MRC Dyspnoea Scale

The mMRC (Modified Medical Research Council) Dyspnoea Scale is used to assess the degree of baseline functional disability due to dyspnoea.

It is useful in characterising baseline dyspnoea in patients with respiratory disease such as COPD. Whilst it moderately correlates with other healthcare-associated morbidity, mortality and quality of life scales (particularly in COPD) the scores are only variably associated with patients' perceptions of respiratory symptom burden. It is used as a component of the BODE Index, which predicts adverse outcomes, including mortality and risk of hospitalisation. The scale is easy and efficient to use.

The mMRC breathlessness scale ranges from grade 0 to 4. It is very similar to the original version and is now widely used in studies. It should be noted that the MRC clearly states on its website that it is unable to give permission for use of any modified version of the scale (including therefore, the mMRC scale). Use of the MRC questionnaire is free but should be acknowledged.

The modified MRC was developed by D A Mahler, see  https://pubmed.ncbi.nlm.nih.gov/3342669/

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Measuring Shortness of Breath (Dyspnea) in COPD

How the Perception of Disability Directs Treatment

Dyspnea is the medical term used to describe shortness of breath, a symptom considered central to all forms of chronic obstructive pulmonary disease (COPD) including emphysema and chronic bronchitis.

As COPD is both a progressive and non-reversible, the severity of dyspnea plays a key role in determining both the stage of the disease and the appropriate medical treatment.

Challenges in Diagnosis

From a clinical standpoint, the challenge of diagnosing dyspnea is that it is very subjective. While spirometry tests (which measures lung capacity) and pulse oximetry (which measures oxygen levels in the blood) may show that two people have the same level of breathing impairment, one may feel completely winded after activity while the other may be just fine.

Ultimately, a person's perception of dyspnea is important as it helps ensure the person is neither undertreated nor overtreated and that the prescribed therapy, when needed, will improve the person's quality of life rather than take from it.  

To this end, pulmonologists will use a tool called the modified Medical Research Council (mMRC) dyspnea scale to establish how much an individual's shortness of breath causes real-world disability.

How the Assessment Is Performed

The process of measuring dyspnea is similar to tests used to measure pain perception in persons with chronic pain. Rather than defining dyspnea in terms of lung capacity, the mMRC scale will rate the sensation of dyspnea as the person perceives it.

The severity of dyspnea is rated on a scale of 0 to 4, the value of which will direct both the diagnosis and treatment plan.

Role of the MMRC Dyspnea Scale

The mMRC dyspnea scale has proven valuable in the field of pulmonology as it affords doctors and researchers the mean to:

  • Assess the effectiveness of treatment on an individual basis
  • Compare the effectiveness of a treatment within a population
  • Predict survival times and rates

From a clinical viewpoint, the mMRC scale correlates fairly well to such objective measures as pulmonary function tests and walk tests . Moreover, the values tend to be stable over time, meaning that they are far less prone to subjective variability that one might assume.  

Using the BODE Index to Predict Survival

The mMRC dyspnea scale is used to calculate the BODE index , a tool which helps estimate the survival times of people living with COPD.

The BODE Index is comprised of a person's body mass index ("B"), airway obstruction ("O"), dyspnea ("D"), and exercise tolerance ("E"). Each of these components is graded on a scale of either 0 to 1 or 0 to 3, the numbers of which are then tabulated for a final value.

The final value—ranging from as low as 0 to as high as 10—provides doctors a percentage of how likely a person is to survive for four years. The final BODE tabulation is described as follows:

  • 0 to 2 points: 80 percent likelihood of survival
  • 3 to 4 points: 67 percent likelihood of survival
  • 5 of 6 points: 57 percent likelihood of survival
  • 7 to 10 points: 18 percent likelihood of survival

The BODE values, whether large or small, are not set in stone. Changes to lifestyle and improved treatment adherence can improve long-term outcomes, sometimes dramatically. These include things like quitting smoking , improving your diet  and engaging in appropriate exercise to improve your respiratory capacity.

In the end, the numbers are simply a snapshot of current health, not a prediction of your mortality. Ultimately, the lifestyle choices you make can play a significant role in determining whether the odds are against you or in your favor.

Janssens T, De peuter S, Stans L, et al. Dyspnea perception in COPD: association between anxiety, dyspnea-related fear, and dyspnea in a pulmonary rehabilitation program . Chest. 2011;140(3):618-625. doi:10.1378/chest.10-3257

Manali ED, Lyberopoulos P, Triantafillidou C, et al. MRC chronic Dyspnea Scale: Relationships with cardiopulmonary exercise testing and 6-minute walk test in idiopathic pulmonary fibrosis patients: a prospective study . BMC Pulm Med . 2010;10:32. doi:10.1186/1471-2466-10-32

Esteban C, Quintana JM, Moraza J, et al. BODE-Index vs HADO-score in chronic obstructive pulmonary disease: Which one to use in general practice? . BMC Med . 2010;8:28. doi:10.1186/1741-7015-8-28

Chhabra, S., Gupta, A., and Khuma, M. " Evaluation of Three Scales of Dyspnea in Chronic Obstructive Pulmonary Disease. " Annals of Thoracic Medicine. 2009; 4(3):128-32. DOI: 10.4103/1817-1737.53351 .

Perez, T.; Burgel, P.; Paillasseur, J.; et al. " Modified Medical Research Council scale vs Baseline Dyspnea Index to Evaluate Dyspnea in Chronic Obstructive Pulmonary Disease. " International Journal of Chronic Obstructive Pulmonary Disease . 2015; 10:1663-72. DOI: 10.2147/COPD.S82408 .

By Deborah Leader, RN  Deborah Leader RN, PHN, is a registered nurse and medical writer who focuses on COPD.

modified medical research council dyspnoea scale

MRC Dyspnoea Scale - MRC

The MRC Dyspnoea Scale, also called the MRC Breathlessness Scale, has been in use for many years for grading the effect of breathlessness on daily activities. This scale measures perceived respiratory disability, using the World Health Organization (WHO) definition of disability being “any restriction or lack of ability to perform an activity in the manner or within the range considered normal for a human being”.

The MRC Dyspnoea Scale is simple to administer as it allows the patients to indicate the extent to which their breathlessness affects their mobility.

The 1-5 stage scale is used alongside the questionnaire to establish clinical grades of breathlessness.

MRC Breathlessness Scales: 1952 and 1959

Questionnaire on Respiratory Symptoms

The questionnaire was first published in 1960 under the approval of the MRC Committee on the Aetiology of Chronic Bronchitis. This was revised and a new version published in 1966. When the committee disbanded, the responsibility for it was passed to the newly formed MRC Committee for Research into Chronic Bronchitis who again revised it in 1976. When this committee disbanded, the responsibility for the questionnaire passed to the Committee on Environmental and Occupational Health (CEOH) who reviewed it and issued what remains to be the most recent version in 1986.

The Questionnaire on Respiratory Symptoms was designed to be used in large scale epidemiological studies only (100-1,000 people). It cannot be used on an individual basis.

Questionnaire on respiratory symptoms and instructions to interviewers (1966)

Questionnaire on respiratory symptoms and instructions to interviewers (1976)

Questionnaire on respiratory symptoms and instructions to interviewers (1986)

Permission to reuse the MRC Dyspnoea Scale

In accordance with MRC’s Open Access Policy , permission is granted from the MRC to use the MRC Dyspnoea Scale for any purpose (including research and commercial purposes) and MRC hereby agrees not to assert its rights in relation to the proposed use of the MRC Dyspnoea Scale.

You must give appropriate credit (“Used with the permission of the Medical Research Council”) and indicate if changes were made. You may do so in any reasonable manner, but not in any way that suggests that the MRC endorses you or your use.

We cannot give permission to use any modified versions of this scale including the MRC Scale.

Note: The MRC is not in a position to authorise translations or check back-translations

Contact information

Ask a question, or get further information about any of the MRC scales. Email: [email protected]

For information about licensing

To view the full Open Government Licence, visit National Archives: Open Government Licence Version 2 .

Further context, best practice and guidance can be found in the National Archives: UK Government Licensing Framework .

LifeArc manages MRC’s intellectual property rights and commercialises findings by licensing them to industry. They can be contacted for support via the contact information on their website .

Last updated: 24 January 2022

This is the website for UKRI: our seven research councils, Research England and Innovate UK. Let us know if you have some quick feedback or help us improve your experience by taking three minutes to tell us what you think of the UKRI website .

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Chronic obstructive pulmonary disease in over 16s: diagnosis and management

NICE guideline [NG115] Published: 05 December 2018 Last updated: 26 July 2019

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1.1 Diagnosing COPD

1.2 managing stable copd, 1.3 managing exacerbations of copd, terms used in this guideline.

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE's information on making decisions about your care .

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

The diagnosis of chronic obstructive pulmonary disease (COPD) depends on thinking of it as a cause of breathlessness or cough. The diagnosis is suspected on the basis of symptoms and signs and is supported by spirometry.

1.1.1 Suspect a diagnosis of COPD in people over 35 who have a risk factor (generally smoking or a history of smoking) and who present with 1 or more of the following symptoms:

exertional breathlessness

chronic cough

regular sputum production

frequent winter 'bronchitis'

wheeze. [2004]

1.1.2 When thinking about a diagnosis of COPD, ask the person if they have:

weight loss

reduced exercise tolerance

waking at night with breathlessness

ankle swelling

occupational hazards

haemoptysis (coughing up blood). These last 2 symptoms are uncommon in COPD and raise the possibility of alternative diagnoses. [2004]

1.1.3 One of the primary symptoms of COPD is breathlessness. The Medical Research Council (MRC) dyspnoea scale (see table 1) should be used to grade the breathlessness according to the level of exertion required to elicit it. [2004]

Adapted from Fletcher CM, Elmes PC, Fairbairn MB et al. (1959) The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population . British Medical Journal 2: 257–66.

1.1.4 Perform spirometry:

at diagnosis

to reconsider the diagnosis, for people who show an exceptionally good response to treatment

to monitor disease progression. [2004, amended 2018]

1.1.5 Measure post-bronchodilator spirometry to confirm the diagnosis of COPD. [2010]

1.1.6 Think about alternative diagnoses or investigations for older people who have an FEV1/FVC ratio below 0.7 but do not have typical symptoms of COPD. [2010]

1.1.7 Think about a diagnosis of COPD in younger people who have symptoms of COPD, even when their FEV1/FVC ratio is above 0.7. [2010]

1.1.8 All healthcare professionals who care for people with COPD should have access to spirometry and be competent in interpreting the results. [2004]

1.1.9 Spirometry can be performed by any healthcare worker who has had appropriate training and has up-to-date skills. [2004]

1.1.10 Spirometry services should be supported by quality control processes. [2004]

1.1.11 It is recommended that European Respiratory Journal GLI 2012 reference values are used, but it is recognised that these values are not applicable for all ethnic groups. [2004, amended 2018]

Incidental findings on chest X‑ray or CT scans

1.1.12 Consider primary care respiratory review and spirometry (see the recommendations on symptoms and spirometry ) for people with emphysema or signs of chronic airways disease on a chest X-ray or CT scan. [2018]

1.1.13 If the person is a current smoker, their spirometry results are normal and they have no symptoms or signs of respiratory disease:

offer smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guideline on stop smoking interventions and services )

warn them that they are at higher risk of lung disease

advise them to return if they develop respiratory symptoms

be aware that the presence of emphysema on a CT scan is an independent risk factor for lung cancer. [2018]

1.1.14 If the person is not a current smoker, their spirometry is normal and they have no symptoms or signs of respiratory disease:

ask them if they have a personal or family history of lung or liver disease and consider alternative diagnoses, such as alpha‑1 antitrypsin deficiency

reassure them that their emphysema or chronic airways disease is unlikely to get worse

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on incidental findings on chest X-ray or CT scans .

Full details of the evidence and the committee's discussion are in evidence review D: Diagnosing COPD and predicting outcomes .

