PHYSIOLOGY and MANAGEMENT of BREATHLESSNESS
LEAFLETS FOR PATIENTS:
www.cks.nhs.uk/palliative_cancer_care_dyspnoea/leaflets_for_patients
phyllistuckwellhospice.org/files/active/0/Managing_breathlessness.pdf

NHS Clinical Knowledge Summary on SOB in palliative care:
www.cks.nhs.uk/palliative_cancer_care_dyspnoea

American Thoracic Society update on the mechanisms, assessment, and
management of dyspnea (2012). Am J Respir Crit Care Med; 185(4):435-52.
doi: 10.1164/rccm.201111-2042ST
https://www.thoracic.org/statements/resources/other/update-on-mamd.pdf


Abernethy AP, McDonald CF, Frith PA (2010) Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet, 376, 9743, 784-93
www.ncbi.nlm.nih.gov/pubmed/20816546
• oxygen does not relieve breathlessness

Ahmedzai SH (2004) A double blind, randomised, controlled phase II trial of Heliox28 gas mixture in lung cancer patients with dyspnoea on exertion. Br J Cancer, 90, 366-71
• Heliox reduces dyspnoea on exertion and increases exercise capacity

Ambrosino N (2006) Is there any treatment other than drugs to alleviate dyspnea in COPD patients? Int J Chron Obstruct Pulmon Dis, 1, 4, 355–361.
• useful description of the mechanics of SOB

Ambrosino N, Serradori M (2006) Determining the cause of dyspnoea:
linguistic and biological descriptors. Chr Respir Dis, 3, 117–122

Barnes D (2010) Breathlessness in advanced disease 1: definitions, epidemiology and pathophysiology. Nurs Times, 106: 43
www.allbusiness.com/medicine-health/diseases-disorders-respiratory/15250843-1.html

Barnes D (2010) Breathlessness in advanced disease 2: patient assessment and management . Nurs Times, 106, 44
www.allbusiness.com/medicine-health/diseases-disorders-blood-anemia/15266549-1.html

Bauldoff GS (2009) Music: more than just a melody. Chron Respir Dis, 6, 195-7
crd.sagepub.com/cgi/pdf_extract/6/4/195?rss=1
• close association between anxiety and breathlessness, so relief of one symptom often relieves the other
• music reduces anxiety during exercise in COPD patients, as well as in surgical, ICU and MI patients (so long as music suits patient’s preferences)

Bausewein C (2007) Measurement of breathlessness in advanced disease: a systematic review. Respir Med 101, 399-410

Bausewein C, et al (2008) Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of Systematic Reviews; Issue 2.

Bestall JC (1996) The MRC breathlessness score as a means of stratification of COPD patients. Eur Respir J, 9(23), 383s.
• rehab increases exercise tolerance and quality of life

Booth S (2004) The use of oxygen in the palliation of breathlessness. A report of the expert working group of the scientific committee of the association of palliative medicine. Resp Med, 98, 66-77
www.sciencedirect.com/science?_ob=ArticleURL&_aset=V-WA-A-W-W-MsSAYWW-UUA-U-AAWAUDDBYZ-AAAYZCYAYZ-AZCDZADEB-W-U&_rdoc=1&_fmt=summary&_udi=B6WWS-49SNBV4-1&_coverDate=01%2F31%2F2004&_cdi=7138&_orig=search&_st=13&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=6ac62da1693b520bc2d55a0954bf224e
• there is little evidence for oxygen relieving SOB; a formal assessment must be made to ensure it reduces breathlessness and improves quality of life

Booth S (2006) Palliative care for intractable breathlessness in cancer. Eur J Cancer Care 15(3), 303-314

Booth S, Farquhar M, Gysels M, et al (2006) The impact of a breathlessness intervention service (BIS) on the lives of patients
with intractable dyspnoea: a qualitative phase 1 study. Palliat Support Care, 4, 287–293

Booth S, Moosavi SH, Higginson IJ (2008) The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy. Nat Clin Pract Oncol, 5, 2, 90-100
• like pain, breathlessness has sensory (intensity) and affective (emotional) components
• optimum management involves pharmacological treatment (principally opioids, occasionally oxygen and anxiolytics) and nonpharmacological interventions (including use of a fan, a tailor-made exercise program, and psychoeducational support for patient and family)

Booth S, Burkin J, Moffat C et al (2014) Managing Breathlessness in Clinical Practice. Springer.
• practical textbook

Burdon JGW (1994) Chronic lung disease and the perception of breathlessness. Eur Respir J, 7, 1342-9.

