The Breathing, Thinking, Functioning clinical model: a proposal to facilitate evidence-based breathlessness management in chronic respiratory disease
Open accessAbstract
Refractory breathlessness is a highly prevalent and distressing symptom in advanced chronic respiratory disease. Its intensity is not reliably predicted by the severity of lung pathology, with unhelpful emotions and behaviours inadvertently exacerbating and perpetuating the problem. Improved symptom management is possible if clinicians choose appropriate non-pharmacological approaches, but these require engagement and commitment from both patients and clinicians. The Breathing Thinking Functioning clinical model is a proposal, developed from current evidence, that has the potential to facilitate effective symptom control, by providing a rationale and focus for treatment.
AI snapshot
Written from the paper’s full text.
TL;DR
Refractory breathlessness in advanced chronic respiratory disease is not reliably predicted by lung pathology, and unhelpful emotional and behavioural reactions can perpetuate it. The authors propose the Breathing, Thinking, Functioning (BTF) clinical model as an evidence-informed, non-pharmacological framework to explain and manage breathlessness, while noting formal evaluation is still required.
Key findings
- Breathlessness severity is poorly predicted by airflow limitation: in an observational study of almost 50,000 UK patients with COPD, a third of those with stage 1 disease described moderate to severe breathlessness, while over 20% of those with stage 4 disease did not have clinically significant breathlessness. Bronchoscopic lung volume reduction improved FEV1 by 25% without relief of breathlessness.
- Single interventions have limited benefit: oxygen did not improve breathlessness in cancer patients; in COPD patients not qualifying for home oxygen, oxygen improved breathlessness by the equivalent of 0.7 cm on a 10 cm visual analogue scale on exercise only, with no benefit before exercise and no quality-of-life improvement. Benzodiazepines showed no beneficial effect, and opioids had only borderline clinical significance.
- Multi-modal non-pharmacological approaches appear most successful: pulmonary rehabilitation produces clinically significant breathlessness reduction; a cognitive-behavioural manual in 222 COPD patients significantly improved breathlessness at 6 months and reduced A&E visits by 42%; breathlessness support services improved mastery of breathlessness by an average of 16% at 6 weeks and improved survival.
- The BTF model proposes three predominant vicious cycles—Breathing, Thinking, and Functioning—and categorises non-pharmacological interventions within these domains to focus management.
Methods
- This is a proposal/clinical model paper, not a primary empirical study. The model was developed by the Cambridge Breathlessness Intervention Service and is theoretically underpinned by a “vicious flower” maintenance model used in cognitive–behavioural therapy.
- The authors synthesise current evidence narratively, including neuroimaging, observational studies, randomised controlled trials, and Cochrane reviews, summarised in Table 1; no systematic review methods are reported.
- Planned evaluation includes mixed-methods qualitative research with in-depth interviews and focus groups, and a cluster-randomised trial in primary care for patients with COPD who remain symptomatic after, or could not complete, pulmonary rehabilitation, or who are ineligible for invasive procedures. Key outcomes will include perceived self-efficacy in symptom management, rate of primary care consultations, and out-of-hours emergency service contacts.
Limitations
- The paper states that formal research evaluation of the model is required, that a mixed-methods approach and cluster-randomised trial are planned, and that further research is required to clarify its effectiveness.
- The text states there has been no research on dysfunctional breathing patterns in other respiratory conditions such as COPD, with extensive anecdotal evidence only; service evaluations and anecdotal evidence from clinical utilisation within CBIS are described as revealing unanticipated benefits.
- Evident from the text: the BTF model itself has not yet been empirically tested in the reported work, and the supporting evidence varies in strength, including low-quality evidence for opioids and marginal or dubious clinical significance for oxygen in some contexts.
Model-written summary. Check it against the paper before relying on it.
Integrity signals
Registry
Cites
Statistics
Claims the paper makes
24 of 45 cited sources checked · 6 supported · 0 flagged · accuracy not yet measured
- Premisecitation
Breathlessness severity is not reliably predicted by the severity of airflow limitation/lung pathology in COPD.
“Its intensity is not reliably predicted by the severity of lung pathology”
- Also stated in: § Relationship between disease and breathlessness severity · plain
“Breathlessness severity is not reliably predicted by the severity of airflow limitation in COPD.”
Quote in the paperSubstantial claim4 of 4 sources checked- cites [7] Agusti, A., Calverley, P., Celli, B., Coxson, H., Edwards, L. & Lomas, D. et al. Characteriation of COPD heterogeneity in the ECLIPSE cohort. Respir. Res. 11, 122 (2010). source
- cites [8] Grønseth, R., Vollmer, W., Hardie, J., Ólafsdóttir, I., Lamprecht, B. & Buist, A. et al. Predictors of dyspnoea prevalence: results from the BOLD study. Eur. Respir. J. 43, 1610–1120 (2013). source
The Results report considerable overlap in lung-function measurements across dyspnoea grades, and the Discussion says adding spirometry had only a minor impact on models explaining dyspnoea. This supports the point that airflow measures do not reliably predict breathlessness intensity, but the analysis was population-based rather than specific to people with COPD, and it did not assess lung pathology beyond spirometry. (LLM, conf=0.83)
Experimental — accuracy not yet measured - cites [2] Mullerova, H., Chao, L., Hao, L. & Tabberer, M. Prevalence and burden of breathlessness in patients with chronic obstructive pulmonary disease managed in primary care. PLoS One 9, e85540 (2014). source
- cites [9] Zoumot, Z., Davey, C., Jordan, S., McNulty, W., Carr, D. & Hind, M. et al. A randomised controlled study of bronchoscopic lung volume reduction with endobronchial valves for patients with heterogeneous emphysema and intact interlobar fissures: the BeLieVeR-HIFi study. Effic. Mech. Eval. 2, 5 (2015). source
The Results section reports that improved FEV1 was associated with reduced breathlessness during exercise, but does not assess whether the severity of lung pathology reliably predicts breathlessness intensity. Searches for that relationship, including dyspnoea severity and airflow obstruction, found no passage addressing the claim. (LLM, conf=0.72)
Experimental — accuracy not yet measured
- Also stated in: § Relationship between disease and breathlessness severity · plain
- Premisecitation
Refractory breathlessness is highly prevalent and distressing in advanced chronic respiratory disease.
“Refractory breathlessness is a highly prevalent and distressing symptom in advanced chronic respiratory disease.”
- Also stated in: § Introduction · plain
“Breathlessness is prevalent in chronic respiratory disease, and primary care bears much of the burden of its management.”
Quote in the paperSubstantial claim2 of 2 sources checked- cites [1] Theander, K., Hasselgren, M., Luhr, K., Eckerblad, J., Unosson, M. & Karlsson, I. Symptoms and impact of symptoms on function and health in patients with chronic obstructive pulmonary disease and chronic heart failure in primary health care. Int. J. Chron. Obstruct. Pulmon. Dis. 9, 785–794 (2014). source
The Introduction reports that shortness of breath is common in COPD and that many symptoms can cause significant distress; the Discussion reports functional limitations due to dyspnea. The paper studies patients with COPD and heart failure in primary health care, but does not establish that their breathlessness was refractory or that they had advanced chronic respiratory disease. Page numbers are not available in our copy. (LLM, conf=0.88)
Experimental — accuracy not yet measured - cites [2] Mullerova, H., Chao, L., Hao, L. & Tabberer, M. Prevalence and burden of breathlessness in patients with chronic obstructive pulmonary disease managed in primary care. PLoS One 9, e85540 (2014). source
The Introduction describes dyspnoea as distressing and says that many patients with COPD continue to experience it despite available treatments. The Discussion reports that dyspnoea was highly prevalent across all stages of airflow limitation. The paper does not establish the prevalence of specifically refractory breathlessness in advanced chronic respiratory disease beyond COPD. (LLM, conf=0.86)
Experimental — accuracy not yet measured
- Also stated in: § Introduction · plain
- Premisecitation
Multiple observational studies link breathlessness with anxiety and depression.
“Multiple observational studies link breathlessness with anxiety and depression.”
Quote in the paperSubstantial claim1 of 2 sources checked- cites [4] Ho, S., O’Mahony, M., Steward, J., Breay, P., Buchalter, M. & Burr, M. Dyspnoea and quality of life in older people at home. Age and Aging 30, 155–159 (2001). source
- cites [5] Chavannes, N., Huiber, M., Schermer, T., Hendricks, A., van Weel, C. & Wouters, E. et al. Associations of depressive symptoms with gender, body mass index and dyspnea in primary care COPD patients. Fam. Pract. 22, 604–607 (2005). source
The Discussion (p. 4) reports an association between dyspnea and depressive symptoms in this study’s patients with mild to moderate COPD. The Methods (p. 3) describe a cross-sectional analysis but do not include an anxiety measure. Although the Introduction (p. 2) discusses studies of depression and anxiety in COPD, it does not say that multiple studies linked breathlessness with both conditions. (LLM, conf=0.87)
Experimental — accuracy not yet measured
- Premisecitation
Patients with intractable breathlessness are commonly fatigued, which limits capacity to retain and process new information.
“Patients with intractable breathlessness are commonly fatigued, which limits the capacity to retain and process new information.”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [41] Baltzan, M., Scott, A., Wolkeove, N., Bailes, S., Bernard, S. & Bourbeau, J. et al. Fatigue in COPD: prevalence and effect on outcomes in pulmonary rehabilitation. Chron. Respir. Dis. 8, 119–128 (2011). source
The Abstract and Discussion (page unavailable) report that fatigue is common among patients with COPD and that patients with high fatigue had greater dyspnea. The Introduction says fatigue may limit participation in rehabilitation activities, but the paper does not establish that it limits patients’ capacity to retain and process new information. (LLM, conf=0.85)
Experimental — accuracy not yet measured
- Interpretationcitation
Deconditioning could, in part, explain the evidence in longitudinal studies for progression in breathlessness severity, despite stable lung function.
“Deconditioning could, in part, explain the evidence in longitudinal studies for progression in breathlessness severity, despite stable lung function.”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [28] Mahler, D., Ward, D., Waterman, L. & Baird, J. Longitudinal changes in patient-reported dyspnoea in patients with COPD. COPD 9, 522–527 (2012). source
- Interpretationcitation
The most successful interventions for breathlessness are multi-modal, non-pharmacological approaches that work concurrently at multiple points within the brain, respiratory and skeletal system.
“Instead the most successful interventions appear to be multi-modal, non-pharmacological approaches that work concurrently at multiple points within the brain, respiratory and skeletal system.”
Quote in the paperSubstantial claim2 of 3 sources checked- cites [21] Howard, C. & Dupont, S. The COPD breathlessness manual’: a randomised controlled trial to test a cognitive-behavioural manual versus information booklets on health service use, mood and health status, in patients with chronic obstructive pulmonary disease. Prim. Care Respir. Med. 24, 14076. doi:14010.11038/npjpcrm.12014.14076 (2014). source
The Materials and methods section describes a non-pharmacological manual combining cognitive-behavioural strategies, breathing control and mobility exercises. But the Discussion says the study cannot identify which component was most effective and calls for trials disentangling their contributions. It does not establish that multimodal approaches are the most successful or that they act concurrently within the brain, respiratory and skeletal systems. Our copy provides section labels but no page numbers. (LLM, conf=0.88)
Experimental — accuracy not yet measured - cites [22] Bausewein, C., Booth, S., Gysels, M. & Higginson, I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst. Rev. 2, CD005623. doi:005610.001002/14651858 (2008).
