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Clinical Investigations: ASTHMA |

Ethnic Differences*: Word Descriptors Used by African-American and White Asthma Patients During Induced Bronchoconstriction FREE TO VIEW

Grace E. Hardie, PhD, RN; Susan Janson, DNSc, RN; Warren M. Gold, MD; Virginia Carrieri-Kohlman, DNSc, RN; Homer A. Boushey, MD
Author and Funding Information

*From the University of California San Francisco, School of Nursing and Department of Medicine, San Francisco, CA

Correspondence to: Grace E. Hardie, PhD, Asst. Professor, San Francisco State University, 1600 Holloway Ave, BH 387, San Francisco, CA 94132; e-mail: ghardie@itsa.ucsf.edu or ghardie@SFSU.edu



Chest. 2000;117(4):935-943. doi:10.1378/chest.117.4.935
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Study objectives: To determine if African-American and white patients with asthma (1) differ in the words they use to describe their breathlessness, and (2) differ in their perception of breathlessness.

Design: Descriptive cross-sectional design.

Setting and participants: The study setting was located in Northern California, an ethnically and economically diverse area. A total of 32 subjects, 16 per group, completed the study.

Measurements: All had a provocation concentration of methacholine chloride causing a 30% fall in FEV1 (PC30) of ≤ 8 mg/mL. Serial pulmonary function testing was performed. Breathlessness was measured using the Borg scale and the visual analog scale. Word descriptors were measured by an open-ended word descriptor questionnaire.

Results: Significant ethnic differences in the words used to describe the sensation of breathlessness were present at PC30. African Americans used upper airway word descriptors: tight throat (p < 0.0004), scared-agitated (p < 0.006), voice tight (p < 0.04), itchy throat (p < 0.03), and tough breath (p < 0.04). Whites used lower airway or chest-wall symptom descriptors: deep breath (p < 0.03), lightheaded (p < 0.03), out of air (p < 0.01), aware of breathing (p < 0.03), and hurts to breathe (p < 0.06). In addition, African Americans required a significantly smaller, 44.3% (mean), dose of methacholine to achieve PC30 (p < 0.02).

Conclusion: This study provides valuable new information about ethnicity and the words used to describe breathlessness during airflow obstruction. Asthmatic African Americans used primarily upper airway word descriptors; whites used lower airway or chest-wall word descriptors. Effective symptom monitoring requires asking the correct question and awareness that ethnic differences in the words used to describe breathlessness may exist.

Figures in this Article

Our knowledge of both symptom perception and the word descriptors for breathlessness used by African Americans with asthma is extremely limited. The present word descriptors for breathlessness are derived from samples of primarily white subjects, and do not reflect the impact of culture and language on symptom perception. Asthma patients are frequently asked by health professionals to describe their sensations of breathlessness using the symptom terms shortness of breath, chest tightness, and wheezing; these terms are culturally limiting. The “language” of breathlessness has not been previously explored for African Americans with asthma.

In the United States, the death rate from asthma is three times higher for African Americans than for whites.1In addition, African Americans with asthma experience limited access to care, may not receive appropriate treatment in the emergency department, and are at a greater risk of death during acute asthma attacks than whites.2 One approach to improve asthma management for African Americans is to understand the specific words or phrases that they use to describe their symptoms during episodes of airflow obstruction. Knowledge of the words used by African Americans at those times may facilitate self-management approaches responsive to their ethnicity.

Simon and colleagues,2in a study of white patients, noted an association between specific word descriptors, or statements, with specific respiratory conditions.3 For example, some of the words associated with particular conditions are exhalation with asthma, and suffocation with congestive heart failure.,2However, ethnic differences in the perception of sensations of breathlessness during episodes of airflow obstruction and in the words used to describe that perception have not been studied previously. In our study, we undertook to have African Americans and whites with asthma describe, in their own words, the sensation of breathlessness that they experience during induced airflow obstruction; our purpose was to find out if the language of breathlessness is unique or shared across cultures.34 A second purpose was to determine if African Americans and whites with asthma differ in how they perceived their sensation of breathlessness during airflow obstruction. The phrase language of breathlessness is defined here as the words used by a particular ethnic group to describe its symptoms of breathlessness.

Study Site and Populations

The study setting and research laboratory were located in Oakland, California, an ethnically and economically diverse community in the East Bay, across from San Francisco. This East Bay area has a large African-American population where the prevalence in asthma has increased. As a result, it is not unusual for the local residents of this East Bay area to use emergency departments as their primary source of health care. Thus, the study participants came from a wide geographic area that included San Francisco, San Rafael, Oakland, Berkeley, Fremont, San Ramon, Livermore, Martinez, Vallejo, and Walnut Creek.