Burki NK, Lee L-Y (2010) Mechanisms of Dyspnea. Chest, 138, 5, 1196–1201.
www.ncbi.nlm.nih.gov/pmc/articles/PMC2972628/?tool=pmcentrez

Carrieri V, Douglas MK (1993) Desensitisation and guided mastery: treatment approaches for the management of dyspnea. Heart Lung, 22, 226-34

Christenbery TL (2005) Dyspnea self-management strategies: Use and effectiveness as reported by patients with COPD. Heart Lung, 34, 6, 406-14
• the most helpful strategies were associated with movement and/or pacing

Clemens K, Klaschik E (2007) Symptomatic therapy of dyspnea with strong opioids and its effect on ventilation in palliative care patients. J Pain Symptom Management, 33, 473-481.

Clini E, Ambrinoso N (2008) Non-pharmacological treatment and relief of symptoms in chronic obstructive pulmonary disease. Euro Respir J, 32, 218-228.
www.erj.ersjournals.com/content/32/1/218.full?sid=8e5e21f8-87fc-420d-a14b-52b47732fbd5
• pulmonary rehab, oxygen, NIV, surgery, nutrition, drugs.

Collins EG et al (2001) Breathing pattern retraining and exercise in persons with COPD. AACN Clin Issues, 12, 202-9.
• literature review

Cullen DL, Rodak B (2002) Clinical utility of measures of breathlessness. Respir Care, 47, 986-93
• relationship between measurement and management of SOB

Currow DC, Abernethy AP, Allcroft P et al (2016) The need to research refractory breathlessness. Eur Respir J; 47(1):342-3. doi: 10.1183/13993003.00653-2015

Currow DC, Ekstrom M, Abernethy AP (2014) Opioids for chronic refractory breathlessness: right patient, right route? Drugs; 74(1):1-6
link.springer.com/article/10.1007/s40265-013-0162-8
• regular low doses of sustained-release morphine can safely reduce breathlessness without respiratory depression or obtundation

David CL (1997) Breathlessness, cough, and other respiratory problems. BMJ, 315, 931
www.ncbi.nlm.nih.gov/pmc/articles/PMC2127624/pdf/9361545.pdf

de Souza A (2004) Descriptors of dyspnea by patients with COPD versus congestive heart failure. Heart Lung, 33, 2, 102-110

DeVos E, Jacobson L (2016) Approach to adult patients with acute dyspnea. Emerg Med Clin; 34(1):129–149

Donesky-Cuenco D, Nguyen HQ, Paul S, Carrieri-Kohlman V (2009) Yoga therapy decreases dyspnea-related distress and improves functional performance in people with chronic obstructive pulmonary disease: a pilot study. J Altern Complement Med, 15, 3, 225-34.
www.liebertonline.com/doi/abs/10.1089/acm.2008.0389

Dorman S et al (2009) Researching breathlessness in palliative care: consensus statement of the National Cancer Research. Pall Med, 23, 213-27.

Dudgeon DJ (2001) Physiological changes and clinical correlations of dyspnea in cancer outpatients. J Pain Symptom Management, 21, 5, 376-9
www.powerbreathe.com/pdf/medical/16_DudgeonJPainSympMan01pdf.pdf

Duranti R (2006) Dyspnea: the importance of a psychological approach, Respiration, 73, 739-40
content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowPDF&ProduktNr=224278&Ausgabe=232249&ArtikelNr=95909&filename=95909.pdf
• importance of measuring the distress as well as the intensity of breathlessness
• mechanism of breathlessness
• mechanism of desensitisation to breathlessness

Ekstr๖m M, Currow DC, Johnson MJ (2016) Outcome measurement of refractory breathlessness: endpoints and important differences. Current Opinion in Supportive & Palliative Care. doi: 10.1097/SPC.0000000000000147