Further investigations

1.1.15 At the time of their initial diagnostic evaluation in addition to spirometry all patients should have:

a chest radiograph to exclude other pathologies

a full blood count to identify anaemia or polycythaemia

body mass index (BMI) calculated. [2004]

1.1.16 Perform additional investigations when needed, as detailed in table 2. [2004, amended 2018]

1.1.17 Offer people with alpha 1 antitrypsin deficiency a referral to a specialist centre to discuss how to manage their condition. [2004]

Reversibility testing

1.1.18 For most people, routine spirometric reversibility testing is not necessary as part of the diagnostic process or to plan initial therapy with bronchodilators or corticosteroids. It may be unhelpful or misleading because:

repeated FEV1 measurements can show small spontaneous fluctuations

the results of a reversibility test performed on different occasions can be inconsistent and not reproducible

over-reliance on a single reversibility test may be misleading unless the change in FEV1 is greater than 400 ml

the definition of the magnitude of a significant change is purely arbitrary

response to long-term therapy is not predicted by acute reversibility testing. [2004]

1.1.19 Untreated COPD and asthma are frequently distinguishable on the basis of history (and examination) in people presenting for the first time. Whenever possible, use features from the history and examination (such as those listed in table 3) to differentiate COPD from asthma. For more information on diagnosing asthma see the NICE guideline on asthma . [2004, amended 2018]

1.1.20 In addition to the features in table 3, use longitudinal observation of people (with spirometry, peak flow or symptoms) to help differentiate COPD from asthma. [2004]

1.1.21 When diagnostic uncertainty remains, or both COPD and asthma are present, use the following findings to help identify asthma:

a large (over 400 ml) response to bronchodilators

a large (over 400 ml) response to 30 mg oral prednisolone daily for 2 weeks

serial peak flow measurements showing 20% or greater diurnal or day-to-day variability. Clinically significant COPD is not present if the FEV1 and FEV1/FVC ratio return to normal with drug therapy. [2004]

1.1.22 If diagnostic uncertainty remains, think about referral for more detailed investigations, including imaging and measurement of transfer factor for carbon monoxide (TLCO). [2004]

1.1.23 Reconsider the diagnosis of COPD for people who report a marked improvement in symptoms in response to inhaled therapy. [2004]

Assessing severity and using prognostic factors

COPD is heterogeneous, so no single measure can adequately assess disease severity in an individual. Severity assessment is, nevertheless, important because it has implications for therapy and relates to prognosis.

1.1.24 Do not use a multidimensional index (such as BODE) to assess prognosis in people with stable COPD. [2018]

1.1.25 From diagnosis onwards, when discussing prognosis and treatment decisions with people with stable COPD, think about the following factors that are individually associated with prognosis:

smoking status

breathlessness (MRC scale)

chronic hypoxia and/or cor pulmonale

severity and frequency of exacerbations

hospital admissions

symptom burden (for example, COPD Assessment Test [CAT] score)

exercise capacity (for example, 6‑minute walk test)

whether the person meets the criteria for long-term oxygen therapy and/or home non-invasive ventilation

multimorbidity

frailty. [2010, amended 2018]

For a short explanation of why the committee made the 2018 recommendation and how it might affect practice, see the rationale and impact section on assessing severity and using prognostic factors .

Assessing and classifying the severity of airflow obstruction

1.1.26 Assess the severity of airflow obstruction according to the reduction in FEV1, as shown in table 4. [2010]

1.1.27 For people with mild airflow obstruction, only diagnose COPD if they have one or more of the symptoms in the recommendation on symptoms . [2010]

ATS/ERS guidance: Celli BR, MacNee W (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. European Respiratory Journal 23(6): 932–46.

GOLD guidance: Global Initiative for Chronic Obstructive Lung Disease (GOLD; 2008) Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease.

Identifying early disease

1.1.28 Perform spirometry in people who are over 35, current or ex‑smokers, and have a chronic cough. [2004]

1.1.29 Consider spirometry in people with chronic bronchitis. A significant proportion of these people will go on to develop airflow limitation. [2004]

Referral for specialist advice

1.1.30 When clinically indicated, refer people for specialist advice. Referral may be appropriate at all stages of the disease and not solely in the most severely disabled people (see table 5). [2004]

1.1.31 People who are referred do not always have to be seen by a respiratory physician. In some cases they may be seen by members of the COPD team who have appropriate training and expertise. [2004]

NICE has also produced a visual summary covering non-pharmacological management and use of inhaled therapies .

1.2.1 For guidance on the management of multimorbidity, see the NICE guideline on multimorbidity . [2018]

Smoking cessation

1.2.2 Document an up-to-date smoking history, including pack years smoked (number of cigarettes smoked per day, divided by 20, multiplied by the number of years smoked) for everyone with COPD. [2004]

1.2.3 At every opportunity, advise and encourage every person with COPD who is still smoking (regardless of their age) to stop, and offer them help to do so. [2004]

1.2.4 Unless contraindicated, offer nicotine replacement therapy, varenicline or bupropion as appropriate to people who want to stop smoking, combined with an appropriate support programme to optimise smoking quit rates for people with COPD. [2010]

1.2.5 For more guidance on helping people to quit smoking, see the NICE guideline on stop smoking interventions and services . [2010]

1.2.6 For more guidance on varenicline see the NICE technology appraisal guidance on varenicline for smoking cessation . [2010]

Inhaled therapy

Short-acting beta2 agonists (saba) and short-acting muscarinic antagonists (sama).

1.2.7 Use short-acting bronchodilators, as necessary, as the initial empirical treatment to relieve breathlessness and exercise limitation. [2004]

Inhaled corticosteroids (ICS)

1.2.8 Do not use oral corticosteroid reversibility tests to identify which people should be prescribed inhaled corticosteroids, because they do not predict response to inhaled corticosteroid therapy. [2004]

1.2.9 Be aware of, and be prepared to discuss with the person, the risk of side effects (including pneumonia) in people who take inhaled corticosteroids for COPD. Follow the MHRA safety advice on the risk of psychological and behavioural side effects associated with inhaled corticosteroids. [2010, amended 2018]

Inhaled combination therapy

Inhaled combination therapy refers to combinations of long-acting muscarinic antagonists (LAMA), long-acting beta2 agonists (LABA), and inhaled corticosteroids (ICS).

1.2.10 Do not assess the effectiveness of bronchodilator therapy using lung function alone. Include a variety of other measures such as improvement in symptoms, activities of daily living, exercise capacity, and rapidity of symptom relief. [2004]

1.2.11 Offer LAMA+LABA to people who:

have spirometrically confirmed COPD and

do not have asthmatic features/features suggesting steroid responsiveness   and

remain breathless or have exacerbations despite:

having used or been offered treatment for tobacco dependence if they smoke and

optimised non-pharmacological management and relevant vaccinations and

using a short-acting bronchodilator. [2018] Follow the MHRA safety advice on Respimat and Handihaler inhalers .

1.2.12 Consider LABA+ICS for people who:

have asthmatic features/features suggesting steroid responsiveness   and

using a short-acting bronchodilator. [2018]

1.2.13 For people who are using long-acting bronchodilators outside of the recommendations on offering LAMA and LABA and considering LABA+ICS and whose symptoms are under control, explain to them that they can continue with their current treatment until both they and their NHS healthcare professional agree it is appropriate to change. [2018]

1.2.14 Before starting LAMA+LABA+ICS, conduct a clinical review to ensure that:

the person's non-pharmacological COPD management is optimised and they have used or been offered treatment for tobacco dependence if they smoke

acute episodes of worsening symptoms are caused by COPD exacerbations and not by another physical or mental health condition

the person's day-to-day symptoms that are adversely impacting their quality of life are caused by COPD and not by another physical or mental health condition . [2019]

1.2.15 For people with COPD who are taking LABA+ICS, offer LAMA+LABA+ICS if:

their day-to-day symptoms continue to adversely impact their quality of life or

they have a severe exacerbation (requiring hospitalisation) or

they have 2 moderate exacerbations within a year. [2019]

1.2.16 For people with COPD who are taking LAMA+LABA, consider LAMA+LABA+ICS if:

1.2.17 For people with COPD who are taking LAMA+LABA and whose day-to-day symptoms adversely impact their quality of life:

consider a trial of LAMA+LABA+ICS, lasting for 3 months only

after 3 months, conduct a clinical review to establish whether or not LAMA+LABA+ICS has improved their symptoms:

if symptoms have not improved, stop LAMA+LABA+ICS and switch back to LAMA+LABA

if symptoms have improved, continue with LAMA+LABA+ICS. [2019]

1.2.18 Document the reason for continuing ICS use in clinical records and review at least annually. [2019]

1.2.19 Base the choice of drugs and inhalers on:

how much they improve symptoms

the person's preferences and ability to use the inhalers

the drugs' potential to reduce exacerbations

their side effects

their cost. Minimise the number of inhalers and the number of different types of inhaler used by each person as far as possible. [2018]

1.2.20 When prescribing long-acting drugs, ensure people receive inhalers they have been trained to use (for example, by specifying the brand and inhaler in prescriptions). [2018]

For a short explanation of why the committee made the 2018 and 2019 recommendations and how they might affect practice, see the rationale and impact section on inhaled combination therapy.

Full details of the evidence and the committee's discussion are in evidence review F: Inhaled therapies and evidence review I: Inhaled triple therapy .

Delivery systems used to treat stable COPD

Most people with COPD – whatever their age – can develop adequate inhaler technique if they are given training. However, people with significant cognitive impairment may be unable to use any form of inhaler device. In most people with COPD, however, a pragmatic approach guided by individual patient assessment is needed when choosing a device.

1.2.21 In most cases bronchodilator therapy is best administered using a hand-held inhaler (including a spacer if appropriate). [2004]

1.2.22 Provide an alternative inhaler if a person cannot use a particular one correctly or it is not suitable for them. [2004]

1.2.23 Only prescribe inhalers after people have been trained to use them and can demonstrate satisfactory technique. [2004]

1.2.24 People with COPD should have their ability to use an inhaler regularly assessed and corrected if necessary by a healthcare professional competent to do so. [2004]

1.2.25 Provide a spacer that is compatible with the person's metered-dose inhaler. [2004]

1.2.26 Advise people to use a spacer with a metered-dose inhaler in the following way:

administer the drug by single actuations of the metered-dose inhaler into the spacer, inhaling after each actuation

there should be minimal delay between inhaler actuation and inhalation

normal tidal breathing can be used as it is as effective as single breaths

repeat if a second dose is required. [2004]

1.2.27 Advise people on spacer cleaning. Tell them:

not to clean the spacer more than monthly, because more frequent cleaning affects their performance (because of a build-up of static)

to hand wash using warm water and washing-up liquid, and allow the spacer to air dry. [2004, amended 2018]

1.2.28 Think about nebuliser therapy for people with distressing or disabling breathlessness despite maximal therapy using inhalers. [2004]

1.2.29 Do not prescribe nebulised therapy without an assessment of the person's and/or carer's ability to use it. [2004]

1.2.30 Do not continue nebulised therapy without assessing and confirming that 1 or more of the following occurs:

a reduction in symptoms

an increase in the ability to undertake activities of daily living

an increase in exercise capacity

an improvement in lung function. [2004]

1.2.31 Use a nebuliser system that is known to be efficient. [2004] Follow the MHRA safety advice on non-CE-marked nebulisers for COPD .

1.2.32 Offer people a choice between a facemask and a mouthpiece to administer their nebulised therapy, unless the drug specifically requires a mouthpiece (for example, anticholinergic drugs). [2004]

1.2.33 If nebuliser therapy is prescribed, provide the person with equipment, servicing, and ongoing advice and support. [2004]

Oral therapy

Oral corticosteroids.

1.2.34 Long-term use of oral corticosteroid therapy in COPD is not normally recommended. Some people with advanced COPD may need long-term oral corticosteroids when these cannot be withdrawn following an exacerbation. In these cases, the dose of oral corticosteroids should be kept as low as possible. [2004]

1.2.35 Monitor people who are having long-term oral corticosteroid therapy for osteoporosis, and give them appropriate prophylaxis. Start prophylaxis without monitoring for people over 65. [2004]

Oral theophylline

In this section of the guideline, the term theophylline refers to slow-release formulations of the drug.