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- cites [23] Zwerink, M., Brusse-Keizer, M., van der Valk, P., Zielhuis, G., Monninkhof, E. & van der Palen, J. et al. Self management for patients with chronic obstructive pulmonary disease. Cochrane Database Syst. Rev. 19, CD002990 (2014). source
The Interventions section describes multicomponent self-management programmes, and the Discussion reports a statistically significant reduction in shortness of breath. But the Discussion says the studies were too different to identify the most effective combination of components. It does not establish that these approaches work concurrently on the brain, respiratory system and skeletal system. (LLM, conf=0.86)
Experimental — accuracy not yet measured
- Premisecitation
Opioids provide benefit of only borderline clinical significance for breathlessness.
“Even opioids, with most evidence to support their use, provide benefit of only borderline clinical significance.”
Quote in the paperNot a substantial claim2 of 2 sources checked- cites [19] Abernethy, A., Currow, D., Frith, P., Fazekas, B., McHugh, A. & Bui, C. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. Br. Med. J. 327, 523–526 (2003). source
The Discussion reports a modest 7–10 mm improvement in breathlessness and calls it clinically significant. The Limitations section acknowledges that the clinical significance of that change may be questioned, but describes a 5–10% improvement as welcome. These passages support a modest benefit, not the categorical claim that opioids provide benefit of only borderline clinical significance. (LLM, conf=0.82)
Experimental — accuracy not yet measured - cites [20] Barnes P., McDonald J., Smallwood N., Manser R. Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness. Cochrane Database Syst. Rev. 3, CD011008 (2016). source
- Premisecitation
When individuals with a chronic condition like COPD actively participate in self-management, their medical outcomes improve.
“The evidence is clear that when individuals with a chronic condition, like COPD, actively participate in their own care through self-management, their medical outcomes improve.”
Quote in the paperSubstantial claim1 of 2 sources checked- cites [37] Bucknall, C., Miller, G., Lloyd, S., Cleland, J., McCluskey, S. & Cotton, M. et al. Glasgow supported self-management trial (GSuST) for patients with moderate to severe COPD: a randomised controlled trial. Br. Med. J. 344, e1060 (2012). source
The Successful self management section reports fewer COPD readmissions among participants who successfully used self-management techniques. But the Conclusions section says the intervention had no overall effect on COPD readmissions or deaths; the benefit came from an exploratory subgroup analysis. The claim presents that narrower finding as a clear, general improvement in medical outcomes. (LLM, conf=0.88)
Experimental — accuracy not yet measured - cites [38] Shively, M., Gardetto, G., Kodiath, M., Kelly, A., Smith, T. & Stepnowsky, C. et al. Effect of patient activation on self-management in patients with heart failure. J. Cardiovasc. Nurs. 28, 20–34 (2013). source
- Interpretationreasoning
The neural complexity of breathlessness limits the potential for a single effective intervention.
“A consequence of this neural complexity is that it limits the potential for a single effective intervention, a point supported by an increasing body of literature (Table 1).”
Quote in the paperSubstantial claim - Premisecitation
Benzodiazepines do not improve breathlessness.
“Benzodiazepines are widely used, but do not improve breathlessness.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [18] Simon, S., Higginson, I., Booth, S., Harding, R. & Bausewein, C. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst. Rev. 1, CD007354. doi:007310.001002/14651858 (2010).
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Premisecitation
Neuroimaging studies have increased understanding of the neural processing of breathlessness and the factors influencing symptom perception.
“Neuroimaging studies over the last decade have significantly increased understanding of the neural processing of the sensation of breathlessness, and the range of factors influencing the symptom perception.”
Quote in the paperNot a substantial claim0 of 2 sources checked- cites [10] Banzett, R., Mulnier, H., Murphy, K., Rosen, S., Wise, R. & Adams, L. Breathlessness in humans activates insular cortex. Neuroreport 11, 2117–2120 (2000). source
- cites [11] Evans, K., Banzett, R., Adams, L., McKay, L., Frackowiak, R. & Corfield, D. Bold fMRI indentifies limbic, paralimbic, and cerebellar activation during air hunger. J. Neurophysiol. 88, 1500–1511 (2002). source
- Interpretationreasoning
Unhelpful emotions and behaviours inadvertently exacerbate and perpetuate breathlessness.
“with unhelpful emotions and behaviours inadvertently exacerbating and perpetuating the problem.”
- Also stated in: § Reactions to breathlessness · plain
“such emotions and behaviours can be unhelpful and inadvertently perpetuate the problem.”
Quote in the paperSubstantial claim- Rests on an assumption: Interoceptive awareness of an acute homoeostatic threat leads to avoidance behaviour motivated by emotion, which confers a survival advantage.
- Also stated in: § Reactions to breathlessness · plain
- Premisecitation
Breathlessness perception is driven by a mismatch between demand for ventilation and afferent information on actual ventilation.
“Breathlessness perception is believed to be driven by a mismatch between the two.”
Quote in the paperSubstantial claim0 of 2 sources checked - Interpretationreasoning
Optimising treatment of the underlying disease has an inconsistent impact on breathlessness.
“Optimising treatment of the underlying disease has an inconsistent impact on the symptom.”
- Also stated in: § Relationship between disease and breathlessness severity · plain
“optimising disease management alone does not guarantee good symptom control.”
Quote in the paperSubstantial claim - Also stated in: § Relationship between disease and breathlessness severity · plain
- Premisecitation
The more information presented in a consultation, the lower the proportion correctly recalled.
“The more information presented in a consultation, the lower the proportion that is correctly recalled.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [42] Anderson, J., Dodman, S., Kopelman, M. & Fleming, A. Patient information recall in a rheumatology clinic. Rheumatol. Rehabil. 18, 245–255 (1979). source
- Premisecitation
Enhancing self-efficacy is a particularly effective way to support self-management.
“Enhancing self-efficacy is a particularly effective way to support self-management.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [40] The Health Foundation. Evidence: helping people help themselves (The Health Foundation, 2011).
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
- Interpretationreasoning
The BTF model is based on three predominant cognitive and behavioural reactions to breathlessness that, by causing vicious cycles, worsen and maintain the symptom.
“The model is based on three predominant cognitive and behavioural reactions to breathlessness that, by causing vicious cycles, worsen and maintain the symptom (Fig. 1).”
Quote in the paperNot a substantial claim- Rests on an assumption: Anxiety increases respiratory rate and can cause muscle tension in the ventilatory pump and other skeletal muscles, further increasing work of breathing and respiratory demand.
- Rests on an assumption: There is extensive anecdotal evidence that dysfunctional breathing patterns occur in respiratory conditions such as COPD.
- Rests on an assumption: Patients intuitively understand the 'deconditioning vicious cycle'.
- Rests on an assumption: Family members and other carers can unwittingly compound the situation by doing activities that the patient might otherwise have done.
- Interpretationreasoning
The human reaction to the perception of breathlessness may worsen the symptom.
“There is growing evidence for a further level of complexity: the human reaction to the perception of breathlessness may worsen the symptom.”
Quote in the paperSubstantial claim- Rests on an assumption: Interoceptive awareness of an acute homoeostatic threat leads to avoidance behaviour motivated by emotion, which confers a survival advantage.
- Premisecitation
Neuroimaging studies reveal that breathlessness activates cortico-limbic areas, particularly the right anterior insula.
“Neuroimaging studies reveal that breathlessness activates cortico-limbic areas, particularly the right anterior insula.”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [10] Banzett, R., Mulnier, H., Murphy, K., Rosen, S., Wise, R. & Adams, L. Breathlessness in humans activates insular cortex. Neuroreport 11, 2117–2120 (2000). source
- cites [11] Evans, K., Banzett, R., Adams, L., McKay, L., Frackowiak, R. & Corfield, D. Bold fMRI indentifies limbic, paralimbic, and cerebellar activation during air hunger. J. Neurophysiol. 88, 1500–1511 (2002). source
- Interpretationreasoning
In the context of chronic perceived threats such as persistent breathlessness, emotions and behaviours can be unhelpful and inadvertently perpetuate the problem.
“However, in the context of chronic perceived threats such as persistent breathlessness, such emotions and behaviours can be unhelpful and inadvertently perpetuate the problem.”
Quote in the paperSubstantial claim- Rests on an assumption: Interoceptive awareness of an acute homoeostatic threat leads to avoidance behaviour motivated by emotion, which confers a survival advantage.
- Premisecitation
The neural processing for the anxiety-breathlessness feedback loop likely occurs in cortico-limbic areas involved in both breathlessness perception and emotion processing.
“The neural processing for this feedback loop is likely to occur in the cortico-limbic areas of the brain, involved in both breathlessness perception and processing of emotion.”
Quote in the paperNot a substantial claim0 of 1 sources checked- cites [34] von Leupoldt, A., Sommer, T., Kegat, S., Baumann, H., Klose, H. D., Dahme, B. & Büchel, C. The unpleasantness of perceived dyspnea is processed in the anterior insula and amygdala. Am. J. Respir. Crit. Care Med. 177, 1026–1032 (2008). source
- Premisecitation
Dysfunctional breathing patterns are well recognised in breathless individuals without underlying respiratory pathology.
“Dysfunctional breathing patterns are well recognised in breathless individuals without underlying respiratory pathology.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [29] Gardner, W. The pathophysiology of hyperventilation disorders. Chest 109, 516–534 (1996). source
- Premisecitation
Anxiety or fear caused by breathlessness can augment the perception of breathlessness.
“It is well-recognised that the anxiety or fear caused by breathlessness can, in turn, augment the perception of breathlessness.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [33] Livermore, N., Butler, J., Sharpe, L., BcBain, R., Gandevia, S. & McKenzie, D. Panic attacks and perception of inspiratory resistive loads in chronic obstructive pulmonary disease. Am. J. Respir. Crit. Care Med. 178, 7–12 (2008). source
- May combine two claims. 15
- Classified as probably not a substantial claim. 4
May combine two claims.
PremisecitationOxygen therapy does not improve breathlessness in patients with cancer, and its marginal benefit in COPD is of dubious clinical significance.
“Oxygen therapy, although it reverses hypoxaemia, does not improve breathlessness in patients with cancer, and the marginal benefit seen in a meta-analysis of COPD patients is of dubious clinical significance.”