Faisal A, Alghamdi BJ, Ciavaglia CE et al (2016) Common mechanisms of dyspnea in chronic interstitial and obstructive lung disorders. Am J Respir Crit Care Med; 193(3):299-309. doi: 10.1164/rccm.201504-0841OC
• people with interstitial lung disease tend to show greater diaphragmatic activity, whereas those with COPD show greater expiratory muscle activity

Farquhar M (2010) Diversity of experience and impacts of caring for a patient with breathlessness in advanced COPD. Palliat Med, 24, 2, 211

Farquhar MC, Prevost AT et al (2016) The clinical and cost effectiveness of a Breathlessness Intervention Service for patients with advanced non-malignant disease and their informal carers: mixed findings of a mixed method randomised controlled trial. Trials; 17:185. doi: 10.1186/s13063-016-1304-6.
www.ncbi.nlm.nih.gov/pmc/articles/PMC4820876/

Fr๘lich A (2012) Impact of exercise capacity on dyspnea and health-related quality of life in patients with chronic obstructive pulmonary disease. J Cardiopulm Rehab Prev, 32, 2, 92-100

Gagliardi E, Innocenti Bruni G, Presi I et al (2014) Thoraco-abdominal motion/displacement does not affect dyspnea following exercise training in COPD patients. Respir Physiol Neurobiol; 190:124-30

Galbraith S, Fagan P, Perkins P et al (2010) Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage, 39, 5, 831-8.

Garcia-Gutierreza S, Quintanaa JM, Unzurrunzaga A et al (2016) Predictors of change in dyspnea level in acute exacerbations of COPD. COPD; 13(3): 303-311. doi: 10.3109/15412555.2015.1078784

Gardiner C (2010) The effect of the Harold Shipman murders on GP prescribing for dyspnoea for end-stage COPD. Palliat Med, 24, 2, 213
• the Shipman case and associated fears of litigation are key barriers to the prescription of opiates

Garrod R, Daly C, Hoarear C (2004) The effect of pursed lip breathing on exercise capacity and breathlessness in patients with COPD. ACPRC Journal, 36, 29-36
• pursed lip breathing during exercise may lower post-exercise respiratory rate

Gigliotti F (2003) Exercise training improves exertional dyspnea in patients with COPD. Chest, 123, 1794 –1802
www.chestjournal.org/cgi/content/full/123/6/1794?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1&FIRSTINDEX=0&sortspec=relevance&volume=123&firstpage=1794&resourcetype=HWCIT

Gysels MH, Higginson IJ (2009) Caring for a person in advanced illness and suffering from breathlessness at home: threats and resources. Pall Supportive Care, 7, 153-62

Gysels MH, Higginson IJ (2008) Access to services for patients with chronic obstructive pulmonary disease: the invisibility of breathlessness. J Pain Symptom Manage, 36, 5, 451-60.
www.ncbi.nlm.nih.gov/pubmed/18495412
• the concept that best captures the experience of breathlessness is "invisibility."
• a palliative care approach is identified to reduce barriers to access.

Herigstad M, Hayen A, Reinecke A et al (2016) Development of a dyspnoea word cue set for studies of emotional processing in COPD. Respir Physiol Neurobiol; 223:37-42. doi: 10.1016/j.resp.2015.12.006

Higginson IJ, Bausewein C, Reilly CC et al (2014) An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. The Lancet Respiratory Medicine, 2(12):979–87.
doi: dx.doi.org/10.1016/S2213-2600(14)70226-7
www.thelancet.com/journals/lanres/article/PIIS2213-2600%2814%2970226-7/fulltext
• breathlessness support service improves mastery.