1.2.36 Theophylline should only be used after a trial of short-acting bronchodilators and long-acting bronchodilators, or for people who are unable to use inhaled therapy, as plasma levels and interactions need to be monitored. [2004]

1.2.37 Take particular caution when using theophylline in older people, because of differences in pharmacokinetics, the increased likelihood of comorbidities and the use of other medications. [2004]

1.2.38 Assess the effectiveness of theophylline by improvements in symptoms, activities of daily living, exercise capacity and lung function. [2004]

1.2.39 Reduce the dose of theophylline for people who are having an exacerbation if they are prescribed macrolide or fluoroquinolone antibiotics (or other drugs known to interact). [2004]

Oral mucolytic therapy

1.2.40 Consider mucolytic drug therapy for people with a chronic cough productive of sputum. [2004]

1.2.41 Only continue mucolytic therapy if there is symptomatic improvement (for example, reduction in frequency of cough and sputum production). [2004]

1.2.42 Do not routinely use mucolytic drugs to prevent exacerbations in people with stable COPD. [2010]

Oral anti-oxidant therapy

1.2.43 Treatment with alpha-tocopherol and beta-carotene supplements, alone or in combination, is not recommended. [2004]

Oral anti-tussive therapy

1.2.44 Anti-tussive therapy should not be used in the management of stable COPD. [2004]

Oral prophylactic antibiotic therapy

1.2.45 Before starting prophylactic antibiotic therapy in a person with COPD, think about whether respiratory specialist input is needed. [2018]

1.2.46 Consider azithromycin (usually 250 mg 3 times a week) for people with COPD if they:

do not smoke and

have optimised non-pharmacological management and inhaled therapies, relevant vaccinations and (if appropriate) have been referred for pulmonary rehabilitation and

continue to have 1 or more of the following, particularly if they have significant daily sputum production:

frequent (typically 4 or more per year) exacerbations with sputum production

prolonged exacerbations with sputum production

exacerbations resulting in hospitalisation. [2018] In July 2019, this was an off-label use of azithromycin. See NICE's information on prescribing medicines .

1.2.47 Before offering prophylactic antibiotics, ensure that the person has had:

sputum culture and sensitivity (including tuberculosis culture), to identify other possible causes of persistent or recurrent infection that may need specific treatment (for example, antibiotic-resistant organisms, atypical mycobacteria or Pseudomonas aeruginosa )

training in airway clearance techniques to optimise sputum clearance (see the recommendation in the section on physiotherapy )

a CT scan of the thorax to rule out bronchiectasis and other lung pathologies. [2018]

1.2.48 Before starting azithromycin, ensure the person has had:

an electrocardiogram (ECG) to rule out prolonged QT interval and

baseline liver function tests. [2018]

1.2.49 When prescribing azithromycin, advise people about the small risk of hearing loss and tinnitus, and tell them to contact a healthcare professional if this occurs. [2018]

1.2.50 Review prophylactic azithromycin after the first 3 months, and then at least every 6 months. [2018]

1.2.51 Only continue treatment if the continued benefits outweigh the risks. Be aware that there are no long-term studies on the use of prophylactic antibiotics in people with COPD. [2018]

1.2.52 For people who are taking prophylactic azithromycin and are still at risk of exacerbations, provide a non-macrolide antibiotic to keep at home as part of their exacerbation action plan (see the recommendation on offering antibiotics to keep at home in the section on self-management ). [2018]

1.2.53 Be aware that it is not necessary to stop prophylactic azithromycin during an acute exacerbation of COPD. [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on oral prophylactic antibiotic therapy .

Full details of the evidence and the committee's discussion are in evidence review E: Predicting and preventing exacerbations .

Oral phosphodiesterase-4 inhibitors

1.2.54 For guidance on treating severe COPD with roflumilast, see NICE's technology appraisal guidance on roflumilast for treating chronic obstructive pulmonary disease . [2018]

Long-term oxygen therapy

1.2.55 Be aware that inappropriate oxygen therapy in people with COPD may cause respiratory depression. [2004]

1.2.56 Assess the need for oxygen therapy in people with:

very severe airflow obstruction (FEV1 below 30% predicted)

cyanosis (blue tint to skin)

polycythaemia

peripheral oedema (swelling)

a raised jugular venous pressure

oxygen saturations of 92% or less breathing air. Also consider assessment for people with severe airflow obstruction (FEV1 30–49% predicted). Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes . [2004]

1.2.57 Assess people for long-term oxygen therapy by measuring arterial blood gases on 2 occasions at least 3 weeks apart in people who have a confident diagnosis of COPD, who are receiving optimum medical management and whose COPD is stable. [2004]

1.2.58 Consider long-term oxygen therapy for people with COPD who do not smoke and who:

have a partial pressure of oxygen in arterial blood (PaO 2 ) below 7.3 kPa when stable or

have a PaO 2 above 7.3 and below 8 kPa when stable, if they also have 1 or more of the following:

secondary polycythaemia

peripheral oedema

pulmonary hypertension. See the MHRA alert on the risk of death and severe harm from failure to obtain and continue flow from oxygen cylinders . [2018]

1.2.59 Conduct and document a structured risk assessment for people being assessed for long-term oxygen therapy who meet the criteria in the recommendation on considering long-term oxygen therapy . As part of the risk assessment, cover the risks for both the person with COPD and the people who live with them, including:

the risks of falls from tripping over the equipment

the risks of burns and fires, and the increased risk of these for people who live in homes where someone smokes (including e‑cigarettes). Base the decision on whether long-term oxygen therapy is suitable on the results of the structured risk assessment. [2018]

1.2.60 For people who smoke or live with people who smoke, but who meet the other criteria for long-term oxygen therapy, ensure the person who smokes is offered smoking cessation advice and treatment, and referral to specialist stop smoking services (see the NICE guidelines on stop smoking interventions and services and medicines optimisation ). [2018]

1.2.61 Do not offer long-term oxygen therapy to people who continue to smoke despite being offered smoking cessation advice and treatment, and referral to specialist stop smoking services. [2018]

1.2.62 Advise people who are having long-term oxygen therapy that they should breathe supplemental oxygen for a minimum of 15 hours per day. [2018]

1.2.63 Do not offer long-term oxygen therapy to treat isolated nocturnal hypoxaemia caused by COPD. [2018]

1.2.64 To ensure everyone eligible for long-term oxygen therapy is identified, pulse oximetry should be available in all healthcare settings. [2004]

1.2.65 Oxygen concentrators should be used to provide the fixed supply at home for long-term oxygen therapy. [2004]

1.2.66 People who are having long-term oxygen therapy should be reviewed at least once per year by healthcare professionals familiar with long-term oxygen therapy. This review should include pulse oximetry. [2004]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on long-term oxygen therapy .

Full details of the evidence and the committee's discussion are in evidence review B: Oxygen therapy in people with stable COPD .

Ambulatory oxygen therapy

1.2.67 Do not offer ambulatory oxygen to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest. [2018]

1.2.68 Consider ambulatory oxygen in people with COPD who have exercise desaturation and are shown to have an improvement in exercise capacity with oxygen, and have the motivation to use oxygen. [2004, amended 2018]

1.2.69 Prescribe ambulatory oxygen to people who are already on long-term oxygen therapy, who wish to continue oxygen therapy outside the home, and who are prepared to use it. [2004]

1.2.70 Only prescribe ambulatory oxygen therapy after an appropriate assessment has been performed by a specialist. The purpose of the assessment is to assess the extent of desaturation, the improvement in exercise capacity with supplemental oxygen, and the oxygen flow rate needed to correct desaturation. [2004]

1.2.71 Small light-weight cylinders, oxygen-conserving devices and portable liquid oxygen systems should be available for people with COPD. [2004]

1.2.72 When choosing which equipment to prescribe, take account of the hours of ambulatory oxygen use and oxygen flow rate needed. [2004]

Short-burst oxygen therapy

1.2.73 Do not offer short-burst oxygen therapy to manage breathlessness in people with COPD who have mild or no hypoxaemia at rest. [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on ambulatory and oxygen short-burst oxygen therapy .

Non-invasive ventilation

1.2.74 Refer people who are adequately treated but have chronic hypercapnic respiratory failure and have needed assisted ventilation (whether invasive or non-invasive) during an exacerbation, or who are hypercapnic or acidotic on long-term oxygen therapy, to a specialist centre for consideration of long-term non-invasive ventilation. [2004]

Managing pulmonary hypertension and cor pulmonale

In this guideline 'cor pulmonale' is defined as a clinical condition that is identified and managed on the basis of clinical features. It includes people who have right heart failure secondary to lung disease and people whose primary pathology is salt and water retention, leading to the development of peripheral oedema (swelling).

Diagnosing pulmonary hypertension and cor pulmonale

1.2.75 Suspect a diagnosis of cor pulmonale for people with:

a raised venous pressure

a systolic parasternal heave

a loud pulmonary second heart sound. [2004]

1.2.76 It is recommended that the diagnosis of cor pulmonale is made clinically and that this process should involve excluding other causes of peripheral oedema (swelling). [2004]

Treating pulmonary hypertension

1.2.77 Do not offer the following treatments solely to manage pulmonary hypertension caused by COPD, except as part of a randomised controlled trial:

nitric oxide

pentoxifylline

phosphodiesterase-5 inhibitors

statins. [2018]

Treating cor pulmonale

1.2.78 Ensure that people with cor pulmonale caused by COPD are offered optimal COPD treatment, including advice and interventions to help them stop smoking. For people who need treatment for hypoxia, see the section on long-term oxygen therapy . [2018]

1.2.79 Oedema associated with cor pulmonale can usually be controlled symptomatically with diuretic therapy. [2004]

1.2.80 Do not use the following to treat cor pulmonale caused by COPD:

alpha-blockers

angiotensin-converting enzyme inhibitors

calcium channel blockers

digoxin (unless there is atrial fibrillation). [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on managing pulmonary hypertension and cor pulmonale .

Full details of the evidence and the committee's discussion are in evidence review A: Managing pulmonary hypertension and cor pulmonale .

Pulmonary rehabilitation

Pulmonary rehabilitation is defined as a multidisciplinary programme of care for people with chronic respiratory impairment. It is individually tailored and designed to optimise each person's physical and social performance and autonomy.

1.2.81 Make pulmonary rehabilitation available to all appropriate people with COPD (see the recommendation on offering pulmonary rehabilitation ), including people who have had a recent hospitalisation for an acute exacerbation. [2010]

1.2.82 Offer pulmonary rehabilitation to all people who view themselves as functionally disabled by COPD (usually Medical Research Council [MRC] grade 3 and above). Pulmonary rehabilitation is not suitable for people who are unable to walk, who have unstable angina or who have had a recent myocardial infarction. [2004]

1.2.83 For pulmonary rehabilitation programmes to be effective, and to improve adherence, they should be held at times that suit people, in buildings that are easy to get to and that have good access for people with disabilities. Places should be available within a reasonable time of referral. [2004]

1.2.84 Pulmonary rehabilitation programmes should include multicomponent, multidisciplinary interventions that are tailored to the individual person's needs. The rehabilitation process should incorporate a programme of physical training, disease education, and nutritional, psychological and behavioural intervention. [2004]

1.2.85 Advise people of the benefits of pulmonary rehabilitation and the commitment needed to gain these. [2004]

Vaccination and anti-viral therapy

1.2.86 Offer pneumococcal vaccination and an annual flu vaccination to all people with COPD, as recommended by the Chief Medical Officer. [2004]

1.2.87 For guidance on preventing and treating flu, see the NICE technology appraisals on oseltamivir, amantadine (review) and zanamivir for the prophylaxis of influenza and amantadine, oseltamivir and zanamivir for the treatment of influenza . [2004]

Lung surgery and lung volume reduction procedures

1.2.88 Offer a respiratory review to assess whether a lung volume reduction procedure is a possibility for people with COPD when they complete pulmonary rehabilitation and at other subsequent reviews, if all of the following apply:

they have severe COPD, with FEV1 less than 50% and breathlessness that affects their quality of life despite optimal medical treatment (see recommendations 1.2.11 to 1.2.17 in the section on inhaled combination therapy )

they do not smoke

they can complete a 6‑minute walk distance of at least 140 m (if limited by breathlessness). [2018]

1.2.89 At the respiratory review, refer the person with COPD to a lung volume reduction multidisciplinary team to assess whether lung volume reduction surgery or endobronchial valves are suitable if they have:

hyperinflation, assessed by lung function testing with body plethysmography and

emphysema on unenhanced CT chest scan and

optimised treatment for other comorbidities. [2018]

1.2.90 Only offer endobronchial coils as part of a clinical trial and after assessment by a lung volume reduction multidisciplinary team. [2018]

1.2.91 For more guidance on lung volume reduction procedures, see the NICE interventional procedures guidance on lung volume reduction surgery , endobronchial valves and endobronchial coils . [2018]

1.2.92 Refer people with COPD for an assessment for bullectomy if they are breathless and a CT scan shows a bulla occupying at least one third of the hemithorax. [2018]

1.2.93 Consider referral to a specialist multidisciplinary team to assess for lung transplantation for people who:

have severe COPD, with FEV1 less than 50% and breathlessness that affects their quality of life despite optimal medical treatment (see recommendations 1.2.11 to 1.2.17 in the section on inhaled combination therapy ) and

have completed pulmonary rehabilitation and

do not have contraindications for transplantation (for example, comorbidities or frailty). [2018]

1.2.94 Do not use previous lung volume reduction procedures as a reason not to refer a person for assessment for lung transplantation. [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on lung volume reduction procedures, bullectomy and lung transplantation .