Quote in the paperSubstantial claim2 of 2 sources checked- cites [16] Uronis, H., Currow, D., McCrory, D., Samsa, G. & Abernethy, A. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. Br. J. Cancer 98, 294–299 (2008). source
The Results (Treatment efficacy; page unavailable) report that oxygen did not improve dyspnoea in mildly- or non-hypoxaemic cancer patients who would not normally qualify for home oxygen therapy. That supports the cancer finding, but not its extension to all patients with cancer. The paper says a separate review addressed COPD; it does not establish that a marginal benefit in a COPD meta-analysis was of dubious clinical significance. (LLM, conf=0.87)
Experimental — accuracy not yet measured - cites [17] Ekström, M., Ahmadi, Z., Bornefalk-Hermansson, A., Abernethy, A. & Currow, D. Oxygen for breathlessness in patients with chronic obstructive pulmonary disease who do not qualify for home oxygen therapy. Cochrane Database Syst. Rev. 11, CD006429 (2016). source
The Discussion (page not available in our copy) reports a modest reduction in COPD breathlessness during exercise and says its clinical importance is unclear; the Authors’ Conclusions likewise find no evidence of a clinically important benefit in daily life. The review does not establish the sentence’s separate claim that oxygen fails to improve breathlessness in patients with cancer. (LLM, conf=0.86)
Experimental — accuracy not yet measured
May combine two claims.
PremisecitationBreathlessness services providing predominantly non-pharmacological approaches are effective, cost-effective, and improve distress from breathlessness, mastery, quality of life, and survival.
“Such services provide a brief, cost-effective intervention that impacts positively on distress from breathlessness, mastery, quality of life, and even survival.”
Quote in the paperSubstantial claim3 of 3 sources checked- cites [25] Farquhar, M., Prevost, A., McCrone, P., Brafman-Price, B., Bentley, A. & Higginson, I. et al. Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial. BMC Med. 12, 194 (2014). source
The Results and Discussion report that the Breathlessness Intervention Service reduced distress due to breathlessness and was likely cost-effective on that outcome; participants also described greater confidence in managing breathlessness. But the Results found no significant improvement in measured mastery or quality-of-life domains, and the copy provides no evidence of improved survival (searched: survival). (LLM, conf=0.90)
Experimental — accuracy not yet measured - cites [26] Higginson, I., Bausewein, C., Reilly, C., Gao, W., Gysels, M. & Dzingina, M. et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. Lancet Respir. Med. 2, 979–987 (2014). source
The Summary (p. 2) reports improved breathlessness mastery and better survival in the service group, while cautioning that the survival finding needs further investigation. The Results (pp. 6–7) report no significant between-group differences in other patient-reported outcomes, including quality of life, and no significant difference in formal care costs. The paper therefore supports mastery and an exploratory survival finding, but does not establish improved breathlessness distress or quality of life relative to usual care, or demonstrate cost-effectiveness. (LLM, conf=0.88)
Experimental — accuracy not yet measured - cites [27] Johnson, M., Kanaan, M., Richardson, G., Nabb, S., Torgerson, D. & English, A. et al. A randomised controlled trial of three or one breathing technique training sessions for breathlessness in people with malignant lung disease. BMC Med. 13, 213 (2015). source
The Background and Discussion report benefits from non-pharmacological breathlessness interventions, including improvements in distress and mastery. The Results find a single breathing-training session likely cost-effective compared with three sessions, not compared with no service. The paper does not show that a breathlessness service improves survival; its Discussion attributes improved survival to a separate early-palliative-care trial. (LLM, conf=0.88)
Experimental — accuracy not yet measured
May combine two claims.
PremisecitationApproaches incorporating cognitive behavioural therapy ameliorate breathlessness, anxiety and depression.
“Approaches incorporating cognitive behavioural therapy ameliorate breathlessness, as well as anxiety and depression.”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [21] Howard, C. & Dupont, S. The COPD breathlessness manual’: a randomised controlled trial to test a cognitive-behavioural manual versus information booklets on health service use, mood and health status, in patients with chronic obstructive pulmonary disease. Prim. Care Respir. Med. 24, 14076. doi:14010.11038/npjpcrm.12014.14076 (2014). source
Probably not a substantial claim: may not pass S3 (load-bearing).
PremisecitationBreathing pattern disorders occur in about a third of asthma patients.
“Breathing pattern disorders occur in about a third of asthma patients”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [31] Thomas, M., McKinley, R., Freeman, E. & Foy, C. Prevalence of dysfunctional breathing in patients treated for asthma in primary care: cross sectional survey. Br. Med. J. 2001, 1098–1100 (2001). source
The Additional information section reports that 29% of adults treated for asthma in primary care had symptoms suggestive of dysfunctional breathing. That supports the approximate proportion, but the study screened adults in one practice; it did not establish that breathing pattern disorders occur in a third of asthma patients generally. (LLM, conf=0.85)
Experimental — accuracy not yet measured
May combine two claims.
PremisecitationInactivity leads to muscle deconditioning, with reduced oxidative capacity, muscle fibre atrophy and fibre type shift from type 1 to type IIb fibres.
“However, inactivity leads to muscle deconditioning, with reduced oxidative capacity, muscle fibre atrophy and fibre type shift from type 1 (oxidative) to type IIb (glycolytic) fibres.”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [35] Kim, H., Mofarrahi, M. & Hussain, S. Skeletal muscle dysfunction in patients with chronic obstructive pulmonary disease. Int. J. Chron. Obstruct. Pulmon. Dis. 3, 637–658 (2008). source
The Inactivity section says physical inactivity causes deconditioning, reduced oxidative capacity, fiber atrophy, and a lower proportion of type I fibers. The Fiber type shift section reports increased type IIb fibers in patients with severe COPD, but does not establish that inactivity alone causes that specific shift; the Inactivity section cautions that inactivity does not fully explain muscle dysfunction in COPD. Page numbers were not available in our copy. (LLM, conf=0.85)
Experimental — accuracy not yet measured
May combine two claims.
PremisecitationPulmonary rehabilitation leads to clinically significant reduction in breathlessness, as well as improvements in fatigue, emotional functioning and quality of life.
“There is strong evidence, for example, that pulmonary rehabilitation, involving exercise, education and support over many weeks, leads to clinically significant reduction in breathlessness, as well as substantial improvements in fatigue, emotional functioning and quality of life.”
Quote in the paperSubstantial claim1 of 1 sources checked- cites [24] McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E. & Lacasse, Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst. Rev. 23, CD003793 (2015). source
May combine two claims.
Study design and conductcitationThe BTF model was developed by the Cambridge Breathlessness Intervention Service (CBIS), a multidisciplinary home-based intervention of proven cost-effectiveness.
“This empirical model was developed by the Cambridge Breathlessness Intervention Service (CBIS), a multidisciplinary home-based intervention of proven cost-effectiveness.”
Quote in the paperNot a substantial claim1 of 1 sources checked- cites [25] Farquhar, M., Prevost, A., McCrone, P., Brafman-Price, B., Bentley, A. & Higginson, I. et al. Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial. BMC Med. 12, 194 (2014). source
Box 1 and the Methods describe BIS as a multidisciplinary intervention delivered predominantly in patients’ homes. The Conclusions say BIS appears cost-effective compared with standard care for patients with breathlessness in advanced cancer, but the paper does not identify a BTF model or say that CBIS developed it. “Proven cost-effectiveness” also states the finding more strongly and broadly than the paper does. (LLM, conf=0.86)
Experimental — accuracy not yet measured
May combine two claims.
PremisecitationNeural integration of breathlessness occurs in cortico-limbic regions of the brain, which are influenced by thoughts and emotions, further modulating breathlessness perception.
“Neural integration occurs in cortico-limbic regions of the brain, which are influenced by thoughts and emotions, further modulating breathlessness perception.”
Quote in the paperSubstantial claim0 of 2 sources checked- cites [11] Evans, K., Banzett, R., Adams, L., McKay, L., Frackowiak, R. & Corfield, D. Bold fMRI indentifies limbic, paralimbic, and cerebellar activation during air hunger. J. Neurophysiol. 88, 1500–1511 (2002). source
- cites [15] Schon, D., Rosenkranz, M., Regelsberger, J., Dahme, B., Buchel, C. & von Leupoldt, A. Reduced perception of dyspnoea and pain after right insular cortex lesion. Am. J. Respir. Crit. Care Med. 178, 1173–1179 (2008). source
Probably not a substantial claim: may not pass S2 (checkable). May combine two claims.
InterpretationreasoningThe BTF model has the potential to fulfil the need for a brief intervention and may be particularly relevant in community settings.
“The BTF model has the potential to fulfil all these needs, and may be particularly relevant in community settings.”
Quote in the paperNot a substantial claim- Rests on an assumption: Time-pressured clinical settings require a brief intervention that targets the specific mechanisms driving an individual's symptoms.
Classified as probably not a substantial claim. May combine two claims.
InterpretationreasoningThe BTF model not only explains how breathlessness perpetuates and worsens, but also provides a structure and rationale for its management through generating 'cycles of improvement'.
“We propose that the BTF model not only explains how breathlessness perpetuates and worsens, but also provides a structure and rationale for its management—through generating the antithesis of vicious cycles, ‘cycles of improvement’—thereby engaging patients and professionals alike.”
Quote in the paperSubstantial claim- Rests on an assumption: Time-pressured clinical settings require a brief intervention that targets the specific mechanisms driving an individual's symptoms.
May combine two claims.
Study design and conductcitationEach of the three BTF domains is supported by research evidence, and the model is theoretically underpinned by a 'vicious flower' maintenance model formulation.
“Each of the three domains is supported by research evidence, as described above, and the model is theoretically underpinned by a ‘vicious flower’ maintenance model formulation, widely used in cognitive–behavioural therapy within psychological medicine.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [36] Moorey, S. The six cycles maintenance model: growing a ‘vicious flower’ for depression. Behav Cogn Psychol. 38, 173–184 (2010). source
May combine two claims.
PremisecitationApical breathing causes reliance on fatiguable accessory muscles, underutilising the diaphragm, further increasing work of breathing and intensifying breathlessness.
“Apical breathing causes reliance on fatiguable accessory muscles of respiration, underutilising the efficient and relatively fatigue-resistant diaphragmatic muscle, further increasing the work of breathing and intensifying breathlessness.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [32] Dempsey, J., Romer, L., Rodman, J., Miller, J. & Smith, C. Consequences of exercise-induced respiratory muscle work. Resp. Phys. Neurobiol. 151, 242–250 (2006). source
May combine two claims.
InterpretationreasoningDeconditioning increases demand on the respiratory system and worsens breathlessness further.
“This increases the demand on the respiratory system, and worsens breathlessness further.”
Quote in the paperSubstantial claimMay combine two claims.
PremisecitationThe 'small changes approach' is an effective and feasible way of achieving behavioural change and can generate rapid and large gains.
“The ‘small changes approach’, accepted as a particularly effective and feasible way of achieving behavioural change, develops the potential to generate rapid and large gains.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [39] Hill, J., Wyatt, H., Reed, G. & Peters, J. Obesity and the environment: where do we go from here? Science 299, 835–855 (2003). source
May combine two claims.
PremisecitationFeatures of dysfunctional breathing include apical breathing, higher ratio of inspiratory to expiratory length, absence of end-expiratory pause and frequent sighs or yawns.