Hirayama F (2010) Breathlessness is associated with urinary incontinence in men. BMC Pulm Med, 10, 2, doi:10.1186/1471-2466-10-2
• there’s a significant association between incontinence and breathlessness in middle-aged and older men

Hill K, Jenkins S, Hillman DR, Eastwood PR (2004) Dyspnoea in COPD: can inspiratory muscle training help? Austr J Physiother, 50,169-80.
• excellent explanation of the physiology of breathlessness; also evidence that specific loading of the respiratory muscles can reduce SOB

Hochstetter JK, Lewis J, Soares-Smith L (2005) An investigation into the immediate impact of breathlessness management on the breathless patient: randomised controlled trial. Physiotherapy, 91, 178-85
www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7CVK-4FDMYF5-1&_user=10&_handle=V-WA-A-W-WW-MsSAYVW-UUA-U-AAVVWADUCA-AAVADEDYCA-DUWYYDBZY-WW-U&_fmt=summary&_coverDate=09%2F30%2F2005&_rdoc=8&_orig=browse&_srch=%23toc%2318081%232005%23999089996%23603496!&_cdi=18081&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=e6afca57632a84535dbf6f63cb87ca9b

Hoyal C (2002) Improving the management of breathlessness using a clinical effectiveness programme. Int J Palliative Nurs, 8, 2, 78-87

Janssens JP (2000) Management of dyspnea in severe COPD. J Pain Symp Man. 19, 378-92
• oxygen is not indicated for SOB, hypoxia plays a limited part in SOB

Jantarakupt P, Porock D (2005) Dyspnea management in lung cancer: applying the evidence from COPD. Oncol Nurs Forum, 32, 785-95.

Javadzadeh S, Chowienczyk S, Booth S et al (2016) Comparison of respiratory health-related quality of life in patients with intractable breathlessness due to advanced cancer or advanced COPD. BMJ Support Palliat Care. 2016 Mar;6(1):105-8. doi: 10.1136/bmjspcare-2015-000949
• patients with breathlessness due to advanced COPD have worse respiratory HRQoL than those with advanced cancer
• greater access to palliative care is needed in advanced COPD

Johnson MJ, Bland JM, Gahbauer EA et al (2016) Breathlessness in elderly adults during the last year of life sufficient to restrict activity: prevalence, pattern, and associated factors. J Am Geriatr Soc; 64(1):73-80. doi: 10.1111/jgs.13865

Kakizaki F (1999) Preliminary report on the effects of respiratory muscle stretch gymnastics on chest wall mobility. Respir Care, 44, 409-14
• stretching exercises reduces breathlessness and increases vital capacity

Kamal AH, Miriovsky BJ, Currow DC et al (2012). Improving the management of dyspnea in the community using rapid learning approaches. Chronic Resp Dis, 9, 1, 51-61

Kathiresan G et al (2010) Dyspnea in lung cancer patients: a systematic review. Lung Cancer: Targets and Therapy, 1:141-150

Kazuya S, Masashi K, Hideaki S et al (2015) Distractive auditory stimuli alleviate the perception of dyspnea induced by low-intensity exercise in elderly subjects with COPD. Respir Care; 60(5):689-694

Kohberg C, Andersen CU, Bendstrup E (2016) Opioids: an unexplored option for treatment of dyspnea in IPF. Europ Clin Respir J; 3:10.3402/ecrj.v3.30629. doi:10.3402/ecrj.v3.30629.
www.ncbi.nlm.nih.gov/pmc/articles/PMC4788766/

Kvangarsnes M, Torheim H, Rotheim H et al 2013) Narratives of breathlessness in chronic obstructive pulmonary disease. J Clin Nurs; 22(21-22):3062–3070. doi: 10.1111/jocn.12033

Leduc D, De TA (2002) Effect of chest wall vibration on the canine diaphragm during breathing. Eur Respir J, 19, 429-33
• mechanical vibration of ribcage reduces SOB, possibly by stimulating the external intercostals

Lee L, Friesen M (1998) Evaluation of dyspnea during physical and speech activities in patients with pulmonary diseases. Chest, 113, 625-32

Luckett T, Disler R, Hosie A et al (2016) Content and quality of websites supporting self-management of chronic breathlessness in advanced illness: a systematic review. Primary Care Respir Med; 26, Article no: 16025. doi: 10.1038/npjpcrm.2016.25
www.nature.com/articles/npjpcrm201625

Mahler DA, Harver A (2000) Do you speak the language of dyspnea? Chest, 117, 928-9

Mahler DA, Fierro-Carrion G, Baired JC (2003) Evaluation of dyspnea in the elderly. Clin Geriatr Med, 19, 19-33