Full details of the evidence and the committee's discussion are in evidence review G: Referral criteria for lung volume reduction procedures, bullectomy or lung transplantation .

Alpha‑1 antitrypsin replacement therapy

1.2.95 Alpha‑1 antitrypsin replacement therapy is not recommended for people with alpha‑1 antitrypsin deficiency (see also the recommendation on referral in the section on further investigations ). [2004]

Multidisciplinary management

1.2.96 COPD care should be delivered by a multidisciplinary team. [2004]

1.2.97 When defining the activity of the multidisciplinary team, think about the following functions:

assessment (including performing spirometry, assessing which delivery systems to use for inhaled therapy, the need for aids for daily living and assessing the need for oxygen)

care and treatment, including:

pulmonary rehabilitation

identifying and managing anxiety and depression

advising people on relaxation techniques

dietary issues

social security benefits and travel

hospital-at-home/early discharge schemes

non-invasive ventilation and palliative care

advising people on self-management strategies

identifying and monitoring people at high risk of exacerbations and undertaking activities to avoid emergency admissions

education for people with COPD, their carers, and for healthcare professionals. [2004]

Respiratory nurse specialists

1.2.98 It is recommended that the multidisciplinary COPD team includes respiratory nurse specialists. [2004]

Physiotherapy

1.2.99 If people have excessive sputum, they should be taught:

how to use positive expiratory pressure devices

active cycle of breathing techniques. [2004, amended 2018]

Identifying and managing anxiety and depression

1.2.100 Be alert for anxiety and depression in people with COPD. Consider whether people have anxiety or depression, particularly if they:

have severe breathlessness

are hypoxic

have been seen at or admitted to a hospital with an exacerbation of COPD. [2004, amended 2018]

1.2.101 For guidance on diagnosing and managing depression, see the NICE guideline on depression in adults with a chronic physical health problem . [2004]

1.2.102 For guidance on managing anxiety, see the NICE guideline on generalised anxiety disorder and panic disorder in adults . [2018]

Nutritional factors

1.2.103 Calculate BMI for people with COPD:

the normal range for BMI is 20 to less than 25 kg/m 2

refer people for dietetic advice if they have a BMI that is abnormal (high or low) or changing over time

for people with a low BMI, give nutritional supplements to increase their total calorific intake and encourage them to exercise to augment the effects of nutritional supplementation. [2004] The NICE guideline on obesity states that a healthy BMI range is 18.5 to 24.9 kg/m 2 , but note that this may not be appropriate for people with COPD.

1.2.104 For guidance on nutrition support, see the NICE guideline on nutrition support for adults . [2004]

1.2.105 Pay attention to changes in weight in older people, particularly if the change is more than 3 kg. [2004]

Palliative care

1.2.106 When appropriate, use opioids to relieve breathlessness in people with end-stage COPD that is unresponsive to other medical therapy. [2004]

1.2.107 When appropriate, use benzodiazepines, tricyclic antidepressants, major tranquillisers and oxygen for breathlessness in people with end-stage COPD that is unresponsive to other medical therapy. [2004]

1.2.108 People with end-stage COPD and their family members or carers (as appropriate) should have access to the full range of services offered by multidisciplinary palliative care teams, including admission to hospices. [2004]

1.2.109 For standards and measures on palliative care, see the NICE quality standard on end of life care for adults . [2018]

1.2.110 For guidance on care for people in the last days of life, see the NICE guideline on care of dying adults . [2018]

Assessment for occupational therapy

1.2.111 Regularly ask people with COPD about their ability to undertake activities of daily living and how breathless these activities make them. [2004]

1.2.112 Clinicians that care for people with COPD should assess their need for occupational therapy using validated tools. [2004]

Social services

1.2.113 Consider referring people for assessment by social services if they have disabilities caused by COPD. [2004]

Advice on travel

1.2.114 Assess people who are using long-term oxygen therapy and who are planning air travel in line with the British Thoracic Society recommendations . [2004]

1.2.115 Assess people with an FEV1 below 50% predicted who are planning air travel in line with the BTS recommendations. [2004]

1.2.116 Warn people with bullous disease that they are at a theoretically increased risk of a pneumothorax during air travel. [2004]

Advice on diving

1.2.117 Scuba diving is not generally recommended for people with COPD. Advise people with queries to seek specialist advice. [2004]

1.2.118 There are significant differences in the response of people with COPD and asthma to education programmes. Programmes designed for asthma should not be used in COPD. [2004]

1.2.119 At diagnosis and at each review appointment, offer people with COPD and their family members or carers (as appropriate):

written information about their condition

opportunities for discussion with a healthcare professional who has experience in caring for people with COPD. [2018]

1.2.120 Ensure the information provided is:

available on an ongoing basis

relevant to the stage of the person's condition

tailored to the person's needs. [2018]

1.2.121 At minimum, the information should cover:

an explanation of COPD and its symptoms

advice on quitting smoking (if relevant) and how this will help with the person's COPD

advice on avoiding passive smoke exposure

managing breathlessness

physical activity and pulmonary rehabilitation

medicines, including inhaler technique and the importance of adherence

vaccinations

identifying and managing exacerbations

details of local and national organisations and online resources that can provide more information and support

how COPD will affect other long-term conditions that are common in people with COPD (for example hypertension, heart disease, anxiety, depression and musculoskeletal problems). [2018]

1.2.122 Be aware of the obligation to provide accessible information as detailed in the NHS Accessible Information Standard . For more guidance on providing information to people and discussing their preferences with them, see the NICE guideline on patient experience in adult NHS services . [2018]

For a short explanation of why the committee made the 2018 recommendations and how they might affect practice, see the rationale and impact section on self-management, education and telehealth monitoring .

Full details of the evidence and the committee's discussion are in evidence review C: Self-management interventions, education and telehealth monitoring .

1.2.123 Advise people with COPD that the following factors increase their risk of exacerbations:

continued smoking or relapse for ex‑smokers

exposure to passive smoke

viral or bacterial infection

indoor and outdoor air pollution

lack of physical activity

seasonal variation (winter and spring). [2018]

For a short explanation of why the committee made the 2018 recommendation and how it might affect practice, see the rationale and impact section on risk factors for COPD exacerbations .

Self-management

1.2.124 Develop an individualised self-management plan in collaboration with each person with COPD and their family members or carers (as appropriate), and:

include education on all relevant points from the recommendation on the information that should be covered in the section on education

review the plan at future appointments. [2018]

1.2.125 Develop an individualised exacerbation action plan in collaboration with each person with COPD who is at risk of exacerbations. [2018]

1.2.126 Offer people a short course of oral corticosteroids and a short course of oral antibiotics to keep at home as part of their exacerbation action plan if:

they have had an exacerbation within the last year, and remain at risk of exacerbations

they understand and are confident about when and how to take these medicines, and the associated benefits and harms

they know to tell their healthcare professional when they have used the medicines, and to ask for replacements. [2018]

1.2.127 For guidance on the choice of antibiotics see the NICE guideline on antimicrobial prescribing for acute exacerbations of COPD . [2018]

1.2.128 At all review appointments, discuss corticosteroid and antibiotic use with people who keep these medicines at home, to check that they still understand how to use them. For people who have used 3 or more courses of oral corticosteroids and/or oral antibiotics in the last year, investigate the possible reasons for this. [2018]

1.2.129 See the recommendations on systemic corticosteroids for more guidance on oral corticosteroids. [2018]

1.2.130 Encourage people with COPD to respond promptly to exacerbation symptoms by following their action plan, which may include:

adjusting their short-acting bronchodilator therapy to treat their symptoms

taking a short course of oral corticosteroids if their increased breathlessness interferes with activities of daily living

adding oral antibiotics if their sputum changes colour and increases in volume or thickness beyond their normal day-to-day variation

telling their healthcare professional. [2018]

1.2.131 Ask people with COPD if they experience breathlessness they find frightening. If they do, consider including a cognitive behavioural component in their self-management plan to help them manage anxiety and cope with breathlessness. [2018]

1.2.132 For people at risk of hospitalisation, explain to them and their family members or carers (as appropriate) what to expect if this happens (including non-invasive ventilation and discussions on future treatment preferences, ceilings of care and resuscitation). [2018]

Telehealth monitoring

1.2.133 Do not offer routine telehealth monitoring of physiological status as part of management for stable COPD. [2018]

Fitness for general surgery

1.2.134 The ultimate clinical decision about whether or not to proceed with surgery should rest with a consultant anaesthetist and consultant surgeon, taking account of comorbidities, functional status and the need for the surgery. [2004]

1.2.135 It is recommended that lung function should not be the only criterion used to assess people with COPD before surgery. Composite assessment tools such as the ASA scoring system are the best predictors of risk. [2004]

1.2.136 If time permits, optimise the medical management of people with COPD before surgery. This might include a course of pulmonary rehabilitation. [2004]

Follow-up of people with COPD

1.2.137 Follow-up of all people with COPD should include:

highlighting the diagnosis of COPD in the case record and recording this using Read Codes on a computer database

recording the values of spirometric tests performed at diagnosis (both absolute and percent predicted)

offering advice and treatment to help them stop smoking, and referral to specialist stop smoking services (see the NICE guideline on stop smoking interventions and services )

recording the opportunistic measurement of spirometric parameters (a loss of 500 ml or more over 5 years will show which people have rapidly progressing disease and may need specialist referral and investigation). [2004, amended 2018]

1.2.138 Review people with COPD at least once per year and more frequently if indicated, and cover the issues listed in table 6. [2004]

1.2.139 For most people with stable severe COPD regular hospital review is not necessary, but there should be locally agreed mechanisms to allow rapid access to hospital assessment when needed. [2004]

1.2.140 When people with very severe COPD are reviewed in primary care they should be seen at least twice per year, and specific attention should be paid to the issues listed in table 6. [2004]

1.2.141 Specialists should regularly review people with severe COPD who need interventions such as long-term non-invasive ventilation. [2004]

Definition of an exacerbation

An exacerbation is a sustained worsening of the patient's symptoms from their usual stable state which is beyond normal day-to-day variations, and is acute in onset. Commonly reported symptoms are worsening breathlessness, cough, increased sputum production and change in sputum colour. The change in these symptoms often necessitates a change in medication.

Assessing the need for hospital treatment

1.3.1 Use the factors in table 7 to assess whether people with COPD need hospital treatment. Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes . [2004]

Investigating an exacerbation

The diagnosis of an exacerbation is made clinically and does not depend on the results of investigations. However, investigations may sometimes be useful in ensuring appropriate treatment is given. Different investigation strategies are needed for people in hospital (who will tend to have more severe exacerbations) and people in the community.

