
thus the total score for each subscale ranges from 4 to 20. The overall score of fatigue is
calculated by adding all subscales, so that the overall score ranges from 20 to 100. A higher
score implies more severe fatigue (Breslin et al., 1998; Lewko et al 2009; Meek & Lareau,
2003; Oh et al., 2004).
The Profile Of Mood States (POMS); POMS is a broader measure that has been used in
investigations of individuals with COPD (Janson-Bjerklie et al., 1986; Woo,2000b). The
POMS is a 30-item questionnaire composed of 6 subscales (tension/anxiety,
depression/dejection, anger/hostility, vigor/activity, confusion/bewilderment, and
fatigue/inertia); the POMS-F subscale consists of 7 items. Subjects are asked to indicate the
degree or intensity of feelings in the past few days on a 5-point Likert scale (0 = not at all to
4 = extremely). The POMS-F presents another possible way to measure fatigue in the COPD
population (Meek, 2004).
The Multidimentional Assessment Of Fatigue (MAF); MAF (16 items) was originally
designed for arthritis patients (Belza, 1993;Tack, 1990), It has been used in cancer patients
(Meek et al., 2001) and with chronic pulmonary disease (Belza et al., 2001). The MAF surveys
four dimensions: severity, measured by items 1 and 2; distress, item 3; degree of interference
in activities of daily living, items 4 through 14; and, finally, timing (frequency of occurrence
and changeability), items 15 and 16 (Belza, 1993; Tack, 1990).
1.2 COPD and pulmonary rehabilitation
Dyspnea and fatigue are closely related symptoms in chronic lung disease that are
consistently encountered in the clinical setting. Pulmonary rehabilitation is an essential,
basic component of an integrated approach to managing chronic lung disease (Nield, 2003).
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When disease’ symptoms affect the patient’s performance of daily activities, the potential
exists for overall quality of life to be decreased. If these symptoms continue to limit daily
activities and the intensity of the symptom increases, patients to become deconditioned.
This results in an interrelationship of symptoms affecting activities, and vice versa, often
referred to as the "dyspnea spiral" or cycle of deconditioning. Pulmonary rehabilitation is
one of the few interventions believed to break this cycle of progressive symptoms limiting
activities (ATS,1999). Most patients are referred for pulmonary rehabilitation in order to
improve the symptom of dyspnea. Nevertheless, patients with high fatigue derive
significant benefit from pulmonary rehabilitation. Research of Baltzan et al. (2011) has
shown that high levels of fatigue are common in patients entering pulmonary rehabilitation.
Fatigued patients benefit from pulmonary rehabilitation, with improved exercise
performance as well as improved health status. Lacasse et al. (2006) concluded that
rehabilitation relieves dyspnea and fatigue, improves emotional function and enhances
patients’ sense of control over their condition. The primary measurable benefits of
pulmonary rehabilitation to date have been a decrease in symptoms, and an increase in
exercise endurance. A pulmonary rehabilitation program is to assess and treat activity
limitations associated with symptoms of COPD including dyspnea in order to maximize
patients’ ability to participate in activities of daily living, leisure, and vocational pursuits
(Migliore, 2004). Dyspnea and fatigue are important symptoms associated with COPD that
improve with pulmonary rehabilitation (Meek &Lareau, 2003).
Fatigue and dyspnea are important symptoms requiring evaluation and management in
patients with COPD. Nurses perform crucial responsibilities for supporting coping-skills
against dyspnea and fatigue complaints of COPD patients. Investigating the correlation
between dyspnea and fatigue will contribute to coping behaviors against dyspnea and
fatigue and the quality of life of the patients. Because of the high prevalence of this
symptom and the severity of suffering that can be associated with it, clinicians need to
become familiar with available methods for the alleviation of dyspnea.
2. Aim
The present research was conducted in order to investigate dyspnea, fatigue-experience and
the correlation between dyspnea and fatigue.
3. Material and methods
The research was consisted of COPD patients who were ambulatory examined and checked
at the pulmonary clinics of a state hospital between February and June 2009. The sample of
the research was made up by 300 patients with COPD who accepted to participate.
Participants were selected according to the following criteria; had been diagnosed of COPD,
aged 18 years or older, understand, and communicate in Turkish, did not have any
communicational and psychiatric problems. Written approvals from the hospital and oral
consents from the patients were obtained. The data of the research were collected using face
to face interview technique, personal information form, Medical Research Council Dyspnea
Scale (MRC) and Brief Fatigue Inventory (BFI).