Man WD-C, Chowdhury F, Taylor RS et al (2016) Building consensus for provision of breathlessness rehabilitation for patients with chronic obstructive pulmonary disease and chronic heart failure. Chr Respir Dis ;13(3):229-39. doi: 10.1177/1479972316642363

Manning HL (1995) Pathophysiology of dyspnoea. New Eng J Med, 333, 1547-52

Manning HL (2000) Dyspnea treatment. Respir Care, 45, 1342-51

Matsumoto K (2004) Chest physiotherapy changed the ventilatory mechanics in patients with COPD. Eur Respir J, 24: Suppl. 48, 291s
www.ersnet.org/ers/lr/browse/media.aspx?id_dossier=16216&id_fiche=120417
• manual stretching of the respiratory muscles can reduce hyperinflation and improve vital capacity

Meek PM et al (1999) Dyspnea: mechanisms, assessment and management. Am J Respir Crit Care Med, 159, 321-40

Meek PM, Lareau SC (2003) Are self-reports of breathing effort and breathing distress stable and valid measures among persons with asthma, persons with COPD, and healthy persons? Heart Lung, 32, 5, 335-46

Mercadante S, Fusco F, Caruselli A (2016) Background and episodic breathlessness in advanced cancer patients followed at home. Curr Med Res Opin; 33(1):155-160

Michaels C (2004) The language of breathing among individuals with COPD. Heart Lung, 33, 6, 390-400

Muers M (1993) Understanding breathlessness. Lancet, 342, 1190-1
• succinct overview of mechanism of breathlessness

Mularski RA, Lynn F. Reinke, Virginia Carrieri-Kohlman V et al (2013) An official American Thoracic Society Workshop report: assessment and palliative management of dyspnea crisis. Am J Respir Crit Care Med; 10(5): S98-S106

Nicholls D (2000) Breathlessness. A qualitative model of meaning. Physiother, 86, 23-7

Nicholls D (2003) The experience of chronic breathlessness. Physiother Th Pract, 19, 123-36
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Nishimura K, Izumi T (2002) Dyspnea is a better predictor of 5-year survival than airway obstruction in patients with COPD. Chest, 121,1434–40
www.chestjournal.org/cgi/content/full/121/5/1434?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&andorexactfulltext=and&searchid=1139147998566_2104&FIRSTINDEX=0&sortspec=relevance&volume=121&firstpage=1434&resourcetype=1&journalcode=chest

Norweg A, Collins EG (2013) Evidence for cognitive–behavioral strategies improving dyspnea and related distress in COPD. Int J Chron Obstruct Pulmon Dis, 8:439–451

O'Donnell DE, Banzett RB, Carrieri-Kohlman V et al (2007) Pathophysiology of dyspnea in chronic obstructive pulmonary disease. Proc Am Thorac Soc, 4, 2, 145-68.
pats.atsjournals.org/cgi/content/full/4/2/145
• comprehensive explanation of mechanism of SOB

Parshall MB et al (2002) Psychometric characteristics of dyspnea descriptor ratings in emergency department patients with exacerbated COPD. Res Nurs Health, 25, 331-4
• breathless measurement

Parshall MB, Schwartzstein RM, Adams L (2012) An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med, 185, 4, 435-452

Peiffer C (2011) Morphine-induced relief of dyspnea: what are the mechanisms? Am J Respir Crit Care Med, 184(8):867-9.

Pianosi PT, Zhang Z, Hernandez P et al (2016) Measuring dyspnea and perceived exertion in healthy adults and with respiratory disease: new pictorial scales. Sports Medicine - Open; 2:17. doi:10.1186/s40798-015-0038-4
www.ncbi.nlm.nih.gov/pmc/articles/PMC4703611/

Polkey MI (1999) Ethical and clinical issues in the use of home NIV for the palliation of breathlessness in motor neurone disease. Thorax, 54, 367-71
thorax.bmjjournals.com/cgi/content/full/54/4/367?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Polkey+&andorexactfulltext=and&searchid=1128073142735_531&stored_search=&FIRSTINDEX=0&sortspec=relevance&volume=54&firstpage=367&resourcetype=1&journalcode=thoraxjnl
• identification and palliation of respiratory muscle weakness and ventilatory failure, including non-invasive ventilation

