**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**

256 Chronic Obstructive Pulmonary Disease – Current Concepts and Practice

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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; Tatlcoğlu, 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

Evaluation of Dyspnea and Fatigue Among the COPD Patients 259

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; Yldrm, 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.

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

**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,

**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)

**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

**1.1 Assessment of dyspnea and fatigue** 

(Meek & Lareau, 2003; Meek, 2004).

to brisk walking uphill (at the top) (McGavin et al.,1978).

1999; Mahler, 2006).

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.

worldwide. Overall, COPD was estimated to have resulted in more than 26 million DALYs

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

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,

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,

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

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

1988; Brunier & Graydon, 1996; O'Brain & Pheifer, 1993; Tel et al., 2011).

cognitive, and behavioral responses (American Thorasic Society, 1999).

with COPD ( Kinsman et al., 1983; Walke et al.,2007).

decreased quality of life in COPD patients.

in 2000 (Lopez et al., 2006).

support needs of the patients (Aras & Tel, 2009).

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; Yldrm, 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

Evaluation of Dyspnea and Fatigue Among the COPD Patients 261

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

**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

**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,

**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

**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

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).

and changeability), items 15 and 16 (Belza, 1993; Tack, 1990).

**1.2 COPD and pulmonary rehabilitation** 

weight. Low scores indicate a better HRQL(Jones et al.,1992; Ståhl et al. 2005).

al.,1998).

2003; Oh et al., 2004).

population (Meek, 2004).

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

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,

**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

**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,

**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.,

**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 &

**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

**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

during, and after progressive exercise (Foglio et al.,1999).

1999; Mahler et al.,1984).

1998; Ries et al., 1995).

2000).

Lareau, 2003).

independent of activities(Weaver et al.,1998).

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).

Evaluation of Dyspnea and Fatigue Among the COPD Patients 263

performed through percentage distribution, ANOVA, t test and Pearson's Correlation

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

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

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 (Çnar &

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

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

Their total fatigue score'mean was 60.36+ 20.57, mean score of activities of affected by

Analysis and p<0.05 was accepted as statistically significant.

**3.2 The Medical Research Council (MRC) dyspnea scale** 

regularly and 47.0% identified their health condition as bad.

was explored that 49.0% of the patients had always fatigue experience.

fatigue was 40.22 + 14.37, and MRC dyspnea mean score was 3.59 + 1.31.

undressing ( Bestall et al., 1999; Stenton, 2008).

**3.3 The Brief Fatigue Inventory (BFI)** 

Olgun, 2010).

**4. Results** 

GOLD criteria classify COPD into four stages (ATS, 1991; GOLD, 2006).

**3.1. Personal information form** 

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.