Data were entered into SPSS software (v. 14.0; SPSS Inc.,Chicago, IL) and recoded as
required according to the questionnaires’ scoring instructions. The data analysis was
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performed through percentage distribution, ANOVA, t test and Pearson’s Correlation
Analysis and p<0.05 was accepted as statistically significant.
3.1. Personal information form
Personal information form includes sociodemographic characteristics such as age, gender,
marital status, educational level and disease characteristics such as disease length, disease
severity, health condition, repeated hospitalization. COPD severity was defined by The
GOLD criteria classify COPD into four stages (ATS, 1991; GOLD, 2006).
3.2 The Medical Research Council (MRC) dyspnea scale
Dyspnea perception during daily activities was measured using the MRC dyspnea scale.
Modified MRC chronic dyspnea self-administered questionnaire consisting of five questions
about perceived breathlessness. Grade 1, "never troubled by breathlessness except on
strenuous activity," to Grade 5, "too breathless to leave the house or breathless after
undressing ( Bestall et al., 1999; Stenton, 2008).
3.3 The Brief Fatigue Inventory (BFI)
The BFI was used to assess the severity of fatigue and the amount of interference with
function caused by fatigue in this study. The BFI has 9 items that were designed to provide a
measure of fatigue. Three items in the BFI ask patients to rate their fatigue during the past
24 hours at its “worst,” “usual” or “average,” and “now,” with “0” being “no fatigue,” and
“10” being “fatigue as bad as you can imagine.” Additional items assess how much fatigue
has interfered with different aspects of the patient’s life during the past 24 hours. The
interference items included in the present study were mood, daily activity, walking ability,
eating, relations with other people and enjoyment of life. Each interference item is scored on
an eleven point rating scale from “0” (does not interfere) to “10” (completely interferes). A
mean BFI score is calculated as the mean of the intensity and interference items (Çınar &
Olgun, 2010).
4. Results
It was found out that mean age of the patients was 66.03 years (SD= 11.33), 50.7 % was male,
58.7% belonged to ≥ 65 age group, 72.0% was married, 49.7% was illiterate, 46.3 % was
housewives, 27.9% was retired, 74.3% had a moderate income level. It was explored that
30.7% of the patients had the disease for ≥12 years (disease length ≥12 years), 38.6%
moderate COPD, 77.3% was repeatedly hospitalized and 89.3% said to use their medications
regularly and 47.0% identified their health condition as bad.
Table 1 demonstrates dyspnea severity and fatigue-experience of the patients. All of the
patients said to have dyspnea and the analysis made using MRC dyspnea scale revealed that
73.3%of the patients had severe dyspnea. 99.3% of the patient told to experience fatigue. It
was explored that 49.0% of the patients had always fatigue experience.
Their total fatigue score’mean was 60.36+ 20.57, mean score of activities of affected by
fatigue was 40.22 + 14.37, and MRC dyspnea mean score was 3.59 + 1.31.
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Characteristics n (%)
Dyspnea Complaint
Mild
Moderate
Severe
12(4.0)
68(22.7)
220(73.3)
Fatigue Complaint
Yes
No
298(99.3)
2(0.7)
Frequency Of Fatigue Experience
Sometimes
Often
Always
60(20.0)
93(31.0)
147(49.0)
Table 1. Dyspnea severity and fatigue experience of the patients
It was concluded in our research that there was a positive correlation between dyspnea and
fatigue (r=0.636, p<0.01) and as dyspnea scores increased so did mean fatigue scores. Also,
there was a significant negative correlation between the measured FEV1 values of the
patients and dyspnea scores (r=-.341 p<0.01) and fatigue scores (r=-.260 p<0.01).
Table 2 demonstrates mean scores of dyspnea, fatigue levels and levels of the daily activities
affected by fatigue accoding to some socio demographic and disease characteristics.
It was explored that there was not any statistically significant difference between fatigue
levels, levels of the daily activities affected by fatigue and dyspnea scores in terms of age and
sex(p>0.05). It was found out that there was statistically significant difference between fatigue
level and levels of the daily activities affected by fatigue and disease length (year) (p<0.05).
It was found out that there was statistically significant difference between fatigue level and
levels of the daily activities affected by fatigue and dyspnea according disease severity, the
number of repeated hospitalization, patients’ perception about their health condition and
frequency of fatigue-experience. High fatigue score and score of the daily activities affected
by fatigue were presented by those who had the disease for ≥ 12 years. High fatigue score
and score of the daily activities affected by fatigue and dyspnea score were presented by
who fourth stage of COPD, who were repeatedly, had hospitalized for ≥ 4 times a year and
who identified their own health condition as very bad and frequency of fatigue as always.