Primary care

1.3.2 For people who have their exacerbation managed in primary care:

sending sputum samples for culture is not recommended in routine practice

pulse oximetry is of value if there are clinical features of a severe exacerbation. Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes . [2004]

People referred to hospital

1.3.3 In all people presenting to hospital with an acute exacerbation:

obtain a chest X-ray

measure arterial blood gas tensions and record the inspired oxygen concentration

record an ECG (to exclude comorbidities)

perform a full blood count and measure urea and electrolyte concentrations

measure a theophylline level on admission in people who are taking theophylline therapy

send a sputum sample for microscopy and culture if the sputum is purulent

take blood cultures if the person has pyrexia. [2004, amended 2018]

Hospital-at-home and assisted-discharge schemes

1.3.4 Hospital-at-home and assisted-discharge schemes are safe and effective and should be used as an alternative way of caring for people with exacerbations of COPD who would otherwise need to be admitted or stay in hospital. [2004]

1.3.5 The multiprofessional team that operates these schemes should include allied health professionals with experience in managing COPD, and may include nurses, physiotherapists, occupational therapists and other health workers. [2004]

1.3.6 There are currently insufficient data to make firm recommendations about which people with COPD with an exacerbation are most suitable for hospital-at-home or early discharge. Selection should depend on the resources available and absence of factors associated with a worse prognosis (for example, acidosis). [2004]

1.3.7 Include people's preferences about treatment at home or in hospital in decision-making. [2004]

Pharmacological management

Increased breathlessness is a common feature of COPD exacerbations. This is usually managed by taking increased doses of short-acting bronchodilators.

Delivery systems for inhaled therapy during exacerbations

1.3.8 Both nebulisers and hand-held inhalers can be used to administer inhaled therapy during exacerbations of COPD. [2004]

1.3.9 The choice of delivery system should reflect the dose of drug needed, the person's ability to use the device, and the resources available to supervise therapy administration. [2004]

1.3.10 Change people to hand-held inhalers as soon as their condition has stabilised, because this may allow them to be discharged from hospital earlier. [2004]

1.3.11 If a person with COPD is hypercapnic or acidotic the nebuliser should be driven by compressed air rather than oxygen (to avoid worsening hypercapnia). If oxygen therapy is needed, administer it simultaneously by nasal cannulae. [2004]

1.3.12 The driving gas for nebulised therapy should always be specified in the prescription. [2004]

Systemic corticosteroids

1.3.13 In the absence of significant contraindications, use oral corticosteroids, in conjunction with other therapies, in all people admitted to hospital with a COPD exacerbation. [2004]

1.3.14 In the absence of significant contraindications, consider oral corticosteroids for people in the community who have an exacerbation with a significant increase in breathlessness that interferes with daily activities. [2004]

1.3.15 Encourage people who need corticosteroid therapy to present early to get maximum benefits. [2004]

1.3.16 Offer 30 mg oral prednisolone daily for 5 days. [2019]

1.3.17 For guidance on stopping oral corticosteroid therapy it is recommended that clinicians refer to the BNF. [2004]

1.3.18 Think about osteoporosis prophylaxis for people who need frequent courses of oral corticosteroids. [2004]

1.3.19 Make people aware of the optimum duration of treatment and the adverse effects of prolonged therapy. [2004]

1.3.20 Give people (particularly people discharged from hospital) clear instructions on why, when and how to stop their corticosteroid treatment. [2004]

For a short explanation of why the committee made the 2019 recommendation and how it might affect practice, see the rationale and impact section on duration of oral corticosteroid for managing exacerbations .

Full details of the evidence and the committee's discussion are in evidence review J: Length of corticosteroid use during exacerbations .

Antibiotics

1.3.21 For guidance on using antibiotics to treat COPD exacerbations, see the NICE guideline on antimicrobial prescribing for acute exacerbations of COPD . [2018]

Theophylline and other methylxanthines

1.3.22 Only use intravenous theophylline as an adjunct to exacerbation management if there is an inadequate response to nebulised bronchodilators. [2004]

1.3.23 Take care when using intravenous theophylline, because of its interactions with other drugs and potential toxicity if the person has been taking oral theophylline. [2004]

1.3.24 Monitor theophylline levels within 24 hours of starting treatment, and as frequently as indicated by the clinical circumstances after this. [2004]

Respiratory stimulants

1.3.25 It is recommended that doxapram is used only when non-invasive ventilation is either unavailable or inappropriate. [2004]

Oxygen therapy during exacerbations of COPD

1.3.26 Measure oxygen saturation in people with an exacerbation if there are no facilities to measure arterial blood gases. [2004]

1.3.27 If necessary, prescribe oxygen to keep the oxygen saturation of arterial blood (SaO 2 ) within the individualised target range. [2010]

1.3.28 Pulse oximeters should be available to all healthcare professionals involved in the care of people with exacerbations of COPD, and they should be trained in their use. Clinicians should be aware that pulse oximetry gives no information about the PaCO 2 or pH. Be aware that some pulse oximeters can underestimate or overestimate oxygen saturation levels, especially if the saturation level is borderline. Overestimation has been reported in people with dark skin. See also the NHS England Patient Safety Alert on the risk of harm from inappropriate placement of pulse oximeter probes . [2004]

1.3.29 Measure arterial blood gases and note the inspired oxygen concentration in all people who arrive at hospital with an exacerbation of COPD. Repeat arterial blood gas measurements regularly, according to the response to treatment. [2004]

Non-invasive ventilation (NIV) and COPD exacerbations

1.3.30 Use NIV as the treatment of choice for persistent hypercapnic ventilatory failure during exacerbations despite optimal medical therapy. [2004]

1.3.31 It is recommended that NIV should be delivered in a dedicated setting, with staff who have been trained in its application, who are experienced in its use and who are aware of its limitations. [2004]

1.3.32 When people are started on NIV there should be a clear plan covering what to do in the event of deterioration, and ceilings of therapy should be agreed. [2004]

Invasive ventilation and intensive care

1.3.33 Treat hospitalised exacerbations of COPD on intensive care units, including invasive ventilation when this is thought to be necessary. [2004]

1.3.34 When assessing suitability for intubation and ventilation during exacerbations, think about functional status, BMI, need for oxygen when stable, comorbidities and previous admissions to intensive care units, in addition to age and FEV1. Neither age nor FEV1 should be used in isolation when assessing suitability. [2004]

1.3.35 Consider NIV for people who are slow to wean from invasive ventilation. [2004]

Respiratory physiotherapy and exacerbations

1.3.36 Consider physiotherapy using positive expiratory pressure devices for selected people with exacerbations of COPD, to help with clearing sputum. [2004, amended 2018]

Monitoring recovery from an exacerbation

1.3.37 Monitor people's recovery by regular clinical assessment of their symptoms and observation of their functional capacity. [2004]

1.3.38 Use pulse oximetry to monitor the recovery of people with non-hypercapnic, non-acidotic respiratory failure. [2004]

1.3.39 Use intermittent arterial blood gas measurements to monitor the recovery of people with respiratory failure who are hypercapnic or acidotic, until they are stable. [2004]

1.3.40 Do not routinely perform daily monitoring of peak expiratory flow (PEF) or FEV1 to monitor recovery from an exacerbation, because the magnitude of changes is small compared with the variability of the measurement. [2004]

Discharge planning

1.3.41 Measure spirometry in all people before discharge. [2004]

1.3.42 Re-establish people on their optimal maintenance bronchodilator therapy before discharge. [2004]

1.3.43 People who have had an episode of respiratory failure should have satisfactory oximetry or arterial blood gas results before discharge. [2004]

1.3.44 Assess all aspects of the routine care that people receive (including appropriateness and risk of side effects) before discharge. [2004]

1.3.45 Give people (or home carers) appropriate information to enable them to fully understand the correct use of medications, including oxygen, before discharge. [2004]

1.3.46 Make arrangements for follow-up and home care (such as visiting nurse, oxygen delivery or referral for other support) before discharge. [2004]

1.3.47 The person, their family and their physician should be confident that they can manage successfully before they are discharged. A formal activities of daily living assessment may be helpful when there is still doubt. [2004]

Asthmatic features/features suggesting steroid responsiveness

This includes any previous, secure diagnosis of asthma or of atopy, a higher blood eosinophil count, substantial variation in FEV1 over time (at least 400 ml) or substantial diurnal variation in peak expiratory flow (at least 20%).

Exacerbation

A general classification of the severity of an acute exacerbation (from a Cochrane Library systematic review ) is:

mild exacerbation, the person has an increased need for medication, which they can manage in their own normal environment

moderate exacerbation, the person has a sustained worsening of respiratory status that requires treatment with systemic corticosteroids and/or antibiotics

severe exacerbation, the person experiences a rapid deterioration in respiratory status that requires hospitalisation.

Mild or no hypoxaemia

People who are not taking long-term oxygen and who have a mean PaO 2 greater than 7.3k Pa.

National Institute for Health and Care Excellence (NICE)

MedicalCRITERIA.com

MedicalCRITERIA.com

Unifying concepts, modified medical research council (mmrc) dyspnea scale.

The modified Medical Research Council (mMRC) scale is recommended for conducting assessments of dyspnea and disability and functions as an indicator of exacerbation.

The modified Medical Research Council (mMRC) scale

An mMRC scale grade of 3 have a significantly poorer prognosis and that the mMRC scale can be used to predict hospitalization and exacerbation.

References:

  • Natori H, Kawayama T, Suetomo M, Kinoshita T, Matsuoka M, Matsunaga K, Okamoto M, Hoshino T. Evaluation of the Modified Medical Research Council Dyspnea Scale for Predicting Hospitalization and Exacerbation in Japanese Patients with Chronic Obstructive Pulmonary Disease. Intern Med. 2016;55(1):15-24. [Medline]
  • Launois C, Barbe C, Bertin E, Nardi J, Perotin JM, Dury S, Lebargy F, Deslee G. The modified Medical Research Council scale for the assessment of dyspnea in daily living in obesity: a pilot study. BMC Pulm Med. 2012 Oct 1;12:61. [Medline]

Created Feb 10, 2021.

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Last Updated on 21 June, 2021 by Guillermo Firman

Qualitative validation of the modified Medical Research Council (mMRC) dyspnoea scale as a patient-reported measure of breathlessness severity

Affiliations.

  • 1 Respiratory Division, The George Institute for Global Health, UNSW Sydney, Sydney, Australia. Electronic address: [email protected].
  • 2 The Woolcock Institute of Medical Research and The University of Sydney, Sydney, Australia.
  • 3 Respiratory Division, The George Institute for Global Health, UNSW Sydney, Sydney, Australia. Electronic address: [email protected].
  • PMID: 36179385
  • DOI: 10.1016/j.rmed.2022.106984

Introduction: The modified Medical Research Council (mMRC) dyspnoea scale is a measure of breathlessness severity recommended by guidelines and utilised as an inclusion criterion or endpoint for clinical trials. No studies have been conducted to validate the categorical descriptors against the dyspnoea severity grade.

Methods: This study utilised cognitive interviews (Think Aloud method) to assess the content validity of the mMRC scale among 16 participants (13 with cardiac/respiratory disease). Participants were recruited to achieve representation across a variety of demographic factors. Interviews were conducted remotely via video conferencing and participants were presented with all 5 mMRC descriptors on screen in random order then asked to rank the statements "in order from the best breathing to the worst breathing".

Results: Mean age of participants was 57 years (range 22-84 years). Eleven had multimorbidity (≥2 comorbidities) including COPD, asthma, lung cancer, lung infection, interstitial lung disease, heart failure, depression, and anxiety. Length of time with breathlessness ranged between 2 weeks and >25 years. The median rank of the mMRC grade descriptors was concordant for mMRC grades 0, 1 and 4 but not grades 2 and 3. Even so, substantial heterogeneity was found in the distribution of responses for mMRC grade 0.

Conclusion: Our study found substantial heterogeneity in participant grading of the mMRC descriptors, particularly for grades 0, 2 and 3, indicating that mMRC might not be a good discriminator of difference or change in dyspnoea severity. This study demonstrates the importance of content validation even for long-established PROs like mMRC.

Keywords: Dyspnoea; Patient reported outcome measures; Validation study; mMRC dyspnoea scale.

Copyright © 2022 Elsevier Ltd. All rights reserved.

