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Published ahead of print on March 27, 2008, doi:10.1164/rccm.200711-1675OC
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American Journal of Respiratory and Critical Care Medicine Vol 177. pp. 1384-1390, (2008)
© 2008 American Thoracic Society
doi: 10.1164/rccm.200711-1675OC

Original Article

The Affective Dimension of Laboratory Dyspnea

Air Hunger Is More Unpleasant than Work/Effort

Robert B. Banzett1,2,3, Sarah H. Pedersen1, Richard M. Schwartzstein1,2 and Robert W. Lansing1,2

1 Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; 2 Department of Medicine, Harvard Medical School, Boston, Massachusetts; and 3 Physiology Program, Harvard School of Public Health, Boston, Massachusetts

Correspondence and requests for reprints should be addressed to Robert B. Banzett, Ph.D., Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215 E-mail: rbanzett{at}bidmc.harvard.edu

Rationale: It is hypothesized that the affective dimension of dyspnea (unpleasantness, emotional response) is not strictly dependent on the intensity of dyspnea.

Objectives: We tested the hypothesis that the ratio of immediate unpleasantness (A1) to sensory intensity (SI) varies depending on the type of dyspnea.

Methods: Twelve healthy subjects experienced three stimuli: stimulus 1: maximal eucapnic voluntary hyperpnea against inspiratory resistance, requiring 15 times the work of resting breathing; stimulus 2: PETCO2 6.1 mm Hg above resting with ventilation restricted to less than spontaneous breathing; stimulus 3: PETCO2 7.7 mm Hg above resting with ventilation further restricted. After each trial, subjects rated SI, A1, and qualities of dyspnea on the Multidimensional Dyspnea Profile (MDP), a comprehensive instrument tested here for the first time.

Measurements and Main Results: Stimulus 1 was always limited by subjects failing to meet a higher ventilation target; none signaled severe discomfort. This evoked work and effort sensations, with relatively low unpleasantness (mean A1/SI = 0.64). Stimulus 2, titrated to produce dyspnea ratings similar to those subjects gave during stimulus 1, evoked air hunger and produced significantly greater unpleasantness (mean A1/SI = 0.95). Stimulus 3, increased until air hunger was intolerable, evoked the highest intensity and unpleasantness ratings and high unpleasantness ratio (mean A1/SI = 1.09). When asked which they would prefer to repeat, all subjects chose stimulus 1.

Conclusions: (1) Maximal respiratory work is less unpleasant than moderately intense air hunger in this brief test; (2) unpleasantness of dyspnea can vary independently from perceived intensity, consistent with the prevailing model of pain; (3) separate dimensions of dyspnea can be measured with the MDP.

Key Words: dyspnea • signs and symptoms, respiratory • pain • psychophysiology


AT A GLANCE COMMENTARY

Scientific Knowledge on the Subject
Pain includes both sensory and affective dimensions. Studies have shown similar brain activations in dyspnea and pain, suggesting that the perceptual model of pain may be appropriate for dyspnea; this hypothesis has not been thoroughly tested.

We show that laboratory-induced air hunger is more potent in causing discomfort than maximal respiratory work/effort. This may be important in evaluating causes of patient discomfort and validates the multidimensional model of dyspnea.

 



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