5. Discussion
Chronic obstructive pulmonay disease is characterised by significant physical and
psychosocial challanges. Dyspnea and fatigue are the two most common symptoms
experienced by patients with COPD (Blinderman et al., 2009; Gift & Shepard, 1999; Kinsman
et al., 1983). Dyspnea is predominantly related to a reduction in vital capacity of lungs.
Dyspnea is the most commonly experienced complaint of the COPD patients (Rabe et al.,
2006; Tel & Akdemir, 1998; Wong et al., 2010). Fatigue may be affected by dyspnea and is
frequently told by the patients (Janson-Bjerklie et al., 1986; Reishtein 2005). Wong et al.(2010)
found that fatigue was experienced by almost all participants with COPD. Çınar and Olgun
(2010) were reported that 97% of patients with COPD experienced high levels of fatigue. The
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Characteristics
Mean Scores
Fatigue
X ± SD
Activities affected by
fatigue
X ± SD
Dyspnea
X ± SD
Age
< 44 51.93±22.22 35.60±13.17 2.73±1.48
45-64 58.30±22.15 38.60±15.68 3.38±1.34
65+ 62.35±19.18 41.61±13.49 3.79±1.23
F, p 2.66 >0.05 2.30 >0.05 6.89 >0.05
Gender
Female 61.72±20.00 41.00±14.17 3.64±1.29
Male 59.03±21.09 39.46±14.58 3.54±1.33
t, p 0.156 >0.05 0.001 >0.05 0.828 >0.05
Disease Length
1-3 Years 53.05±22.81 35.23±16.20 3.29±1.36
4-7 Years 59.57±19.61 40.61±13.44 3.46±1.35
8-11Years 62.77±17.46 42.00±12.01 3.90±1.28
12+ Years 66.51±18.57 43.77±13.21 3.76±1.20
F, p 7.358 <0.05 6.187 <0.05 3.493 >0.05
Disease Severity
Stage I(Mild) 52.58±21.65 54.46±15.28 2.96±1.28
Stage II Moderate) 56.30±21.25 37.64±14.75 3.26±1.27
StageIII(Severe) 67.21±17.22 44.97±12.19 4.14±1.13
Stage IV(Very severe) 69.78±15.60 46.43±10.43 4.34±1.11
F, p 10.615 <0.05 10.413 <0.05 17.928 <0.05
Repeated Hospitalization
No 52.29±23.52 34.57±16.26 3.11±1.37
Once 55.76±19.89 36.63±14.05 3.22±1.24
Twice 61.31±21.28 40.96±14.60 3.82±1.23
Three times 67.77±15.82 45.40±11.03 3.97±1.15
Four times and more 71.42±11.41 48.40±7.92 4.22±1.17
F, p 9.695 <0.01 10.631 <0.01 8.931 <0.01
Health Condition
Good 47.00±23.35 32.96±16.48 3.04±1.33
Normal 58.39±21.27 38.19±15.02 3.45±1.29
Bad 62.02±18.90 40.91±13.49 3.63±1.31
Very Bad 76.60±9.50 50.25±6.52 4.86±0.52
F, p 8.986 <0.01 5.953 <0.01 8.054 <0.01
Frequency Of Fatigue Experience
Sometimes 46.50±23.90 31.58±16.61 2.93±1.36
Often 57.31±17.58 37.45±12.25 3.16±1.20
Always 67.95±17.27 45.49±12.39 4.13±1.13
F, p 29.305 <0.01 26.231 <0.01 2.864 <0.01
Table 2. Mean scores of dyspnea, fatigue levels and levels of the daily activities affected by
fatigue accoding to some characteristics
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rates of the patients who experienced dyspnea and fatigue were higher in our study too;
which concurred with literature.
Reishtein (2005) found out that means scores for dyspnea and fatigue were moderately high
in patients with COPD. In this study, it was found that the mean scores of fatigue and
dyspnea of the participant patients were high.
It was explored that there was not any statistically significant difference between fatigue
levels, levels of the daily activities affected by fatigue and dyspnea scores in terms of age
and sex. Kapella et al. (2006) reported that fatigue complaint was significantly correlated
with age. Skumlien et al. (2006) reported that 82% of the women and 70% of the men had
dyspnea complaint and there was not any difference among the sex in terms of dyspnea
number and dyspnea scores. Gift and Shepard (1999) reported that men and women did not
differ in their level of fatigue. Oh et al. (2004) and Kapella et al. (2006), reported that there
were small differences between women and men; however, these difference were not
statistically significant. It was observed in our research that although the dyspnea scores
and fatigue scores of the women were higher than those of men, it was statistically
insignificant.