  • Aged, 80 and over
  • Biomedical Research*
  • Dyspnea / diagnosis
  • Dyspnea / psychology
  • Middle Aged
  • Patient Reported Outcome Measures
  • Pulmonary Disease, Chronic Obstructive* / drug therapy
  • Severity of Illness Index
  • Young Adult
  • Research article
  • Open access
  • Published: 01 October 2012

The modified Medical Research Council scale for the assessment of dyspnea in daily living in obesity: a pilot study

  • Claire Launois 1 ,
  • Coralie Barbe 2 ,
  • Eric Bertin 3 ,
  • Julie Nardi 1 ,
  • Jeanne-Marie Perotin 1 ,
  • Sandra Dury 1 ,
  • François Lebargy 1 &
  • Gaëtan Deslee 1  

BMC Pulmonary Medicine volume  12 , Article number:  61 ( 2012 ) Cite this article

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Dyspnea is very frequent in obese subjects. However, its assessment is complex in clinical practice. The modified Medical Research Council scale (mMRC scale) is largely used in the assessment of dyspnea in chronic respiratory diseases, but has not been validated in obesity. The objectives of this study were to evaluate the use of the mMRC scale in the assessment of dyspnea in obese subjects and to analyze its relationships with the 6-minute walk test (6MWT), lung function and biological parameters.

Forty-five obese subjects (17 M/28 F, BMI: 43 ± 9 kg/m 2 ) were included in this pilot study. Dyspnea in daily living was evaluated by the mMRC scale and exertional dyspnea was evaluated by the Borg scale after 6MWT. Pulmonary function tests included spirometry, plethysmography, diffusing capacity of carbon monoxide and arterial blood gases. Fasting blood glucose, total cholesterol, triglyceride, N-terminal pro brain natriuretic peptide, C-reactive protein and hemoglobin levels were analyzed.

Eighty-four percent of patients had a mMRC ≥ 1 and 40% a mMRC ≥ 2. Compared to subjects with no dyspnea (mMRC = 0), a mMRC ≥ 1 was associated with a higher BMI (44 ± 9 vs 36 ± 5 kg/m 2 , p = 0.01), and a lower expiratory reserve volume (ERV) (50 ± 31 vs 91 ± 32%, p = 0.004), forced expiratory volume in one second (FEV 1 ) (86 ± 17 vs 101 ± 16%, p = 0.04) and distance covered in 6MWT (401 ± 107 vs 524 ± 72 m, p = 0.007). A mMRC ≥ 2 was associated with a higher Borg score after the 6MWT (4.7 ± 2.5 vs 6.5 ± 1.5, p < 0.05).

This study confirms that dyspnea is very frequent in obese subjects. The differences between the “dyspneic” and the “non dyspneic” groups assessed by the mMRC scale for BMI, ERV, FEV 1 and distance covered in 6MWT suggests that the mMRC scale might be an useful and easy-to-use tool to assess dyspnea in daily living in obese subjects.

Peer Review reports

Obesity, defined as a Body Mass Index (BMI) greater than or equal to 30 kg/m 2 , is a significant public health concern. According to the World Health Organization, worldwide obesity has more than doubled since 1980 and in 2008 there were about 1.5 billion overweight adults (25 ≤ BMI < 30 kg/m 2 ). Of these, over 200 million men and nearly 300 million women were obese [ 1 ].

Dyspnea is very frequent in obese subjects. In a large epidemiological study, 80% of obese patients reported dyspnea after climbing two flights of stairs [ 2 ]. In a series of patients with morbid obesity, Collet et al. found that patients with a BMI > 49 kg/m 2 had more severe dyspnea assessed with BDI (Baseline Dyspnea Index) than obese patients with a BMI ≤ 49 kg/m 2 [ 3 ]. The most frequent pulmonary function abnormalities associated with obesity [ 4 , 5 ] are a decrease in expiratory reserve volume (ERV) [ 6 – 8 ], functional residual capacity (FRC) [ 6 – 8 ], and an increase in oxygen consumption [ 9 ]. Although the mechanisms of dyspnea in obesity remain unclear, it is moderately correlated with lung function [ 3 , 10 – 16 ]. Of note, type 2 diabetes [ 17 ], insulin resistance [ 18 ] and metabolic syndrome [ 19 ] have been shown to be associated with reduced lung function in obesity. It must be pointed out that dyspnea is a complex subjective sensation which is difficult to assess in clinical practice. However, there is no specific scale to assess dyspnea in daily living in obesity. The modified Medical Research Council (mMRC) scale is the most commonly used validated scale to assess dyspnea in daily living in chronic respiratory diseases [ 20 – 22 ] but has never been assessed in the context of obesity without a coexisting pulmonary disease.

The objectives of this pilot study were to evaluate the use of the mMRC scale in the assessment of dyspnea in obese subjects and to analyze its relationships with the 6-minute walk distance (6MWD), lung function and biological parameters.

Adult obese patients from the Department of Nutrition of the University Hospital of Reims (France) were consecutively referred for a systematic respiratory evaluation without specific reason and considered for inclusion in this study. Inclusion criteria were a BMI ≥ 30 kg/m 2 and an age > 18 year-old. Exclusion criteria were a known coexisting pulmonary or neuromuscular disease or an inability to perform a 6MWT or pulmonary function testing. The study was approved by the Institutional Review Board (IRB) of the University Hospital of Reims, and patient consent was waived.

Clinical characteristics and mMRC scale

Demographic data (age, sex), BMI, comorbidities, treatments and smoking status were systematically recorded. Dyspnea in daily living was evaluated by the mMRC scale which consists in five statements that describe almost the entire range of dyspnea from none (Grade 0) to almost complete incapacity (Grade 4) (Table 1 ).

  • Six-minute walk test

The 6MWT was performed using the methodology specified by the American Thoracic Society (ATS-2002) [ 23 ]. The patients were instructed that the objective was to walk as far as possible during 6 minutes. The 6MWT was performed in a flat, long, covered corridor which was 30 meters long, meter-by-meter marked. Heart rate, oxygen saturation and modified Borg scale assessing subjectively the degree of dyspnea graded from 0 to 10, were collected at the beginning and at the end of the 6MWT. When the test was finished, the distance covered was calculated.

Pulmonary function tests

Pulmonary function tests (PFTs) included forced expiratory volume in one second (FEV 1 ), vital capacity (VC), forced vital capacity (FCV), FEV 1 /VC, functional residual capacity (FRC), expiratory reserve volume (ERV), residual volume (RV), total lung capacity (TLC) and carbon monoxide diffusing capacity of the lung (DLCO) (BodyBox 5500 Medisoft Sorinnes, Belgium). Results were expressed as the percentage of predicted values [ 24 ]. Arterial blood gases were measured in the morning in a sitting position.

Biological parameters

After 12 hours of fasting, blood glucose, glycated hemoglobin (HbAIc), total cholesterol, triglyceride, N-terminal pro brain natriuretic peptide (NT-pro BNP), C-reactive protein (CRP) and hemoglobin levels were measured.

Statistical analysis

Quantitative variables are described as mean ± standard deviation (SD) and qualitative variables as number and percentage. Patients were separated in two groups according to their dyspnea: mMRC = 0 (no dyspnea in daily living) and mMRC ≥ 1 (dyspnea in daily living, ie at least short of breath when hurrying on level ground or walking up a slight hill).

Factors associated with mMRC scale were studied using Wilcoxon, Chi-square or Fisher exact tests. Factors associated with Borg scale were studied using Wilcoxon tests or Pearson’s correlation coefficients. A p value < 0.05 was considered statistically significant. All analysis were performed using SAS version 9.0 (SAS Inc, Cary, NC, USA).

Results and discussion

Demographic characteristics.

Fifty four consecutive patients with a BMI ≥ 30 kg/m 2 were considered for inclusion. Of these, 9 patients were excluded because of an inability to perform the 6MWT related to an osteoarticular disorder (n = 2) or because of a diagnosed respiratory disease (n = 7; 5 asthma, 1 hypersensitivity pneumonia and 1 right pleural effusion).

Results of 45 patients were considered in the final analysis. Demographic characteristics of the patients are presented in Table 2 . Mean BMI was 43 ± 9 kg/m 2 , with 55% of the patients presenting an extreme obesity (BMI ≥ 40 kg/m 2 , grade 3). Regarding smoking status, 56% of patients were never smokers and 11% were current smokers. The main comorbidities were hypertension (53%), dyslipidemia (40%) and diabetes (36%). Severe obstructive sleep apnea syndrome was present in 16 patients (43%).

Dyspnea assessment by the mMRC scale and 6MWT

Results of dyspnea assessment are presented in Table 3 . Dyspnea symptom assessed by the mMRC scale was very frequent in obese subjects with 84% (n = 38) of patients with a mMRC scale ≥ 1 and 40% (n = 18) of patients with a mMRC scale ≥ 2 (29% mMRC = 2, 9% mMRC = 3 and 2% mMRC = 4).

The mean distance covered in 6MWT was 420 ± 112 m. Sixteen percent of patients had a decrease > 4% of SpO2 during the 6MWT and one patient had a SpO2 < 90% at the end of the 6MWT (Table 4 ). The dyspnea sensation at rest was very slight (Borg = 1 ± 1.5) but severe after exertion (Borg = 5.4 ± 2.4). Fifty-three percent of patients exhibited a Borg scale ≥ 5 after the 6MWT which is considered as severe exertional dyspnea. No complication occurred during the 6MWT. Subjects with a mMRC score ≥ 2 had a higher Borg score after the 6MWT than subjects with a mMRC score < 2 (6.5 ± 1.5 vs 4.7 ± 2.5, p < 0.05).

Lung function tests

Results of spirometry, plethysmography and arterial blood gases are shown in Table 4 . Overall, the PFTs results remained in the normal range for most of the patients, except for ERV predicted values which were lower (ERV = 56 ± 34%). There were an obstructive ventilatory disorder defined by a FEV 1 /VC < 0.7 in 5 patients (11%) with 5 patients (13%) exhibiting a mMRC ≥ 1, a restrictive ventilatory disorder defined by a TLC < 80% in 5 patients (13%) with 5 patients (16%) exhibiting a mMRC ≥ 1, and a decrease in alveolar diffusion defined by DLCO < 70% in 10 patients (26%) with 9 patients (28%) exhibiting a mMRC ≥ 1. Arterial blood gases at rest were in the normal range with no hypoxemia < 70 mmHg and no significant hypercapnia > 45 mmHg.

Fifteen percent (n = 7) of patients presented anemia. All patients had a hemoglobin level ≥ 11 g/dL. Mean NT pro-BNP was 117 ± 285 pg/mL. Four patients (10%) had a pro-BNP > 300 pg/mL.Forty-five percent of patients had a fasting glucose level > 7 mmol/L, 51% a Hba1c > 6%, 29% a triglyceride level ≥ 1.7 mmol/L, 35% a total cholesterol level > 5.2 mmol/L and 31% a CRP level > 10 mg/L.

Relationships between the mMRC scale and clinical characteristics, PFTs and biological parameters

The comparisons between the mMRC scale and demographic, lung functional and biological parameters are shown in Table 5 . Subjects in the mMRC ≥ 1 group had a higher BMI (p = 0.01) (Figure 1 A), lower ERV (p < 0.005) (Figure 1 B), FEV 1 (p < 0.05), covered distance in 6MWT (p < 0.01) (Figure 1 C) and Hb level (p < 0.05) than subjects in the mMRC = 0 group. Of note, there was no association between the mMRC scale and age, sex, smoking history, arterial blood gases, metabolic parameters and the apnea/hypopnea index.

figure 1

Differences in Body Mass Index (BMI) (A), Expiratory reserve volume (ERV) (B) and 6-minute walk distance (C) between non-dyspneic (modified Medical Research Council score = 0) and dyspneic (mMRC score ≥ 1) subjects. *p < 0.05, **p < 0.01. A Wilcoxon test was used.

The relationships between the Borg scale after 6MWT and demographic, lung functional and biological parameters were also analysed. The Borg score after 6MWT was correlated with a higher BMI (correlation coefficient = +0.44, p < 0.005) and a lower FEV 1 (correlation coefficient = -0.33, p < 0.05). No relationship was found between the Borg score after 6MWT and ERV or hemoglobin level. The Borg score after 6MWT was correlated with a higher fasting glucose (correlation coefficient = +0.46, p < 0.005) whereas this parameter was not associated with the mMRC scale (data not shown). We found no statistically different change in Borg scale ratings of dyspnea from rest to the end of the 6MWT between the two groups (p = 0.39).

