Pathophysiology of dyspnea in chronic obstructive pulmonary disease: a roundtable.
Effective management of dyspnea in chronic obstructive pulmonary disease (COPD) requires a clearer understanding of its underlying mechanisms. This roundtable reviews what is currently known about the neurophysiology of dyspnea with the aim of applying this knowledge to the clinical setting. Dyspnea is not a single sensation, having multiple qualitative descriptors. Primary sources of dyspnea include: (1) inputs from multiple somatic proprioceptive and bronchopulmonary afferents, and (2) centrally generated signals related to inspiratory motor command output or effort. Respiratory disruption that causes a mismatch between medullary respiratory motor discharge and peripheral mechanosensor afferent feedback gives rise to a distressing urge to breathe which is independent of muscular effort. Recent brain imaging studies have shown increased limbic system activation in response to various dyspneogenic stimuli and emphasize the affective dimension of this symptom. All of these mechanisms are likely instrumental in exertional dyspnea causation in COPD. Increased central motor drive (and effort) is required to increase ventilation during activity because the inspiratory muscles become acutely overloaded and functionally weakened. Abnormal dynamic ventilatory mechanics and excessive chemostimulation during exercise also result in a widening disparity between escalating central neural drive and restricted thoracic volume displacement. This neuromechanical uncoupling may form the basis for the distressing sensation of unsatisfied inspiration. Interventions that alleviate dyspnea in COPD do so by improving ventilatory mechanics, reducing central neural drive, or both-thereby partially restoring neuromechanical coupling of the respiratory system. Self-management strategies address the affective aspect of dyspnea and are essential to successful treatment.
O'Donnell
Denis E
DE
Department of Medicine, Queen's University, 102 Stuart Street, Kingston, ON, K7L 2V6 Canada. odonnell@post.queensu.ca
Banzett
Robert B
RB
Carrieri-Kohlman
Virginia
V
Casaburi
Richard
R
Davenport
Paul W
PW
Gandevia
Simon C
SC
Gelb
Arthur F
AF
Mahler
Donald A
DA
Webb
Katherine A
KA
D000818:Animals; D001249:Asthma / Q000503:physiopathology; D001696:Biomechanical Phenomena; D001993:Bronchodilator Agents / Q000627:therapeutic use; D004417:Dyspnea / Q000188:drug therapy / Q000503:physiopathology*; D017079:Exercise Tolerance / Q000502:physiology; D006371:Helium / Q000627:therapeutic use; D006801:Humans; D000860:Hypoxia / Q000503:physiopathology; D008019:Life Style; D009434:Neural Pathways / Q000503:physiopathology; D010100:Oxygen / Q000627:therapeutic use; D010102:Oxygen Inhalation Therapy; D005082:Physical Exertion; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy / Q000503:physiopathology*; D012129:Respiratory Function Tests; D015656:Respiratory Mechanics
D001993:Bronchodilator Agents; D006371:Helium; C038949:heliox; D010100:Oxygen