High fatigue score and score of the daily activities affected by fatigue were presented by
those who had the disease for ≥ 12 years. High fatigue score and score of the daily activities
affected by fatigue and dyspnea score were presented by who fourth stage of COPD, who
were repeatedly, had hospitalized for ≥ 4 times a year and who identified their own health
condition as very bad and frequency of fatigue as always. Several studies show that fatigue
is a common symptom in COPD and it has been associated with reduced health status and
dyspnea (Breslin et al., 1998; Guyatt et al.,1987). We were found out that dyspnea and
fatigue scores were higher in patients which health status is very bad. This result was
statically significant. Hospitalization rates in the patients with COPD are high, and increase
with age. Baghai-Ravary et al (2009) suggested that increased fatigue was related to
dyspnea, exacerbation frequency, health status and time spent outdoors. In this study, we
found that the hospitalization rates in the patients with COPD were high and these
patients’dyspnea and fatigue scores were also high.
Baghai-Ravary et al.(2009) and Wong et al.(2010) explored that they did not find a
correlation betweeen severty of COPD and fatigue. Breslin et al.(1998) reported that physical
dimensions of fatigue correlated with an increase in the severity of pulmonary impairment
and reduction in exercise tolerance. In this study we found that fatigue score was higher in
patients with very severe COPD. These data show a relationship between fatigue and
pulmonary function in COPD.
Previous studies have noted significant relationships between dyspnea and fatigue (Baghai-
Ravary et al., 2009; Janson-Bjerklie et al.,1986; Kinsman et al.,1983; Peters et al.,2010,
Reishtein, 2005; Theander et al., 2009). As in earlier studies, we found correlations between
fatigue and dyspnea. It was concluded in our research that there was a positive correlation
between dyspnea and fatigue (r=0.636, p<0.01) and as dyspnea scores increased so did mean
fatigue scores. This result is consistent with previous research reports. Also, there was a
significant negative correlation between the measured FEV1 values of the patients and
dyspnea scores (r=-.341 p<0.01) and fatigue scores (r=-.260 p<0.01). McCarley (2003)
discovered that there was moderately significant correlation between dyspnea and fatigue
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Evaluation of Dyspnea and Fatigue Among the COPD Patients
267
experienced COPD patients whereas Kapella et al. (2006) reported that there was significant
correlation between dyspnea and fatigue scores among the COPD patients. Reishtein (2005)
reported that there was moderately negative correlation between dyspnea and fatigue and
functional lung capacity among the COPD patients. Baghai-Ravary et al.(2009) found that
fatigue was related to change in FEV1. Breslin et al.(1998) found that there was a significant
negative correlation between general and physical fatigue and predicted FEV1 values and
that physical aspect of fatigue was associated with the severity of pulmonary deterioration.
In the light of these findings, patients undergo dyspnea and fatigue more as lung capacity
decreases.
6. Conclusion
According to the results of the present research which was conducted in order to investigate
dyspnea, fatigue-experience and the correlation between dyspnea and fatigue; all of the
patients experienced dyspnea and almost all of them had fatigue. Mean scores of fatigue and
dyspnea of the women were higher than those of men. Dyspnea severity and fatigue was
more intensified among those who belonged to ≥ 65 age group, who had the disease for ≥ 12
years, who had fourth stage of COPD, who were repeatedly hospitalized and fatigue scores
increased as dyspnea severity increased and there was significant negative correlation
between FEV1 values and dyspnea and fatigue scores. As a result, it was recommended that
nurses who care COPD patients should assess dyspnea and fatigue-situations and the
complaint severity of the patients using scales; should plan and practice the appropriate
nursing interventions considering the linear correlation between dyspnea and fatigue;
should perform personal care plans for those COPD patients who belonged to ≥ 65 age
group, who had longer disease length, who had advanced stage of COPD, who were
repeatedly hospitalized due to the fact that the rates of severe dyspnea and fatigue were
higher. Dyspnea and fatigue should be evaluated in usual care with a questionnaire that
corrects for them in order to tailor treatment to patients’ need. Dyspnea and fatigue is an
important symptom requiring evaluation and management in patients with COPD.
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Chronic Obstructive Pulmonary Disease - Current Concepts and
Practice
Edited by Dr. Kian-Chung Ong
ISBN 978-953-51-0163-5
Hard cover, 474 pages
Publisher InTech
Published online 02, March, 2012
Published in print edition March, 2012
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A decade or so ago, many clinicians were described as having an unnecessarily 'nihilistic' view of COPD. This
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interventions on COPD. Management of patients with COPD challenges the whole gamut of Respiratory
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