Subjects were recruited either through advertisements in two local East Bay newspapers or from the Asthma Clinical Research Center at University of California, San Francisco. Informed consent was obtained in accordance with the guidelines of the Committee on Human Research at the University of California, San Francisco. Inclusion criteria were as follows: FEV1, ≥70% of predicted normal; provocative concentration of methacholine causing a 30% fall in FEV1 (PC30), ≤ 8 mg/mL; either African-American or white ethnicity; a diagnosis of asthma; age, 18 to 60 years; intermittent use only of an inhaled β-agonist; and atopy as indicated by two or more positive skin prick reactions (wheal diameter ≥3 mm) to 12 extracts of allergens common to Northern California. Exclusion criteria were as follows: any significant coronary artery disease, or history of malignancy (≤ 5 years); diabetes mellitus, immune disorders, or hypertension; smoking history≥ 10 pack-years or any smoking in the last year; use of either inhaled or oral corticosteroids, oral theophyllines or antihistamines in the last 6 weeks; and an exacerbation of asthma, or a cold, or flu-like symptoms, in the last 6 weeks.

Word Descriptor Questionnaire

An open-ended word descriptor questionnaire allowed subjects to describe in their own words the sensations and/or symptoms they were experiencing during induced airflow obstruction. The questionnaire was a blank form except for lines and the heading identifying it as the word descriptor form. The blank form allowed subjects to describe in their own words the breathing discomfort they were feeling at that time, and they were informed that they could use as many words as necessary to explain the sensation(s) they were experiencing at that time. In addition, they were informed that there were no correct answers and that we were interested only in their personal descriptions of the sensation(s) that related to their breathing discomfort. During the challenge, the word descriptor questionnaires were administered 2 min after each methacholine dose; subjects were not allowed to see their prior word descriptor questionnaires.

Breathlessness Measurements

To measure the perception of breathlessness during induced airflow obstruction (by a methacholine challenge), we used both the modified Borg scale 56 and the visual analogue scale (VAS).7 Breathlessness was defined as the sensation subjects may feel when their asthma is worse, and that they may feel this sensation as unpleasant or distressful. Before any procedures, from a written script on a flash card, the following instructions on how to fill out the Borg scale and the VAS were read to each subject:“ During the challenge your breathing may change. Two minutes after each dose, I will ask you to rate the sensation of breathlessness that you feel. You may feel this sensation as unpleasant, or as distress, and it may be similar to the sensation you experience when your asthma is worse.”

Subjects were instructed on how to “mark” both the modified Borg scale and VAS. For the Borg scale, they were asked to select either a verbal descriptor or a numerical value that best represented their sensation of breathlessness at that moment. For the VAS, a 100-mm scale was used with the words not breathless as the lower anchor and extremely breathless as the upper anchor (word). Subjects were instructed to mark a straight vertical line, such that its position was relative to the two extreme anchors. In addition, subjects were instructed that they could use the entire scale to rate their sensation of breathlessness.

Pulmonary Function

Baseline pulmonary function testing (PFT) was performed using a Collins Eagle II system water-seal 8-L spirometer (Warren Collins; Quincy, MA). A minimum of three maneuvers were performed until three reproducible maneuvers (within 5%) were obtained.89 The best maneuver was selected, and this served as the baseline. We measured FEV1, FVC, peak expiratory flow rate, and forced expiratory flow after 25 to 75% of vital capacity had been expelled.

All PFT results reported have been corrected for race and body size, since race has been shown to be an important determinant of lung function. African Americans have a smaller trunk/leg ratio than white persons.1011 As a result, African Americans have smaller (13% less) static and dynamic lung volumes.1011 To accommodate for these differences, a 13% reduction in the predicted volumes 8,10 for African Americans was programmed, as a permanent feature, into the pulmonary function software.

Methacholine Challenge

Methacholine chloride was administered using a standardized procedure.12 A DSM-2 Micro-Dosimeter (S & M Instruments; Doylestown, PA) was used to nebulize the methacholine. Aerosols were nebulized using a Devilbiss 646 nebulizer (Devilbiss Health Care; Somerset, PA) and oxygen, regulated to generate 20 lb/square inch, with an output of 0.13 mL/min. After an initial control solution of a buffered phosphate saline solution, doubling concentrations of methacholine (0.078 to 10 mg/mL) were given, and subjects were instructed to inspire from functional residual capacity to total lung capacity for a total of five inhalations of each solution. The response was measured 3 min after completion of the inhalation, and another dose was given 5 min after completion of the prior dose. We stopped the test when the FEV1 had fallen by ≥ 30% (PC30) or when a subject had been given 8 mg/mL of methacholine. We selected a 30% fall in the FEV1 as the end point to ensure that the sensation of breathlessness was induced across the cohort. By selecting a PC30 rather than the conventional provocative concentration causing a 20% fall in FEV1 (PC20), we hoped to replicate, to some degree, the symptoms experienced by an asthma patient during a spontaneous asthma attack.