“Features include apical breathing, higher ratio of inspiratory to expiratory length, absence of end-expiratory pause and frequent sighs or yawns.”
Quote in the paperSubstantial claim0 of 1 sources checked- cites [30] Chaitow L., Bardley D., Gilbert C. Multidisciplinary approaches to breathing pattern disorders. (Churchill Livingstone, London, 2002).
Couldn’t be matched to a paper in Crossref, so it can’t be checked.
May combine two claims.
InterpretationreasoningAttempting to avoid the perception of breathlessness by reducing activity leads to deconditioning that, in turn, worsens breathlessness.
“For example, attempting to avoid the perception of breathlessness by reducing activity, leads to deconditioning that, in turn, worsens breathlessness.”
Quote in the paperSubstantial claimProbably not a substantial claim: may not pass S4 (based).
InterpretationreasoningThe wide array of potentially effective non-pharmacological interventions for breathlessness fit neatly within the three domains of the BTF model.
“The wide array of potentially effective non-pharmacological interventions for breathlessness fit neatly within the three domains of the clinical model (Table 2).”
Quote in the paperNot a substantial claim- Rests on an assumption: Clinical experience shows that although all three vicious cycles occur to a degree in each breathless patient, one or two tend to predominate.
- Rests on an assumption: Focusing on interventions that impact the predominant cycle can increase adherence and provide early 'quick wins' that contribute to patient engagement and self-efficacy.
- Rests on an assumption: Compassionately challenging misconceptions driving a predominant vicious cycle can be highly effective and time-efficient.
The paper relies on this without support.
Interoceptive awareness of an acute homoeostatic threat leads to avoidance behaviour motivated by emotion, which confers a survival advantage.
“Interoceptive awareness of an acute homoeostatic threat leads to an avoidance behaviour motivated by emotion, which, in evolutionary terms, clearly confers a survival advantage.”
The paper relies on this without support.
Anxiety increases respiratory rate and can cause muscle tension in the ventilatory pump and other skeletal muscles, further increasing work of breathing and respiratory demand.
“In addition, anxiety increases the respiratory rate and can cause muscle tension in both the ventilatory pump and other skeletal muscles, so further increasing the work of breathing and respiratory demand.”
The paper relies on this without support.
There is extensive anecdotal evidence that dysfunctional breathing patterns occur in respiratory conditions such as COPD.
“although there has been no research in other respiratory conditions, such as COPD, there is extensive anecdotal evidence that dysfunctional breathing patterns do occur.”
The paper relies on this without support.
Patients intuitively understand the 'deconditioning vicious cycle'.
“Patients intuitively understand this ‘deconditioning vicious cycle’, being aware that less ‘fit’ people are more breathless on exertion.”
The paper relies on this without support.
Family members and other carers can unwittingly compound the situation by doing activities that the patient might otherwise have done.
“Family members and other carers can unwittingly compound the situation, by trying to help through doing activities that the patient might otherwise have done.”
The paper relies on this without support.
Non-pharmacological interventions are under-utilised because patients need commitment to make and sustain behaviour change.
“Non-pharmacological interventions are under-utilised, not least because patients need commitment to make and sustain behaviour change.”
The paper relies on this without support.
Providing a clear and logical rationale for symptom deterioration or perpetuation beyond an initial trigger can be profoundly motivating.
“Providing a clear and logical rationale for symptom deterioration, or perpetuation beyond an initial trigger, can be profoundly motivating.”
The paper relies on this without support.
Clinical experience shows that although all three vicious cycles occur to a degree in each breathless patient, one or two tend to predominate.
“Clinical experience shows that, although all three vicious cycles occur to a degree in each breathless patient, in practice, one or two tend to predominate.”
The paper relies on this without support.
Focusing on interventions that impact the predominant cycle can increase adherence and provide early 'quick wins' that contribute to patient engagement and self-efficacy.
“Focusing on those interventions which impact on the predominant cycle can increase adherence and, importantly, provide early ‘quick wins’ that further contribute to patient engagement and self-efficacy.”
The paper relies on this without support.
Compassionately challenging misconceptions driving a predominant vicious cycle can be highly effective and time-efficient.
“Simply, for example, compassionately challenging one of the misconceptions driving a predominant vicious cycle (Fig. 2) can, in itself, be highly effective and time-efficient in a busy healthcare setting.”
The paper relies on this without support.
Time-pressured clinical settings require a brief intervention that targets the specific mechanisms driving an individual's symptoms.
“Time-pressured clinical settings require a brief intervention that targets the specific mechanisms driving an individual’s symptoms.”
The paper relies on this without support.
Clinical training prioritises disease-modification over symptom control and doctors are rarely taught how to support behaviour change.
“Clinical training prioritises disease-modification over symptom control and, unlike allied health professionals, doctors are rarely taught how to support behaviour change.”
The paper relies on this without support.
Providing a rationale for why breathlessness should be amenable to intervention can be helpful for clinicians.
“Providing a rationale, not just for the presence of the symptom, but also for why it should be amenable to intervention, can be helpful for clinicians too.”
Self-check
Percentages, sums and reported differences re-computed from the paper’s own numbers.
Each contradiction between two passages listed here was confirmed by an independent check.
Table 1 misidentifies reference 44 as a 2008 cancer review
MinorTable 1 groups reference 44 under a 2008 review of oxygen for cancer patients, but the reference list identifies it as a 2011 review concerning COPD.
“Uronis et al. 200816, 44 | Systematic review and meta-analysis of five studies evaluating oxygen for dyspnoea in mildly- or non-hypoxaemic cancer patients”
“44. Uronis H McCrory D Samsa G Currow D Abernethy A Symptomatic oxygen for non-hypoxaemic chronic obstructive pulmonary disease Cochrane Database Syst. Rev. 2011 6 CD006429 21678356”
Cited works that were retracted
Works this paper cites that were later retracted, from the retraction notices publishers deposit. Major when the notice came out before this paper was published.
Cites a retracted work: 10.1002/14651858.cd005623.pub2
MajorThe cited work was retracted on 2013-11-22 (notice 10.1002/14651858.cd005623.pub3), before this paper was published (2017-04-21). Its authors could have known.
Cited work 10.1002/14651858.cd005623.pub2 · retracted 2013-11-22 · notice 10.1002/14651858.cd005623.pub3 · this paper published 2017-04-21
“Bausewein C Booth S Gysels M Higginson I Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases Cochrane Database Syst. Rev. 2008 2 CD005623 18425927”
Cites a retracted work: 10.1002/14651858.cd005623.pub3
InfoThe cited work was retracted; the date of the notice is not on record.
Cited work 10.1002/14651858.cd005623.pub3 · retraction date not known · this paper published 2017-04-21
Cites
2 retracted
Bausewein, C., Booth, S., Gysels, M., & Higginson, I. J. (2013) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd005623.pub3 · Cited by 287 · see citing works
Self-citationRetractedBausewein, C., Booth, S., Gysels, M., & Higginson, I. J. (2008) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd005623.pub2 · Cited by 210 · see citing works
Self-citationRetracted‘Small Changes' to Diet and Physical Activity Behaviors for Weight Management
Hills, A. P., Byrne, N. M., Lindstrom, R. C., & Hill, J. O. (2013) · Obesity Facts · doi:10.1159/000345030 · Cited by 9,526 · see citing works
Pulmonary rehabilitation for chronic obstructive pulmonary disease
McCarthy, B., Casey, D., Devane, D., Murphy, K., Murphy, E., & Lacasse, Y. (2015) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd003793.pub3 · Cited by 2,643 · see citing works
Obesity and the Environment: Where Do We Go from Here?
Hill, J. O., Wyatt, H. R., Reed, G. W., & Peters, J. C. (2003) · Science · doi:10.1126/science.1079857 · Cited by 2,180 · cited 1× · see citing works
“The ‘small changes approach’, accepted as a particularly effective and feasible way of achieving behavioural change, develops the potential to generate rapid and large gains.(39) Enhancing selfefficacy is a particularly effective way to support selfmanagement.”
BackgroundCharacterisation of COPD heterogeneity in the ECLIPSE cohort
the Evaluation of COPD Longitudinally to Identify Predictive Surrogate Endpoints (ECLIPSE) investigators, Agusti, A., Calverley, P. M., Celli, B., Coxson, H. O., Edwards, L. D., Lomas, D. A., MacNee, W., Miller, B. E., Rennard, S., et al. (2010) · Respiratory Research · doi:10.1186/1465-9921-11-122 · Cited by 1,157 · see citing works
Higginson, I. J., Bausewein, C., Reilly, C. C., Gao, W., Gysels, M., Dzingina, M., McCrone, P., Booth, S., Jolley, C. J., & Moxham, J. (2014) · The Lancet Respiratory Medicine · doi:10.1016/s2213-2600(14)70226-7 · Cited by 605 · see citing works
Self-citationSelf management for patients with chronic obstructive pulmonary disease
Zwerink, M., Brusse-Keizer, M., van der Valk, P. D., Zielhuis, G. A., Monninkhof, E. M., van der Palen, J., Frith, P. A., & Effing, T. (2014) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd002990.pub3 · Cited by 572 · see citing works
Abernethy, A. P., Currow, D. C., Frith, P., Fazekas, B. S., McHugh, A., & Bui, C. (2003) · BMJ · doi:10.1136/bmj.327.7414.523 · Cited by 521 · see citing works
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Consequences of exercise-induced respiratory muscle work
Dempsey, J. A., Romer, L., Rodman, J., Miller, J., & Smith, C. (2006) · Respiratory Physiology & Neurobiology · doi:10.1016/j.resp.2005.12.015 · Cited by 398 · see citing works
BOLD fMRI Identifies Limbic, Paralimbic, and Cerebellar Activation During Air Hunger
Evans, K. C., Banzett, R. B., Adams, L., McKay, L., Frackowiak, R. S. J., & Corfield, D. R. (2002) · Journal of Neurophysiology · doi:10.1152/jn.2002.88.3.1500 · Cited by 391 · see citing works
Simon, S. T., Higginson, I. J., Booth, S., Harding, R., Weingärtner, V., & Bausewein, C. (2016) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd007354.pub3 · Cited by 367 · cited 1× · see citing works
“17 Benzodiazepines are widely used, but do not improve breathlessness.(18) Even opioids, with most evidence to support their use, provide benefit of only borderline clinical significance.”
BackgroundSelf-citationDavey, C., Zoumot, Z., Jordan, S. J., McNulty, W. H., Carr, D., Hind, M. D., Hansell, D. M., Rubens, M. B., BANYA, W. A. S., Polkey, M. I., et al. (2015) · The Lancet · doi:10.1016/s0140-6736(15)60001-0 · Cited by 363 · see citing works
Breathlessness in humans activates insular cortex
Banzett, R. B., Mulnier, H. E., Murphy, K., Rosen, S. D., S. Wise, R. J., & Adams, L. (2000) · NeuroReport · doi:10.1097/00001756-200007140-00012 · Cited by 350 · see citing works
Bredin, M., Corner, J. L., Krishnasamy, M., Plant, H., Bailey, C., & A’Hern, R. (1999) · BMJ · doi:10.1136/bmj.318.7188.901 · Cited by 322 · see citing works
The Pathophysiology of Hyperventilation Disorders
Gardner, W. N. (1996) · Chest · doi:10.1378/chest.109.2.516 · Cited by 312 · cited 1× · see citing works
“Dysfunctional breathing patterns are well recognised in breathless individuals without underlying respiratory pathology.(29) Features include apical breathing, higher ratio of inspiratory to expiratory length, absence of end-expiratory pause and frequent sighs or yawns.”