In this study, 45 consecutive obese subjects were specifically assessed for dyspnea in daily living using the mMRC scale. Our study confirms the high prevalence of dyspnea in daily living in obese subjects [ 2 ] with 84% of patients exhibiting a mMRC scale ≥ 1 and 40% a mMRC scale ≥ 2. Interestingly, the presence of dyspnea in daily living (mMRC ≥ 1) was associated with a higher BMI and a lower ERV, FEV 1 , distance covered in 6MWT and hemoglobin level. Furthermore, a mMRC score ≥ 2 in obese subjects was associated with a higher Borg score after the 6MWT (data not shown).

The assessment of dyspnea in clinical practice is difficult. Regarding the mMRC scale, two versions of this scale have been used, one with 5 grades [ 20 ] as used in this study and an other with 6 grades [ 25 ] leading to some confusion. Other scales have been also used to assess dyspnea [ 26 ]. Collet at al. [ 3 ], Ofir et al. [ 11 ] and El-Gamal [ 27 ] et al provided some evidence to support the use of the BDI, Oxygen cost diaphragm (OCD) and Chronic Respiratory Disease Questionnaire (CRQ) to evaluate dyspnea in obesity. El-Gamal et al [ 27 ] demonstated the responsiveness of the CRQ in obesity as they did measurements before and after gastroplaty-induced weight loss within the same subjects. The Baseline Dyspnea Index (BDI) uses five grades (0 to 4) for 3 categories, functional impairment, magnitude of task and magnitude of effort with a total score from 0 to 12 [ 28 ]. The University of California San Diego Shortness of Breath Questionnaire comprises 24 items assessing dyspnea over the previous week [ 29 ]. It must be pointed out that these scores are much more time consuming than the mMRC scale and are difficult to apply in clinical practice.

To our knowledge, the mMRC scale has not been investigated in the assessment of dyspnea in daily living in obese subjects without a coexisting pulmonary disease. The mMRC scale is an unidimensional scale related to activities of daily living which is widely used and well correlated with quality of life in chronic respiratory diseases [ 20 ] such as chronic obstructive pulmonary disease (COPD) [ 21 ] or idiopathic pulmonary fibrosis [ 22 ]. The mMRC scale is easy-to-use and not time consuming, based on five statements describing almost the entire range of dyspnea in daily living. Our study provides evidence for the use of the mMRC scale in the assessment of dyspnea in daily living in obese subjects. Firstly, as expected, our results demonstrate an association between the mMRC scale and the BMI in the comparison between “dyspneic” and “non dyspneic” groups. Secondly, in our between-group comparisons, the mMRC scale was associated with pulmonary functional parameters (lower ERV, FEV 1 and distance walked in 6MWT) which might be involved in dyspnea in obesity. The reduction in ERV is the most frequent functional respiratory abnormality reported in obesity [ 6 – 8 ]. This decrease is correlated exponentially with BMI and is mainly due to the effect of the abdominal contents on diaphragm position [ 30 ]. While the FEV 1 might be slightly reduced in patients with severe obesity, the FEV 1 /VC is preserved as seen in our study [ 31 ]. The determination of the walking distance and the Borg scale using the 6MWT is known to be a simple method to assess the limitations of exercise capacity in chronic respiratory diseases [ 23 ]. Two studies have shown a good reproducibility of this test [ 32 , 33 ] but did not investigate the relationships between the 6MWD and dyspnea in daily living. Our study confirms the feasibility of the 6MWD in clinical practice in obesity and demonstrates an association between covered distance in 6MWT and the presence or the absence of dyspnea in daily living assessed by the mMRC scale. It must be pointed out that the 6MWT is not a standardized exercise stimulus. Exercise testing using cycloergometer or the shuttle walking test could be of interest to determine the relationships between the mMRC scale and a standardize exercise stimulus. In our between-group comparisons, BMI and FEV 1 were associated with the mMRC scale and correlated with the Borg scale after 6MWT. Surprisingly, the ERV was associated with the mMRC scale but not with the Borg scale. Moreover, the fasting glucose was correlated with the Borg scale after 6MWT but not associated with the mMRC scale. Whether these differences are due to a differential involvement of these parameters in dyspnea in daily living and at exercise, or simply related to a low sample size remains to be evaluated.

As type 2 diabetes, insulin resistance, metabolic syndrome [ 17 – 19 ], anemia and cardiac insufficiency have been shown to be associated with lung function and/or dyspnea, we also investigated the relationships between dyspnea in daily living and biological parameters. A mMRC scale ≥ 1 was associated with a lower hemoglobin level. However, all patients had a hemoglobin level > 11 g/dL and the clinical significance of the association between dyspnea in daily living and a mildly lower hemoglobin level has to be interpreted cautiously and remains to be evaluated. Of note, we did not find any associations between the mMRC scale and triglyceride, total cholesterol, fasting glucose, HbA1C, CRP or NT pro-BNP.

The strength of this study includes the assessment of the relationships between the mMRC scale and multidimensional parameters including exertional dyspnea assessed by the Borg score after 6MWT, PFTs and biological parameters. The limitations of this pilot study are as follows. Firstly, the number of patients included is relatively low. This study was monocentric and did not include control groups of overweight and normal weight subjects. Due to the limited number of patients, our study did not allow the analysis sex differences in the perception of dyspnea. Secondly, we did not investigate the relationships between the mMRC scale and other dyspnea scales like the BDI which has been evaluated in obese subjects and demonstrated some correlations with lung function [ 3 ]. Thirdly, it would have been interesting to assess the relationships between the mMRC scale and cardio-vascular, neuromuscular and psycho-emotional parameters which might be involved in dyspnea. Assessing the relationships between health related quality of life and dyspnea would also be useful. Finally, fat distribution (eg Waist circumferences or waist/hip ratios) has not been specifically assessed in our study but might be assessed at contributing factor to dyspnea. Despite these limitations, this pilot study suggests that the mMRC scale might be of value in the assessment of dyspnea in obesity and might be used as a dyspnea scale in further larger multicentric studies. It remains to be seen whether it is sensitive to changes with intervention.

Conclusions

This pilot study investigated the potential use of the mMRC scale in obesity. The differences observed between the “dyspneic” and the “non dyspneic” groups as defined by the mMRC scale with respect to BMI, ERV, FEV 1 and distance covered in 6MWT suggests that the mMRC scale might be an useful and easy-to-use tool to assess dyspnea in daily living in obese subjects.

Abbreviations

Body Mass Index

  • Modified Medical Research Council scale

Expiratory volume in one second

Vital capacity

Forced vital capacity

Functional residual capacity

Expiratory reserve volume

Residual volume

Total lung capacity

Carbon monoxide diffusing capacity of the lung

Glycated hemoglobin

N-terminal pro brain natriuretic peptide

Serum C reactive protein.

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Acknowledgements

We thank the personnel of the Department of Nutrition and Pulmonary Medicine of the University Hospital of Reims for the selection and clinical/functional assessment of the patients.

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Launois, C., Barbe, C., Bertin, E. et al. The modified Medical Research Council scale for the assessment of dyspnea in daily living in obesity: a pilot study. BMC Pulm Med 12 , 61 (2012). https://doi.org/10.1186/1471-2466-12-61

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Agreement of the modified Medical Research Council and New York Heart Association scales for assessing the impact of self-rated breathlessness in cardiopulmonary disease

Zainab ahmadi.

1 Lund University, Faculty of Medicine, Dept of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund, Sweden

Helena Igelström

2 Dept of Neuroscience, Physiotherapy, Uppsala University, Uppsala, Sweden

Jacob Sandberg

Josefin sundh.

3 Dept of Respiratory Medicine, School of Medical Sciences, Örebro University, Örebro, Sweden

Magnus Sköld

4 Respiratory Medicine Unit, Dept of Medicine Solna and Center for Molecular Medicine, Karolinska Institutet, Stockholm, Sweden

5 Dept of Respiratory Medicine and Allergy, Karolinska University Hospital Solna, Stockholm, Sweden

Christer Janson

6 Dept of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden

Anders Blomberg

7 Dept of Public Health and Clinical Medicine, Section of Medicine, Umeå University, Umeå, Sweden

Hans Bornefalk

8 Hans Bornefalk AB, Vallentuna, Sweden

Anna Bornefalk-Hermansson

9 Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden

Magnus Ekström

Associated data.

Please note: supplementary material is not edited by the Editorial Office, and is uploaded as it has been supplied by the author.

Supplementary material 00460-2021.SUPPLEMENT

Supplementary material ONLINE SUPPLEMENT

The functional impact of breathlessness is assessed using the modified Medical Research Council (mMRC) scale for chronic respiratory disease and with the New York Heart Association Functional Classification (NYHA) scale for heart failure. We evaluated agreement between the scales and their concurrent validity with other clinically relevant patient-reported outcomes in cardiorespiratory disease.

Outpatients with stable chronic respiratory disease or heart failure were recruited. Agreement between the mMRC and NYHA scales was analysed using Cramér's V and Kendall's tau B tests. Concurrent validity was evaluated using correlations with clinically relevant measures of breathlessness, anxiety, depression, and health-related quality of life. Analyses were conducted for all participants and separately in chronic obstructive pulmonary disease (COPD) and heart failure.

In a total of 182 participants with cardiorespiratory disease, the agreement between the mMRC and NYHA scales was moderate (Cramér's V: 0.46; Kendall's tau B: 0.57) with similar results for COPD (Cramér's V: 0.46; Kendall's tau B: 0.66) and heart failure (Cramér's V: 0.46; Kendall's tau B: 0.67). In the total population, the scales correlated in similar ways to other patient-reported outcomes.

In outpatients with cardiorespiratory disease, the mMRC and NYHA scales show moderate to strong correlations and similar associations with other patient-reported outcomes. This supports that the scales are comparable when assessing the impact of breathlessness on function and patient-reported outcomes.

Short abstract

There is moderate agreement between the mMRC and NYHA scales for assessment of functional impact of breathlessness in outpatients with COPD and heart failure. https://bit.ly/2XBPuXF

Introduction

Breathlessness is a key characteristic of chronic cardiorespiratory disease, often limiting daily life [ 1 , 2 ]. Breathlessness is reported to be a stronger predictor of mortality than airflow limitation in chronic obstructive pulmonary disease (COPD) [ 3 ] and is a negative prognostic factor for survival across severities of heart failure [ 4 , 5 ].

Breathlessness comprises several dimensions that can be differentiated by the individual, including the experienced intensity and unpleasantness, the associated emotional response, and the functional impact on the individual's life [ 6 ]. In an everyday clinical context, the modified Medical Research Council (mMRC) scale is often used among COPD patients to rate the functional impact of their breathlessness [ 7 ] together with health status ratings from the COPD Assessment Test (CAT) [ 8 ]. The New York Heart Association Functional Classification (NYHA) scale is routinely used in heart failure to assess the functional impact of breathlessness on patients, to classify disease severity [ 9 ], for risk stratification as well as for clinical trial enrolment and candidacy for drugs and devices [ 10 ].

The mMRC and NYHA scales are quite alike in both content and structure, consisting of four categories with higher classes indicating more severe symptoms, limitation of physical activity and worse health [ 7 , 9 ]. While the scales share many similarities, the mMRC scale reflects the patient's subjective experience, whereas an NYHA class is assigned by a clinician on the basis of an indirect interpretation of symptoms reported by the patient or, in some cases, self-completed questionnaires. Despite being used extensively both in clinical practice and research [ 11 ], the agreement between the scales has not been reported.

Information on how well the scales correlate might be useful for patients with both lung and heart disease or when research data from studies employing both scales are compared or pooled. As of today, research including patients with chronic respiratory disease and/or heart failure may have used both scales. If the scales were interchangeable, one of the scales could be prioritised, at least when it comes to assessments of the functional impact of breathlessness.

The primary aim of this study was to evaluate the correlation between self-reported mMRC and NYHA scales and their concurrent validity with other relevant patient-reported outcome measures (PROMs) in patients with chronic respiratory disease or chronic heart failure. The secondary aim was to explore differences in terms of measurement properties between the patient groups. Our hypothesis was that the scales would show high agreement and similar concurrent validity with other PROMs.

Material and methods

Study design and population.

This was a prospective, multi-centre, cohort study of outpatients with breathlessness and physician-diagnosed chronic cardiorespiratory disease in Sweden. The database was previously used for validation of the Swedish versions of the Multidimensional Dyspnoea Profile (MDP) and Dyspnoea-12 (D-12) scales [ 12 – 14 ]. Written informed consent was obtained from all participants and the protocol was approved by the regional ethics committee at Lund University (DNr: 2016/16).