Reilly CC, Bausewein C, Pannell C et al (2016) Patients’ experiences of a new integrated breathlessness support service for patients with refractory breathlessness: Results of a postal survey. Palliative Med; 30(3):313-322. doi: 10.1177/0269216315600103.
www.ncbi.nlm.nih.gov/pmc/articles/PMC4778380/

Renwick D (2001) Breathlessness and quality of life in old age. Age Ageing; 30, 110-112
ageing.oxfordjournals.org/content/30/2/110.full.pdf+html

Ripamonti C (2007) Dyspnea: pathology and assessment. J Pain Symptom Management, 13, 220-32

Rocker G (2012) Palliation of dyspnea. Chronic Resp Dis, 9, 1, 49-50

Simon et al (2010) Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Systematic Reviews, Issue 1

Solomon BK, Wilson KG, Henderson PR et al (2015) A breathlessness catastrophizing scale for chronic obstructive pulmonary disease. J Psychosom Res; 79(1):62-8. doi: 10.1016/j.jpsychores.2014.11.020

Stokes NR, Dietz BW, Liang JJ (2016) Cardiopulmonary laboratory biomarkers in the evaluation of acute dyspnea. Open Access Emergency Medicine; 8:35-45. doi: 10.2147/OAEM.S71446.
www.ncbi.nlm.nih.gov/pmc/articles/PMC4886298/

Strohl K, Thomas AJ (1998) Breathlessness, anxiety and respiratory physiology. Psychosom Med, 60, 680-1
www.psychosomaticmedicine.org/cgi/reprint/60/6/680.pdf
• early childhood experiences may modulate respiratory drive

Swigris JJ, Streiner DL, Brow KK et al (2014) Assessing exertional dyspnea in patients with idiopathic pulmonary fibrosis. Respir Med; 108(1):181-188
www.resmedjournal.com/article/S0954-6111%2813%2900495-2/fulltext

Thomas M et al (2010) The impact of home-based physiotherapy interventions on breathlessness during activities of daily living in severe COPD. Physiother; 96, 2, 108-119

Thomas R, Jenkins S, Eastwood PR et al (2015) Physiology of breathlessness associated with pleural effusions. Curr Opin Pulm Med; 21(4):338-45. doi: 10.1097/MCP.0000000000000174

Tobin MJ (1990) Dyspnea: pathological basis, clinical presentation and management. Arch .Intern Med, 150, 1604-12.

Travers J, Dudgeon DJ, Amjadi K et al (2007) Mechanisms of exertional dyspnea in patients with cancer. J Appl Physiol, 104, 57-66, 200
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• breathlessness in patients with cancer may be due to respiratory muscle weakness.

Uronis et al (2008) Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis Br J Cancer, 98, 294-99

Vicent, L., Olarte, J.M.N., Puente, L., 2017. Degree of dyspnoea at admission and discharge in patients with heart failure and respiratory diseases. BMC Palliative Care. 16:35

Von Leupoldt (2006) Sensory and affective aspects of dyspnea contribute differentially to the borg scale's measurement of dyspnea. Respiration, 73, 762-8
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• different influence of sensory and affective aspects of dyspnoea on the Borg scale
• differentiation between these aspects through the use of separate rating scales could yield more detailed information

Williams MT, Cafarella P, Catherine P (2015) Cognitive behavioral therapy for management of dyspnea: a pilot study. Respir Care; 60(9):1303-1313

Wilson RC (1989) A comparison of the visual analogue scale and modified Borg scale for measurement of dyspnoea during exercise. Clin Sci, 76, 277-82

Wilson RC, Jones PW (1991) Differentiation between the intensity of breathlessness and the distress it evokes in normal subjects during exercise. Clin Sci, 80, 65-70.

Wong CH, Ching HWA, Chan WY et al (2013) Implementation of a breathlessness management programme with an incentive handheld fan as a nonpharmacological approach in dyspnoea management in patients with advanced chronic obstructive pulmonary disease and chronic heart failure. Hong Kong Physiother J, 31(2):101