BackgroundThe Unpleasantness of Perceived Dyspnea Is Processed in the Anterior Insula and Amygdala
von Leupoldt, A., Sommer, T., Kegat, S., Baumann, H. J., Klose, H., Dahme, B., & Büchel, C. (2008) · American Journal of Respiratory and Critical Care Medicine · doi:10.1164/rccm.200712-1821oc · Cited by 302 · cited 1× · see citing works
“The neural processing for this feedback loop is likely to occur in the cortico-limbic areas of the brain, involved in both breathlessness perception and processing of emotion.(34) In addition, anxiety increases the respiratory rate and can cause muscle tension in both the ventilatory pump and other skeletal muscles, s…”
BackgroundThomas, M., McKinley, R. K., Freeman, E., & Foy, C. (2001) · BMJ · doi:10.1136/bmj.322.7294.1098 · Cited by 294 · see citing works
Barnes, H., McDonald, J., Smallwood, N., & Manser, R. (2016) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd011008.pub2 · Cited by 280 · see citing works
Booth, S., Silvester, S., & Todd, C. J. (2003) · Palliative & Supportive Care · doi:10.1017/s1478951503030499 · Cited by 227 · cited 1× · see citing works
“5 Carers also suffer significantly, burdened by distress, social isolation and a devastating sense of helplessness.(6) The management of breathlessness is hampered by its inherent complexity.”
BackgroundSelf-citationBucknall, C. E., Miller, G., Lloyd, S. M., Cleland, J., McCluskey, S., Cotton, M., Stevenson, R. D., Cotton, P., & McConnachie, A. (2012) · BMJ · doi:10.1136/bmj.e1060 · Cited by 226 · see citing works
Skeletal muscle dysfunction in patients with chronic obstructive pulmonary disease
Hussain, S., Cheol, K., & Mofarrahi, M. (2008) · International Journal of Chronic Obstructive Pulmonary Disease · doi:10.2147/copd.s4480 · Cited by 224 · cited 1× · see citing works
“However, inactivity leads to muscle deconditioning, with reduced oxidative capacity, muscle fibre atrophy and fibre type shift from type 1 (oxidative) to type IIb (glycolytic) fibres.(35) This increases the demand on the respiratory system, and worsens breathlessness further.”
BackgroundEffect of Patient Activation on Self-Management in Patients With Heart Failure
Shively, M. J., Gardetto, N. J., Kodiath, M. F., Kelly, A., Smith, T. L., Stepnowsky, C., Maynard, C., & Larson, C. B. (2013) · Journal of Cardiovascular Nursing · doi:10.1097/jcn.0b013e318239f9f9 · Cited by 203 · see citing works
Farquhar, M. C., Prevost, A. T., McCrone, P., Brafman-Price, B., Bentley, A., Higginson, I. J., Todd, C., & Booth, S. (2014) · BMC Medicine · doi:10.1186/s12916-014-0194-2 · Cited by 201 · cited 1× · see citing works
“This empirical model was developed by the Cambridge Breathlessness Intervention Service (CBIS), a multidisciplinary homebased intervention of proven cost-effectiveness.(25) Each of the three domains is supported by research evidence, as described above, and the model is theoretically underpinned by a ‘vicious flower’…”
MethodSelf-citationPATIENT INFORMATION RECALL IN A RHEUMATOLOGY CLINIC
ANDERSON, J. L., DODMAN, S., KOPELMAN, M., & FLEMING, A. (1979) · Rheumatology · doi:10.1093/rheumatology/18.1.18 · Cited by 167 · cited 1× · see citing works
“The more information presented in a consultation, the lower the proportion that is correctly recalled.(42) The wide array of potentially effective non-pharmacological interventions for breathlessness fit neatly within the three domains of the clinical model (Table 2).”
BackgroundTanaka, K., Akechi, T., Okuyama, T., Nishiwaki, Y., & Uchitomi, Y. (2002) · Journal of Pain and Symptom Management · doi:10.1016/s0885-3924(02)00376-7 · Cited by 166 · cited 1× · see citing works
“2 It is a debilitating symptom, with a negative impact on quality of life, psychological wellbeing and functional status.(3) Multiple observational studies link breathlessness with anxiety and depression.”
BackgroundUronis, H. E., Currow, D. C., McCrory, D. C., Samsa, G. P., & Abernethy, A. P. (2008) · British Journal of Cancer · doi:10.1038/sj.bjc.6604161 · Cited by 165 · see citing works
Predictors of dyspnoea prevalence: results from the BOLD study
Grønseth, R., Vollmer, W. M., Hardie, J. A., Ólafsdóttir, I. S., Lamprecht, B., Buist, A. S., Gnatiuc, L., Gulsvik, A., Johannessen, A., & Enright, P. (2014) · European Respiratory Journal · doi:10.1183/09031936.00036813 · Cited by 148 · see citing works
Müllerová, H., Lu, C., Li, H., & Tabberer, M. (2014) · PLoS ONE · doi:10.1371/journal.pone.0085540 · Cited by 139 · cited 1× · see citing works
“8 An observational study of almost 50,000 patients with COPD in the UK revealed that a third of those with stage 1 disease described moderate to severe breathlessness, whereas over 20% of those with stage 4 disease did not have clinically significant breathlessness.(2) In a recent controlled trial, bronchoscopic lung…”
BackgroundDyspnoea and quality of life in older people at home
Ho, S. F. (2001) · Age and Ageing · doi:10.1093/ageing/30.2.155 · Cited by 137 · see citing works
Simon, S. T., Higginson, I. J., Booth, S., Harding, R., & Bausewein, C. (2010) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd007354.pub2 · Cited by 129 · see citing works
Self-citationPanic Attacks and Perception of Inspiratory Resistive Loads in Chronic Obstructive Pulmonary Disease
Livermore, N., Butler, J. E., Sharpe, L., McBain, R. A., Gandevia, S. C., & McKenzie, D. K. (2008) · American Journal of Respiratory and Critical Care Medicine · doi:10.1164/rccm.200711-1700oc · Cited by 113 · cited 1× · see citing works
“It is well-recognised that the anxiety or fear caused by breathlessness can, in turn, augment the perception of breathlessness.(33) This vicious cycle can lead to a rapidly escalating sense of panic, which most breathless patients experience at some point.”
BackgroundEkström, M., Ahmadi, Z., Bornefalk-Hermansson, A., Abernethy, A., & Currow, D. (2016) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd006429.pub3 · Cited by 98 · see citing works
Reduced Perception of Dyspnea and Pain after Right Insular Cortex Lesions
Schön, D., Rosenkranz, M., Regelsberger, J., Dahme, B., Büchel, C., & von Leupoldt, A. (2008) · American Journal of Respiratory and Critical Care Medicine · doi:10.1164/rccm.200805-731oc · Cited by 91 · see citing works
Chavannes, N., Huibers, M., Schermer, T., Hendriks, A., van Weel, C., Wouters, E., & van Schayck, C. (2005) · Family Practice · doi:10.1093/fampra/cmi056 · Cited by 91 · see citing works
Multidisciplinary Approaches to Breathing Pattern Disorders
(2002) · Elsevier eBooks · doi:10.1016/b978-0-443-07053-2.x5001-1 · Cited by 82 · cited 1× · see citing works
“Features include apical breathing, higher ratio of inspiratory to expiratory length, absence of end-expiratory pause and frequent sighs or yawns.(30) Breathing pattern disorders occur in about a third of asthma patients,(31) and although there has been no research in other respiratory conditions, such as COPD, there i…”
BackgroundSchwartzstein, R. M., Manning, H. L., Weiss, J. W., & Weinberger, S. E. (1990) · Lung · doi:10.1007/bf02719692 · Cited by 80 · see citing works
Theander, K., Unosson, M., Karlsson, I., Eckerblad, J., Luhr, K., & Hasselgren, M. (2014) · International Journal of Chronic Obstructive Pulmonary Disease · doi:10.2147/copd.s62563 · Cited by 68 · see citing works
Johnson, M. J., Kanaan, M., Richardson, G., Nabb, S., Torgerson, D., English, A., Barton, R., & Booth, S. (2015) · BMC Medicine · doi:10.1186/s12916-015-0453-x · Cited by 68 · see citing works
Self-citationThe Six Cycles Maintenance Model: Growing a “Vicious Flower” for Depression
Moorey, S. (2010) · Behavioural and Cognitive Psychotherapy · doi:10.1017/s1352465809990580 · Cited by 67 · cited 1× · see citing works
“Each of the three domains is supported by research evidence, as described above, and the model is theoretically underpinned by a ‘vicious flower’ maintenance model formulation, widely used in cognitive–behavioural therapy within psychological medicine.(36) It was initially conceived in 2012 for use as an educational t…”
MethodSymptomatic oxygen for non-hypoxaemic chronic obstructive pulmonary disease
Uronis, H. E., McCrory, D. C., Samsa, G. P., Currow, D. C., & Abernethy, A. P. (2011) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd006429.pub2 · Cited by 64 · see citing works
Fatigue in COPD: Prevalence and effect on outcomes in pulmonary rehabilitation
Baltzan, M. A., Scott, A. S., Wolkove, N., Bailes, S., Bernard, S., Bourbeau, J., Maltais, F., & Canadian COPD Pulmonary Rehabilitation Research Group (2011) · Chronic Respiratory Disease · doi:10.1177/1479972310396737 · Cited by 61 · cited 1× · see citing works
“Patients with intractable breathlessness are commonly fatigued, which limits the capacity to retain and process new information.(41) The more information presented in a consultation, the lower the proportion that is correctly recalled.”