Participants were recruited from five outpatient clinics between 29 August 2016 and 23 December 2017. Inclusion criteria (all required) were: age 18 years or older; physician-diagnosed chronic respiratory disease and/or chronic heart failure; self-reported breathlessness during daily life defined as an answer “yes” to the question “did you experience any breathlessness during the last 2 weeks?”; and ability to provide written informed consent.

Exclusion criteria were: inability to write or understand Swedish adequately to participate; cognitive or other inability to participate in the study; and estimated survival less than 3 months.

Assessments

The mMRC and NYHA scales ( table 1 ) were self-completed by the participants at the first clinical visit (baseline), together with a questionnaire on demographics, smoking status and pack-years of smoking, MDP scale, D-12 scale, 0–10 numeric rating scale (NRS), disease-specific health status using the CAT scale, generic health status using the EuroQol-five dimension-five level scale (EQ-5D-5L index), the Hospital Anxiety and Depression Scale (HADS), and the Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F). The time period for all self-reported measures (except for current distressing breathlessness) was “during the previous 2 weeks”.

TABLE 1

The modified Medical Research Council (mMRC) scale and the New York Heart Association (NYHA) scale

Clinical and physiological data were obtained from the participants’ medical records on diagnosed disease; current medications; height and weight; left ventricular ejection fraction from echocardiography; spirometry post-bronchodilator values of forced expiratory volume in 1 s and, if not available, replaced by pre-bronchodilator values.

Statistical analyses

Baseline patient characteristics were tabulated using standard descriptive statistics. Agreement between the mMRC and NYHA scales was evaluated using non-parametric correlation analyses Kendall's tau B and Cramér's V. Concurrent validity with other PROMs (MDP, D-12, CAT, EQ-5D-5L index, HADS, FACIT-F and 0–10 NRS) was analysed using Spearman's rank-order correlation test. The analyses were conducted for all participants, and separately in participants with COPD and heart failure as the primary cause of breathlessness. Missing data were handled as missing at random and only complete cases were used in analyses.

Statistical significance was defined as a two-sided p-value<0.05. Statistical analyses were conducted using the software packages Stata, version 13 (StataCorp LP; College Station, TX), and Matlab R2018b (Mathworks, Inc., Natick, MA).

A total of 182 participants were included: mean age 68.6 (standard deviation ( sd ) 13.8) years; 53% women; main reasons for breathlessness were COPD (25%), asthma (21%), idiopathic pulmonary fibrosis (19%) and heart failure (19%), as shown in table 2 .

TABLE 2

Baseline characteristics in 182 patients with cardiorespiratory disease

Data are presented as mean± sd deviation or frequency (percentage) for all participants (n=182) and for participants with COPD (n=45) and heart failure (n=35), respectively, as the primary cause of breathlessness.

CAT: COPD Assessment Test; D-12: Dyspnoea-12; EQ-5D-5L: EuroQol Five-Dimension Five-Level scale; FACIT-F: Functional Assessment of Chronic Illness Therapy–Fatigue; FEV 1 : forced expired volume in 1 s; HADS: Hospital Anxiety and Depression Scale; MDP: Multidimensional Dyspnoea Profile; mMRC: modified Medical Research Council breathlessness scale; NYHA: New York Heart Association scale; VC: vital capacity (the highest value of the slow and forced VC).

Agreement between the mMRC and NYHA scales

In the total population, mMRC≥2 was reported by n=127 (70%) and, among these, all of them reported NYHA≥2. Similarly, NYHA≥2 was reported by n=180 (99%) of the total population and among them 71% also reported mMRC≥2 ( figure 1 ).

An external file that holds a picture, illustration, etc.
Object name is 00460-2021.01.jpg

Percentage of patients in each response category in the modified Medical Research Council breathlessness (mMRC) scale and the New York Heart Association (NYHA) scale. a) All patients. b) Patients with chronic obstructive pulmonary disease. c) Patients with heart failure.

The agreement between the mMRC and NYHA scales was moderate in the total sample (Cramér's V: 0.46; Kandall's tau B: 0.57; n=181). For the subgroups, similar moderate agreement was found both in participants with COPD (Cramér's V: 0.46; Kendall's tau B: 0.66; n=44) and heart failure (Cramér's V: 0.46; Kendall's tau B: 0.67; n=35).

Concurrent validity

Concurrent validity of the instruments is compared in figure 2 . The mMRC and NYHA scales associated with other PROMs very similarly, including for measures of breathlessness (MDP, D-12), health-related quality of life (CAT, EQ-5D-5L index), anxiety and depressive symptoms (HADS scores), and fatigue (FACIT-F). All estimates are shown in supplementary table E1 .

An external file that holds a picture, illustration, etc.
Object name is 00460-2021.02.jpg

Concurrent validity between the modified Medical Research Council (mMRC) scale and the New York Heart Association (NYHA) scale, respectively, and the Multidimensional Dyspnoea Profile (MDP), Dyspnoea-12 (D-12), COPD Assessment Test (CAT), EuroQol-five dimension-five level scale (EQ-5D-5L), Hospital Anxiety and Depression Scale (HADS) and the Functional Assessment of Chronic Illness Therapy–Fatigue (FACIT-F). a) All participants. b) Chronic obstructive pulmonary disease subgroup. c) Heart failure subgroup. The dashed line indicates the significance level of r (p=0.002). aff: affective; anx: anxiety; depr: depression; perc: percentage; phys: physical; tot: total.

In the two diagnosis subgroups, however, the two scales showed different patterns. Among patients with COPD, both scales showed moderate concurrent validity to all PROMs measuring breathlessness. However, the NYHA scale was not associated to the affective dimension of breathlessness (D-12 affective). In this group, the strongest concurrent validity was found between the NYHA scale and the EQ-5D-5L index ( r= −0.73). In patients with heart failure, the mMRC scale showed stronger correlations than the NYHA scale for several aspects of breathlessness (MDP and D-12 total and physical domain score) and fatigue (FACIT-F). In COPD, the NYHA scale had stronger associations to anxiety and depressive symptoms (HADS total, anxiety, depression), while the mMRC scale had no correlation to depressive symptoms (HADS depression). In heart failure, both scales had similar concurrent validity to anxiety and depressive symptoms (HADS total, anxiety). However, the NYHA scale was not associated to depressive symptoms (HADS depression).

The main findings were that, in outpatients with cardiorespiratory diseases, the mMRC and NYHA scales showed moderate agreement regarding the functional impact of breathlessness, both overall and among patients with COPD and heart failure, respectively. Since the scales are used for characterisation and discrimination of disease severity, the mMRC and NYHA scales associated in a similar way to other clinically relevant patient-reported outcomes.

The findings of moderate agreement but similar concurrent validity can be interpreted as that although the scores on the mMRC and NYHA scales are not directly interchangeable, higher scores on the scales associate similarly to markers of disease severity and relevant patient-reported outcomes.

What this study adds

This is the first study to evaluate the agreement between self-reported mMRC and NYHA scales and their concurrent validity with clinically relevant PROMs in outpatients with cardiorespiratory diseases. The present findings extend our knowledge that both scales exhibit similar concurrent validity with other relevant PROMs measuring breathlessness (assessed using D-12), health status (EQ-5D-5L index and CAT), anxiety and depressive symptoms (HADS), and fatigue (FACIT-F) and we think that these results suggest that the scales may be comparable and useful across the cardiorespiratory conditions. Findings were generally similar between the subgroups of COPD and heart failure patients. Some minor differences in correlations seen between the subgroups should be interpreted with caution owing to lower precision due to fewer participants in the subgroups. In general, the mMRC and NYHA scales seem to capture similar findings that are consistent with other PROMs in the total population as well as in COPD and heart failure.

Strengths and limitations

The strengths of the present study are that it included a large sample of outpatients in clinical practice. We included participants across a range of chronic respiratory diseases such as COPD, asthma and idiopathic pulmonary fibrosis and included a comparison group of patients with chronic heart failure. In the present study, we analysed the total sample and the subgroups separately, because in clinical practice there is usually a significant overlap of respiratory and heart disease in patients and to maximise the power of the study.

Limitations include that the number of participants in each of the groups was relatively small to allow specific analyses for those diagnoses. Although the study was multicentre, the findings should be interpreted within the context of only including individuals with knowledge of the Swedish language and, thus, require validation in other target populations and settings in order to be generalizable. In the present study, self-reported mMRC and NYHA scales were employed, in contrast with the clinician-assigned NYHA scale, which is more common in clinical practice. However, we believe that our analysis with self-reported questionnaires make the scales more comparable and the data more robust. The study was conducted in the setting of outpatient clinics, which might affect the standardisation of the conditions, including the information and instructions given in relation to the assessments. At the clinical visit, the research staff were instructed to inform the participants that the questions mostly pertained to experiences during the past 2 weeks.

Implications

The findings support that the scales measure the same underlying construct of the functional impact of breathlessness and are comparable for use in clinical practice and research when assessing the functional impact of breathlessness and in terms of patient-reported outcomes. More knowledge could be generated by recruiting larger patient samples with chronic heart failure and concurrent COPD. A few studies have been conducted and they report a prevalence of 10–35% of co-existing COPD and heart failure depending on the criteria used for diagnosis of disease [ 15 , 16 ]. In those with overlap of COPD and heart failure, either the mMRC scale or the NYHA scale could be used in clinical practice to assess the functional impact of breathlessness given that the scales seem to be comparable.

Interestingly, in the total sample, both scales were associated with anxiety and depression (HADS), but some differences were found, with the mMRC scale showing concurrent validity to depressive symptoms (HADS depression) in heart failure and the NYHA scale having better concurrent validity regarding anxiety and depression in persons with COPD. We hypothesise that this finding reflects that depression and anxiety increase along with the deterioration of physical status in people with chronic cardiorespiratory disease. Although our subgroup findings might be due to chance, given the small subgroup sizes, the stronger concurrent validity of the mMRC scale with other breathlessness scales (MDP and D-12) in chronic heart failure is of special interest and should be further validated.

The results of this study suggest that there is moderate agreement between the mMRC and NYHA scales for assessments of the functional impact of breathlessness in outpatients with COPD and heart failure.

Supplementary material

Acknowledgements.

The authors thank all research nurses who dedicated their time and work to make this study possible: nurses at the respiratory outpatient clinic in Karlskrona; Lisa Carlson, Karolinska University Hospital Solna, Stockholm; Annika Johansson and Frida Holmström, University Hospital, Umeå; Karin Johansson, Örebro University Hospital; and Jonatan Blomqvist, Lund, for help with data input and quality checking. The authors extend their warm thanks to all patients who made this research possible.

Provenance: Submitted article, peer reviewed.

This article has supplementary material available from openres.ersjournals.com

Conflict of interest: No conflicts of interest exist for the authors.

Support statement: The study was funded by unrestricted grants from the Swedish Respiratory Society, the Swedish Heart-Lung Foundation, the Swedish Society for Medical Research and the Swedish Research Council (Dnr: 2019-02081). Funding information for this article has been deposited with the  Crossref Funder Registry .

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    1. Introduction. Breathlessness is a highly prevalent symptom [1] and a prognostic marker for many respiratory diseases [2, 3].Various scales are used to measure breathlessness severity; the modified Medical Research Council (MRC) dyspnoea scale ("mMRC") measures the effect of breathlessness on daily activities, and is recommended in respiratory guidelines [3] and as a core endpoint in ...

  22. The modified Medical Research Council (mMRC) scale

    The scale ranges from 0 to 4, where higher grade correlates to less exertion before breathlessness supervenes [26]. mMRC 1 is defined as breathlessness when hurrying or walking up a slight hill ...

  23. Agreement of the modified Medical Research Council and New York Heart

    Concurrent validity between the modified Medical Research Council (mMRC) scale and the New York Heart Association (NYHA) scale, respectively, and the Multidimensional Dyspnoea Profile (MDP), Dyspnoea-12 (D-12), COPD Assessment Test (CAT), EuroQol-five dimension-five level scale (EQ-5D-5L), Hospital Anxiety and Depression Scale (HADS) and the ...