BackgroundHoward, C., & Dupont, S. (2014) · npj Primary Care Respiratory Medicine · doi:10.1038/npjpcrm.2014.76 · Cited by 50 · cited 1× · see citing works
“Approaches incorporating cognitive behavioural therapy ameliorate breathlessness, as well as anxiety and depression.(21) Evidence is emerging for the effectiveness of breathlessness services, providing a range of predominantly non-pharmacological approaches, such as breathing and relaxation techniques, use of a handhe…”
BackgroundLongitudinal Changes in Patient-reported Dyspnea in Patients with COPD
Mahler, D. A., Ward, J., Waterman, L. A., & Baird, J. C. (2012) · COPD: Journal of Chronic Obstructive Pulmonary Disease · doi:10.3109/15412555.2012.701678 · Cited by 27 · see citing works
Effect of induced leg muscle fatigue on exertional dyspnea in healthy subjects
Sharma, P. K., Morris, N. R., & Adams, L. (2014) · Journal of Applied Physiology · doi:10.1152/japplphysiol.00393.2014 · Cited by 19 · cited 1× · see citing works
“11 Demand for ventilation, sensed by chemo-receptors and metabo-receptors, is compared with afferent information on actual ventilation from widespread sources, including pulmonary stretch receptions, pulmonary C fibres, chest wall joint and skin receptors, and skeletal muscle ergoreceptors.(12) Breathlessness percepti…”
BackgroundLove, Honor, and Protect (Your Liver)
Davidson, A., & Zon, L. (2003) · Science · doi:10.1126/science.1082006 · Cited by 16 · see citing works
Zoumot, Z., Davey, C., Jordan, S., McNulty, W. H., Carr, D. H., Hind, M. D., Hansell, D. M., Rubens, M. B., Banya, W., Polkey, M. I., et al. (2015) · Efficacy and Mechanism Evaluation · doi:10.3310/eme02050 · Cited by 10 · cited 1× · see citing works
“In a recent controlled trial, bronchoscopic lung volume reduction significantly improved FEV1 by 25%, without relief of breathlessness.(9) The inconsistent relationship between pathology and breathlessness perception explains why optimising disease management alone does not guarantee good symptom control.”
Background
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The therapy of idiopathic pulmonary fibrosis: what is next?
Somogyi, V., Chaudhuri, N., Torrisi, S. E., Kahn, N. C., Müller, V., & Kreuter, M. (2019) · European Respiratory Review · doi:10.1183/16000617.0021-2019 · Cited by 266 · see citing works
Maddocks, M. M., Lovell, N., Booth, S., Man, W. D., & Higginson, I. J. (2017) · The Lancet · doi:10.1016/s0140-6736(17)32127-x · Cited by 225 · see citing works
“The following may have value for the mobile patient: increasing physical activity by means of activity pacing, mobility aids, and an individual exercise plan; use of the hand held fan or cold water spray to palliate the sensation of breathlessness;(57) breathing retraining;(58) and support for carers including educati…”
Self-citationSingh, S. J., Baldwin, M. M., Daynes, E., Evans, R. A., Greening, N. J., Jenkins, G. R., Lone, N., McAuley, H. J. C., Mehta, P., Newman, J. V., et al. (2023) · The Lancet Respiratory Medicine · doi:10.1016/s2213-2600(23)00159-5 · Cited by 198 · see citing works
Brighton, L. J., Miller, S., Farquhar, M. C., Booth, S., Yi, D., Gao, W., Bajwah, S., Man, W. D., Higginson, I. J., & Maddocks, M. M. (2018) · Thorax · doi:10.1136/thoraxjnl-2018-211589 · Cited by 153 · see citing works
Self-citationLiving with breathlessness: a systematic literature review and qualitative synthesis
Hutchinson, A., Barclay-Klingle, N., Galvin, K., & Johnson, M. J. (2018) · European Respiratory Journal · doi:10.1183/13993003.01477-2017 · Cited by 153 · see citing works
“33 Education and training for clinicians in primary and secondary care in the assessment of Breathing Space and the management of breathlessness, such as that provided around the Breathing, Thinking Functioning model,(142) could improve patients’ access to breathlessness-targeted treatments delivered by the multidisci…”
BackgroundHanania, N. A., & O’Donnell, D. E. (2019) · International Journal of COPD · doi:10.2147/copd.s188141 · Cited by 150 · see citing works
“Self-management interventions enable patients to actively participate in their care, which can help them to achieve better outcomes.(71) Holistic services that encompass multidisciplinary team-supported strategies to help patients engage in self-management, in addition to providing educational and psychological suppor…”
BackgroundManagement of breathlessness in patients with cancer: ESMO Clinical Practice Guidelines
Hui, D., Maddocks, M. M., Johnson, M. J., Ekström, M. P., Simon, S. T., Ogliari, A. C., Booth, S., & Ripamonti, C. I. (2020) · ESMO Open · doi:10.1136/esmoopen-2020-001038 · Cited by 125 · see citing works
Self-citationImproving the quality of life of people with advanced respiratory disease and severe breathlessness
Booth, S., & Johnson, M. J. (2019) · Breathe · doi:10.1183/20734735.0200-2019 · Cited by 79 · see citing works
Self-citationBreathlessness services as a new model of support for patients with respiratory disease
Bausewein, C., Schunk, M. V., Schumacher, P., Dittmer, J., Bolzani, A., & Booth, S. (2017) · Chronic Respiratory Disease · doi:10.1177/1479972317721557 · Cited by 60 · see citing works
“However, there is an inconsistent relationship between pathology and breathlessness perception, explaining why optimizing disease management alone does not guarantee good symptom control.(6) There are a wide range of non-pharmacological interventions with various strengths of evidence.”
BackgroundMethodSelf-citationAddressing Post-COVID Symptoms: A Guide for Primary Care Physicians
Vance, H., Maslach, A., Stoneman, E. K., Harmes, K. M., Ransom, A., Seagly, K., & Furst, W. (2021) · The Journal of the American Board of Family Medicine · doi:10.3122/jabfm.2021.06.210254 · Cited by 49 · see citing works
Nonpharmacological management of psychological distress in people with COPD
Volpato, E., Farver-Vestergaard, I., Brighton, L. J., Peters, J. B., Verkleij, M., Hutchinson, A., Heijmans, M., & von Leupoldt, A. (2023) · European Respiratory Review · doi:10.1183/16000617.0170-2022 · Cited by 53 · see citing works
Reijnders, T., Schüler, M., Wittmann, M., Jelusic, D., Troosters, T., Janssens, W., Stenzel, N., Schultz, K., & von Leupoldt, A. (2018) · Respiratory Medicine · doi:10.1016/j.rmed.2018.12.004 · Cited by 49 · see citing works
Reilly, C. C., Floyd, S. V., Lee, K., Warwick, G., James, S., Gall, N., & Rafferty, G. F. (2020) · Autonomic Neuroscience · doi:10.1016/j.autneu.2019.102601 · Cited by 48 · see citing works
Ferreira, D. H., Kochovska, S., Honson, A., Phillips, J. L., & Currow, D. C. (2020) · BMC Palliative Care · doi:10.1186/s12904-020-00572-7 · Cited by 50 · see citing works
“Chronic breathlessness was described as the product of breathing, thinking and functioning vicious cycles that generate and aggravate the syndrome [24].”
BackgroundInfluentialBreathlessness and COVID-19: A Call for Research
Hentsch, L., Cocetta, S., Allali, G., Santana, I., Eason, R., Adam, E., & Janssens, J.-P. (2021) · Respiration · doi:10.1159/000517400 · Cited by 41 · see citing works
Similowski, T. (2018) · European Respiratory Journal · doi:10.1183/13993003.00316-2018 · Cited by 43 · see citing works
Orme, M. W., Free, R. C., Manise, A., Jones, A., Akylbekov, A., Barton, A., Emilov, B., Girase, B., Jayamaha, A. R., Jones, R. C. M., et al. (2020) · Journal of Global Health · doi:10.7189/jogh.10.020316 · Cited by 39 · see citing works
The Hand-Held Fan and the Calming Hand for People With Chronic Breathlessness: A Feasibility Trial
Swan, F., English, A., Allgar, V. L., Hart, S. P., & Johnson, M. J. (2019) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2019.02.017 · Cited by 34 · see citing works
“(7) A clinical framework of “Breathing”, “Thinking” and “Functioning”, can be used to target interventions which address vicious circles (ineffective ventilation, anxiety, reduced physical activity) that perpetuate the effe cts of breathlessness.(8)”
BackgroundDisability and long-term breathlessness: a cross-sectional, population study
Kochovska, S., Ferreira, D. H., Chang, S., Brunelli, V. N., Morgan, D. D., Similowski, T., Johnson, M. J., Ekström, M. P., & Currow, D. C. (2024) · BMJ Open Respiratory Research · doi:10.1136/bmjresp-2023-002029 · Cited by 28 · see citing works
Luckett, T., Phillips, J. L., Johnson, M. J., Garcia, M., Vandersman, P., Carrieri‐Kohlman, V., Hutchinson, A., Disler, R. T., Currow, D. C., Agar, M. R., et al. (2017) · BMJ Open · doi:10.1136/bmjopen-2017-017536 · Cited by 27 · see citing works
Elliott-Button, H. L., Johnson, M. J., Nwulu, U., & Clark, J. (2019) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2019.10.014 · Cited by 27 · see citing works
Perspectives on palliative oxygen for breathlessness: systematic review and meta-synthesis
Kochovska, S., Ferreira, D. H., Garcia, M., Phillips, J. L., & Currow, D. C. (2021) · European Respiratory Journal · doi:10.1183/13993003.04613-2020 · Cited by 24 · see citing works
The impact of unpredictability on dyspnea perception, anxiety and interoceptive error processing
Tan, Y., Van den Bergh, O., Qiu, J., & von Leupoldt, A. (2019) · Frontiers in Physiology · doi:10.3389/fphys.2019.00535 · Cited by 22 · see citing works
Williams, M., Lewthwaite, H., Brooks, D., Jensen, D., Abdallah, S. J., & Johnston, K. (2019) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2019.10.012 · Cited by 23 · see citing works
Spathis, A., Burkin, J., Moffat, C., Tuffnell, R., Barclay, S. I. G., Mant, J., & Booth, S. (2021) · npj Primary Care Respiratory Medicine · doi:10.1038/s41533-021-00237-9 · Cited by 24 · see citing works
Self-citationNeo, H., Yap, C. W., Teo, L.-M., Lee, L.-T., Tan, H.-W., Xu, H., Hum, A. Y. M., & Abisheganaden, J. A. (2021) · Journal of the American Medical Directors Association · doi:10.1016/j.jamda.2021.05.031 · Cited by 23 · see citing works
Maddocks, M. M., Brighton, L. J., Farquhar, M. C., Booth, S., Miller, S., Klass, L., Tunnard, I., Yi, D., Gao, W., Bajwah, S., et al. (2019) · Health Services and Delivery Research · doi:10.3310/hsdr07220 · Cited by 22 · see citing works
Self-citationLower workforce participation is associated with more severe persisting breathlessness
Clark, J., Chang, S., Kinchin, I., Ferreira, D. H., Kochovska, S., Morgan, D. D., Poulos, L. M., Johnson, M. J., Ekström, M. P., & Currow, D. C. (2022) · BMC Pulmonary Medicine · doi:10.1186/s12890-022-01861-y · Cited by 22 · see citing works
“This is despite the evidence-based non-pharmacological and pharmacological interventions which may reduce symptomatic persisting breathlessness and, potentially, improve function [18].”
BackgroundBreathing difficulties after covid-19: a guide for primary care
Evans, R. A., Pick, A., Lardner, R., Masey, V., Smith, N., & Greenhalgh, T. (2023) · BMJ · doi:10.1136/bmj-2023-074937 · Cited by 22 · see citing works
Affective traits, states, and breathlessness
von Leupoldt, A., & Denutte, Y. (2020) · Current Opinion in Supportive and Palliative Care · doi:10.1097/spc.0000000000000506 · Cited by 22 · see citing works
“Moreover, additional (mediating and moderating) factors are likely involved, which might further vary across patients [9].”
BackgroundAcute-on-Chronic Breathlessness: Recognition and Response
Hutchinson, A., Johnson, M. J., & Currow, D. C. (2019) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2019.01.012 · Cited by 20 · see citing works
Hosey, M. M., Wegener, S. T., Hinkle, C. E., & Needham, D. M. (2021) · Journal of Clinical Medicine · doi:10.3390/jcm10040872 · Cited by 19 · see citing works
“Self-management in acute respiratory failure (SMARF) is a 6-session intervention which was adapted from existing protocols to improve anxiety in acute respiratory failure survivors [19,32,33].”
MethodVarkonyi-Sepp, J., Freeman, A. T., Ainsworth, B., Kadalayil, L., Haitchi, H. M., & Kurukulaaratchy, R. J. (2022) · Journal of Personalized Medicine · doi:10.3390/jpm12091435 · Cited by 19 · see citing works
“It is suggested to be applicable to advanced cardio-respiratory conditions, however it has not been trialled in severe asthma [106].”
BackgroundJohnston, K., Young, M., Kay, D., Booth, S., Spathis, A., & Williams, M. (2020) · BMC Medical Education · doi:10.1186/s12909-020-02006-7 · Cited by 19 · see citing works
“The BTF model has been used as an educative framework for teaching health care clinicians, consumers, and carers about breathlessness genesis and management [14].”
BackgroundMethodInfluentialSelf-citationShould Benzodiazepines be Used for Reducing Dyspnea in Patients with Advanced Illnesses?
Simon, S. T., Mori, M., Ekström, M. P., Pralong, A., Yamaguchi, T., & Hui, D. (2022) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2022.11.018 · Cited by 18 · see citing works
The Role of Illness Perceptions in Dyspnoea-Related Fear in Chronic Obstructive Pulmonary Disease
Hill, K., Hug, S., Smith, A. J., & O’Sullivan, P. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm13010200 · Cited by 19 · see citing works
“Further insight into addressing unhelpful beliefs has been addressed in the Breathing, Thinking, Functioning model developed by the Cambridge Breathlessness Intervention Service [25].”
MethodStandardized measurement of breathlessness during exercise
Lewthwaite, H., Koch, E. M., Tracey, L., & Jensen, D. (2019) · Current Opinion in Supportive and Palliative Care · doi:10.1097/spc.0000000000000443 · Cited by 18 · see citing works
Non-pharmacological Management in Palliative Care for Patients With Advanced COPD
Pyszora, A., & Lewko, A. (2022) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2022.907664 · Cited by 20 · see citing works
“The ‘Breathing, Thinking, Functioning’ model used by the Cambridge Breathlessness Intervention Service (CBIS), has been developed by Spathis and colleagues (21, 22).”
MethodPsychological distress and physical symptoms in advanced cancer: cross-sectional study
Podbury, B., Gurgenci, T., Huggett, G., Greer, R. M., Hardy, J. R., & Good, P. D. (2024) · BMJ Supportive & Palliative Care · doi:10.1136/spcare-2024-004940 · Cited by 17 · see citing works
“14 Anxiety may lead to increased respiratory rate and demand, which can be fatiguing for patients.”
Luckett, T., Roberts, M. M., Smith, T., Garcia, M., Dunn, S., Swan, F., Ferguson, C., Kochovska, S., Phillips, J. L., Pearson, M., et al. (2022) · BMC Pulmonary Medicine · doi:10.1186/s12890-022-01925-z · Cited by 16 · see citing works
Reitzel, T., Bergmann, A., Schloesser, K., Pauli, B., Eisenmann, Y., Randerath, W. J., Tuchscherer, A., Frank, K. F., Simon, S. T., & Pralong, A. (2022) · Annals of Palliative Medicine · doi:10.21037/apm-21-3361 · Cited by 16 · see citing works
Williams, M., Lewthwaite, H., Paquet, C., Cafarella, P., & Frith, P. A. (2023) · Journal of Clinical Medicine · doi:10.3390/jcm12237286 · Cited by 16 · see citing works
“Breathlessness services were evolving [66,67], embedding evidence-based non-pharmacological strategies (i.e., handheld fan, cognitive approaches) and an assessment model founded on cognitive and behavioral reactions to breathlessness (Breathing Thinking Function model) [68,69].”
Palliative Care for People Living With Heart Disease—Does Sex Make a Difference?
Sobański, P., Krajnik, M., & Goodlin, S. J. (2021) · Frontiers in Cardiovascular Medicine · doi:10.3389/fcvm.2021.629752 · Cited by 16 · see citing works
“FIGURE 1 | The breathing, thinking, functioning clinical model (98).”
BackgroundInfluentialGilliam, E. A., Kilgore, K., Liu, Y., Bernier, L., Criscitiello, S., Litrownik, D., Wayne, P. M., Moy, M. L., & Yeh, G. Y. (2021) · Respiratory Medicine · doi:10.1016/j.rmed.2021.106463 · Cited by 15 · see citing works
Lovell, N., Etkind, S. N., Bajwah, S., Maddocks, M. M., & Higginson, I. J. (2019) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2019.06.004 · Cited by 14 · see citing works
Doe, G. E., Williams, M., Chantrell, S., STEINER, M. C., Armstrong, N., Hutchinson, A., & Evans, R. A. (2023) · British Journal of General Practice · doi:10.3399/bjgp.2022.0475 · Cited by 13 · see citing works
“16,22 A symptom-based approach is commonly used with chronic pain, 50 which like breathlessness is a complex symptom with affective and sensory components.”
Hutchinson, A., Galvin, K., & Johnson, M. J. (2020) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2020.03.014 · Cited by 14 · see citing works
Clinical management of COVID-19
World Health Organization (2025) · World Health Organization eBooks · doi:10.2471/b09467 · Cited by 17 · see citing works
Schloesser, K., Bergmann, A., Eisenmann, Y., Pauli, B., Pralong, A., Hellmich, M., Oberste, M., Hamacher, S., Tuchscherer, A., Frank, K. F., et al. (2023) · Annals of Palliative Medicine · doi:10.21037/apm-22-1304 · Cited by 12 · see citing works
Richardson, B. R., Decavèle, M., Demoule, A., Murtagh, F. E., & Johnson, M. J. (2024) · Annals of Intensive Care · doi:10.1186/s13613-024-01338-7 · Cited by 14 · see citing works
“Yet, unlike other symptoms such as pain [7], and despite an evidence-base for breathlessness management in general [8], in the ICU setting [9] breathlessness management is not supported by any guidelines [10].”
BackgroundBarnes-Harris, M., Daniel, S. M., Venkateswaran, C., Hutchinson, A., & Johnson, M. J. (2021) · Indian Journal of Palliative Care · doi:10.4103/ijpc.ijpc_139_20 · Cited by 12 · see citing works
“[13] The clinician’s role appears crucial; those responding to the symptom in their disease management help to maximize the patient’s “Breathing Space” (living well with chronic breathlessness).”
BackgroundCristea, L., Olsson, M., Currow, D. C., Johnson, M. J., Sandberg, J., & Ekström, M. P. (2021) · BMJ Open Respiratory Research · doi:10.1136/bmjresp-2021-000990 · Cited by 12 · see citing works
“ME accepts full responsibility for the work and the conduct of the study, had access to the data, and controlled the decision to publish.”
Decavèle, M., Serresse, L., Gay, F., Nion, N., Lavault, S., Freund, Y., Nierat, M., Steichen, O., Demoule, A., Morélot‐Panzini, C., et al. (2022) · Medical Education Online · doi:10.1080/10872981.2022.2133588 · Cited by 12 · see citing works
“Indeed, existing dyspneaoriented teaching instruments and courses (like the educational dimension of the ‘Breathing, Thinking, Functioning’ clinical model [28,29]; see also [30,31]) can change participants’ previous beliefs and attitudes, but they do not involve experiential aspects.”
BackgroundHutchinson, A., Allgar, V. L., Cohen, J., Currow, D. C., Griffin, S. C., Hart, S. P., Hird, K., Hodge, A., Mason, S. M., Northgraves, M. J., et al. (2022) · ERJ Open Research · doi:10.1183/23120541.00257-2022 · Cited by 11 · see citing works
“Non-pharmacological interventions can be effective [6] and include breathing retraining, anxiety management, activity pacing [7] and cool facial airflow [8].”
Broese, J. M., van der Kleij, R., Verschuur, E. M. L., Kerstjens, H. A. M., Bronkhorst, E. M., Engels, Y., & Chavannes, N. H. (2023) · Palliative Medicine · doi:10.1177/02692163231165106 · Cited by 11 · see citing works
Episodic Breathlessness in Patients with Advanced Cancer: Characteristics and Management
Mercadante, S. (2018) · Drugs · doi:10.1007/s40265-018-0879-5 · Cited by 11 · see citing works
“Several papers and reviews have assessed the many aspects of persistent dyspnea in chronic respiratory disease, including assessment and treatment, both pharmacological and non-pharmacological [13, 14].”
BackgroundExploring the Experience of Breathlessness with the Common-Sense Model of Self-Regulation (CSM)
Johnston, K., Burgess, R., Kochovska, S., & Williams, M. (2023) · Healthcare · doi:10.3390/healthcare11121686 · Cited by 12 · see citing works
“, breathlessness means I am getting worse or damaging my body) about the symptom [55].”
BackgroundMüller, A., Wouters, E. F. �., Burney, P., Potts, J., Cardoso, J., Ghobain, M. A., Studnicka, M., Obaseki, D., Elsony, A., Mortimer, K. J., et al. (2025) · Pulmonology · doi:10.1080/25310429.2025.2470566 · Cited by 10 · see citing works
“38 This clinical model comprises respiratory interventions (e.g., handheld fan, breathing techniques, respiratory muscle training) alongside psychological support (e.g., relaxation techniques, cognitive behavioural therapy) and active rehabilitation and can be used to develop and guide integrated…”
Integrated breathlessness services for people with chronic conditions
Bausewein, C., Schumacher, P., & Bolzani, A. (2018) · Current Opinion in Supportive and Palliative Care · doi:10.1097/spc.0000000000000361 · Cited by 10 · see citing works
Howell, D. (2021) · Lung Cancer Management · doi:10.2217/lmt-2020-0017 · Cited by 12 · see citing works
Patient perspectives on how to optimise benefits from a breathlessness service for people with COPD
Luckett, T., Roberts, M. M., Smith, T., Swami, V., Cho, J., & Wheatley, J. R. (2020) · npj Primary Care Respiratory Medicine · doi:10.1038/s41533-020-0172-4 · Cited by 10 · see citing works
Schloesser, K., Eisenmann, Y., Bergmann, A., & Simon, S. T. (2020) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2020.09.034 · Cited by 10 · see citing works
Schloesser, K., Bergmann, A., Eisenmann, Y., Pauli, B., Hellmich, M., Oberste, M., Hamacher, S., Tuchscherer, A., Frank, K. F., Randerath, W. J., et al. (2021) · Journal of Pain and Symptom Management · doi:10.1016/j.jpainsymman.2021.11.003 · Cited by 11 · see citing works
Ferreira, D. H., Ekström, M. P., Verberkt, C. A., et al. (2022) · ERJ Open Research · doi:10.1183/23120541.00530-2022 · Cited by 10 · see citing works
Blütgen, S., Pralong, A., Wilharm, C., Eisenmann, Y., Voltz, R., & Simon, S. T. (2025) · BMC Palliative Care · doi:10.1186/s12904-025-01670-0 · Cited by 10 · see citing works
Interdisciplinary management of chronic breathlessness
Reilly, C. C., Brighton, L. J., & Maddocks, M. M. (2019) · Current Opinion in Supportive and Palliative Care · doi:10.1097/spc.0000000000000435 · Cited by 9 · see citing works
A Mixed Methods Evaluation of a Pilot Multidisciplinary Breathlessness Support Service
Drury, A., Goss, J., Afolabi, J. A., McHugh, G., O’Leary, N., & Brady, A. (2023) · Evaluation Review · doi:10.1177/0193841x231162402 · Cited by 9 · see citing works
“The BTF provides a framework within the MBSS to support an individual to actively participate in their healthcare; firstly, by identifying the factors influencing breathlessness; secondly, by providing practical information and support to make small changes in the selfmanagement of breathlessness; and finally, support…”
BackgroundMethodInfluentialNursing support for breathlessness in patients with cancer: a scoping review
Kako, J., Morikawa, M., Kobayashi, M., Kanno, Y., Kajiwara, K., Nakano, K., Matsuda, Y., Shimizu, Y., Hori, M., Niino, M., et al. (2023) · BMJ Open · doi:10.1136/bmjopen-2023-075024 · Cited by 10 · see citing works
“Therefore, it is possible that nursing support components not included in the results of this study are provided in clinical practice.”
BackgroundNon-pharmacological interventions for breathlessness in people with cancer
Booth, S., Chin, C. A., Spathis, A., Maddocks, M. M., Yorke, J., Burkin, J., Moffat, C., Farquhar, M. C., & Bausewein, C. (2018) · Expert Review of Quality of Life in Cancer Care · doi:10.1080/23809000.2018.1524708 · Cited by 9 · see citing works
Self-citationBinnie, K., McGuire, C. A., & Carel, H. (2020) · Journal of Material Culture · doi:10.1177/1359183520931900 · Cited by 9 · see citing works
“The severity of breathlessness is not reliably predicted by disease stage – a discrepancy that is well documented in medical literature and has led to judgmental terms such as ‘disproportionate breathlessness’ and ‘unexplained breathlessness’ (Spathis et al., 2017).”
BackgroundThe load of dyspnoea on brain and legs
von Leupoldt, A., & Farré, N. (2020) · European Respiratory Journal · doi:10.1183/13993003.01096-2020 · Cited by 9 · see citing works
Alfano, P., Cuttitta, G., Audino, P., Fazio, G., Grutta, S. L., Marcantonio, S., Snamid Palermo Cooperative Group, & Bucchieri, S. (2022) · Journal of Clinical Medicine · doi:10.3390/jcm11030656 · Cited by 10 · see citing works
“In addition, the experience of breathlessness was linked to intolerance to physical activity and was distressing and debilitating for patients, affecting their quality of life [59].”
BackgroundRationale for targeted self-management strategies for breathlessness in heart failure
Asano, R., Newton, P. J., Currow, D. C., et al. (2019) · Heart Failure Reviews · doi:10.1007/s10741-019-09907-w · Cited by 9 · see citing works
Wang, J., Ly, L., Barson, E., & Smallwood, N. (2025) · npj Primary Care Respiratory Medicine · doi:10.1038/s41533-025-00430-0 · Cited by 10 · see citing works
“Participants with moderate-to-severe breathlessness were chosen given the well-documented associations between breathlessness severity and increased burden of psychological distress 4,21,22 .”
InfluentialSilva, L., Maricoto, T., Mota, Â., Lemos, L., Santos, M., Cunha, H. F., Azevedo, I., Berger‐Estilita, J., Costa, P., & Padilha, J. M. (2024) · BMC Nursing · doi:10.1186/s12912-024-01999-6 · Cited by 8 · see citing works
“Dyspnea will be assessed by the modified Medical Research Council (mMRC) scale [32].”
BackgroundMethodChronic breathlessness: time for Cinderella to go to the ball!
Johnson, M. J., & Fallon, M. (2018) · European Respiratory Journal · doi:10.1183/13993003.01452-2018 · Cited by 8 · see citing works
Luckett, T., Roberts, M. M., Swami, V., Smith, T., Cho, J., Klimkeit, E., & Wheatley, J. R. (2021) · BMJ Open · doi:10.1136/bmjopen-2021-050149 · Cited by 8 · see citing works
van den Bosch, L., Wang, T., Bakal, J. A., Richman–Eisenstat, J., & Kalluri, M. (2022) · American Journal of Hospice and Palliative Medicine® · doi:10.1177/10499091221096416 · Cited by 8 · see citing works
Filling the Gap: A Feasibility Study of a COPD-Specific Breathlessness Service
Mooren, K., Wester, D., Kerstjens, H. A. M., Bergkamp, E., Spathis, A., & Engels, Y. (2022) · COPD Journal of Chronic Obstructive Pulmonary Disease · doi:10.1080/15412555.2022.2099821 · Cited by 8 · see citing works
“CBIS has developed the breathing-thinking-functioning model (BTF), an educational tool for health professionals caring for breathless people, that is increasingly used in practice with breathless patients [18].”
BackgroundSelf-citationLo, S. B., Svensson, A. D., Presley, C. J., & Andersen, B. L. (2023) · Palliative & Supportive Care · doi:10.1017/s1478951523000640 · Cited by 8 · see citing works
Chronic breathlessness: re-thinking the symptom
Johnson, M. J., Yorke, J., Hansen-Flaschen, J. H., Ekström, M. P., & Currow, D. C. (2018) · European Respiratory Journal · doi:10.1183/13993003.00340-2018 · Cited by 8 · see citing works
McGuire, C. A. (2019) · The British Journal for the History of Science · doi:10.1017/s0007087419000232 · Cited by 8 · see citing works
Challenges of symptom management in interstitial lung disease: dyspnea, cough, and fatigue
Pascoe, A., Holland, A. E., & Smallwood, N. (2025) · Expert Review of Respiratory Medicine · doi:10.1080/17476348.2025.2453657 · Cited by 9 · see citing works
“The Cambridge Breathlessness Intervention Service, an integrated multi-disciplinary respiratory care service in the UK, has described this cycle in depth and developed the Breathing Thinking Functioning clinical model to help address each domain of dyspnea [31].”
Walker, A. M., Sullivan, D. R., Nguyen, P., Holland, A. E., & Smallwood, N. (2025) · Therapeutic Advances in Respiratory Disease · doi:10.1177/17534666241305497 · Cited by 8 · see citing works
Farver-Vestergaard, I., Buksted, E. H., Sørensen, D., Jonstrup, S., Hansen, H., Christiansen, C. F., & Løkke, A. (2024) · Frontiers in Rehabilitation Sciences · doi:10.3389/fresc.2024.1428893 · Cited by 7 · see citing works
Elliott-Button, H. L., Johnson, M. J., Hutchinson, A., Currow, D. C., & Clark, J. (2025) · npj Primary Care Respiratory Medicine · doi:10.1038/s41533-024-00409-3 · Cited by 8 · see citing works
Johnson, M. J., & Gozal, D. (2018) · European Respiratory Journal · doi:10.1183/13993003.00306-2018 · Cited by 7 · see citing works
Broese, J. M., van der Kleij, R., Kerstjens, H. A. M., Verschuur, E. M. L., Engels, Y., & Chavannes, N. H. (2020) · BMC Palliative Care · doi:10.1186/s12904-020-00657-3 · Cited by 7 · see citing works
Lucena, A., & Yuguero, O. (2022) · OMEGA - Journal of Death and Dying · doi:10.1177/00302228221089123 · Cited by 8 · see citing works
“Breathlessness is one of the main refractory symptoms described (Spathis et al., 2017).”
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Chronic breathlessness: re-thinking the symptom
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Breathlessness and other respiratory symptoms in palliative care
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Self-citationPhysical interventions for breathlessness in adults with advanced diseases
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Self-citationRetractedLong COVID and breathlessness: an overview.
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[Quantitative analysis of breathing patterns based on wearable systems].
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- Authors
- Spathis, A., Booth, S., Moffat, C., Hurst, R., Ryan, R., Chin, C., & Burkin, J.
- Affiliations
- University of Cambridge (GB)
- Cambridge University Hospitals NHS Foundation Trust (GB)
- Corresponding author
- Spathis, Anna
- Venue
- npj Primary Care Respiratory Medicine
- Published
- 2017-04-21
- Volume
- 27
- Issue
- 1
- Pages
- 27-27
- ISSN
- 2055-1010 (ISSN-L)
- PMC
- PMC5435098
- OpenAlex
- W2605479401
- Semantic Scholar
- ce556c7bb94ab4f38c2b81f1f3f28f4cb2d6a07d
- Cited by
- 226
- References
- 47
- Citations by year
- 2026: 15 · 2025: 29 · 2024: 28 · 2023: 37 · 2022: 25 · 2021: 24 · 2020: 23 · 2019: 22 · 2018: 15 · 2017: 8
- FWCI
- 13.86
- Type
- journal article
- Language
- en
- Open access
- gold
- doi.org
- Locations
- npj Primary Care Respiratory Medicine (publishedVersion, cc-by)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (submittedVersion, cc-by)
- PubMed Central (submittedVersion, cc-by)
- DOAJ (DOAJ: Directory of Open Access Journals) (submittedVersion, cc-by-sa)
- Apollo (University of Cambridge) (submittedVersion, cc-by)
- Apollo (cc-by)
- Topics
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Chronic Obstructive Pulmonary Disease (COPD) Research
- Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Respiratory and Cough-Related Research
- Health Sciences › Medicine › Physiology › Asthma and respiratory diseases
- Keywords
- dyspnea, chronic respiratory disease, refractory breathlessness, symptom management, non-pharmacological treatment, clinical model, patient engagement, clinician engagement, evidence-based care
- MeSH terms
- Self-Management, Chronic Disease, Delivery of Health Care, Dyspnea, Heart Diseases, Humans, Respiratory Tract Diseases, Evidence-Based Medicine, Pulmonary Disease, Chronic Obstructive
About these checks
Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
Claims read by deepseek-v4.1-flash under definition version 3 (extract-v3) on 2026-10-17.
Classified by jev-1.13-20260917 (gold-guideline-v0.2) on 2026-10-17.
Cited sources are checked by gpt-6-sol.
Statistics and arithmetic are recomputed, not judged.
Confidence bands are shown only for fields calibrated on our annotated test set. None is calibrated yet, so no band is shown.
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