Protocol

Subjects were asked to withhold inhaled bronchodilators, caffeine, and alcohol for 8 h before testing. If a subject had to use an inhaler within 8 h of the visit, the visit was rescheduled.

First, the laboratory procedures, (challenges, breathlessness measures, and word descriptor questionnaire) were explained to a subject, and then informed consent was obtained. All subjects had a screening chest examination prior to PFT, and if any adventitious breath sounds (wheezing) were present, the subject’s visit was rescheduled. Demographic data were collected, and allergen skin testing was performed. Before baseline spirometry was performed, baseline breathlessness measurements were obtained. Subjects were asked to rate their breathlessness by both the modified Borg scale and the VAS. In addition, they were asked to describe in their own words, in writing, any sensations of breathlessness that they were having at that time. All the breathlessness measurements, including the word descriptor questionnaires, were obtained 2 min after each methacholine dose using new breathlessness measurements forms until a PC30 was achieved.

Statistical Analysis

Values are expressed as mean ± SD, and the word descriptors are expressed as χ2 or by p value. A p value< 0.05 was considered statistically significant.

The PC30 was measured from a linear interpolation of the FEV1 against the logarithmic transformation of the methacholine concentration.13 A PC30 was calculated for each subject and then for each group; the group results are expressed as mean ± SEM.

For the purpose of data analysis, the study population was classified into two groups, white and African American, in order to delineate the effect of race on specific study variables. A Student’s t test for unpaired data was used to assess for group differences, in the FEV1, and in the Borg and VAS scores.14 A repeated measure analysis of variance (ANOVA) was used to determine the change in breathlessness scores in each of the two groups at each measurement level from baseline, diluent, PC20, to PC30. A repeated measure ANOVA was, also, used to evaluate the effect of race on the change in FEV1, percent predicted FEV1 (PPFEV1), and on the Borg and VAS scores in each of the two groups. A multivariate analysis assessed the linear associations and interactions of race, in each of the two groups, on the change in FEV1, PPFEV1, the dose of methacholine at PC30, and the change, over time (during the methacholine challenge), in the Borg and VAS scores.

Word descriptors collected after each measurement interval from each person in both groups were ranked and coded according to the frequency of the same or similar word descriptor response. The word descriptors from each measurement interval that occurred most frequently (used by≥ 75% of the participants in each group) formed a word cluster for that ethnic group. χ2 testing was conducted on all the word descriptors (clusters) collected at baseline, diluent, PC20, and PC30 for each group. All analyses were conducted using SPSS 6.1 for Macintosh (SPSS; Chicago, IL).

Forty subjects were enrolled; 32 completed the study (16 African-American and 16 white asthmatics). Eight subjects were excluded because they did not have a PC30 ≤ 8 mg/mL. Six of the eight subjects excluded were African Americans, and all of those excluded were novices to the methacholine challenge procedure. The sample characteristics of those who completed the study are summarized in Table 1 . There were no significant differences between the African Americans and whites in age, baseline FEV1, FVC, PPFEV1, level of education, smoking history, allergen skin testing, or β-agonist use (Table 1). All of the participants had at least a high school education, and the socioeconomic status of the two groups were comparable (Table 1). One difference was that the African-American group subjects were twice as likely to report nocturnal awakenings or asthma symptoms that woke them up at night (relative risk, 1.5).15

Pulmonary Function–Bronchoconstrictor Challenge

At baseline, the mean FEV1 (2.85 L for African Americans and 3.25 L for whites) did not differ significantly between groups (Fig 1 and Table 2 ). Moreover, the mean PPFEV1, which adjusts for physiologic ethnic differences,1011,13 was comparable between groups (95.7% for African Americans and 99.3% for whites). Of significance was the actual dose of methacholine in milligrams required to induce a PC30(Table 2). At PC30, the African-American group had a mean methacholine dose of 2.71 mg (Fig 2 ), compared to the white group, who had a mean methacholine dose 5.19 mg (p < 0.02, ANOVA). Both groups reached comparable levels (Table 2) of airflow obstruction at PC30, even though the methacholine dose varied significantly. At PC30, the absolute change in FEV1, by group, was explained by race (p < 0.03; r = 0.88).

As expected, the VAS/FEV1 slopes were negatively correlated (r = 0.89 for African Americans; r = 0.84 for whites), indicating that as airflow obstruction increased, subjects rated their breathlessness higher on the VAS scale (Fig 3 ). The VAS/Δ FEV1 data presented in Figure 3 reflects the effects of race on changes (percentage) in the FEV1 and VAS scores from baseline to PC30.

Word Descriptors

The following word descriptors represent the unique language and personal interpretation of breathlessness by asthmatic African Americans and whites. Because one of the study purposes was to determine if the perception of breathlessness varied by ethnicity, only those word descriptors collected at PC30 are reported. By ethnicity, the word descriptors were uniquely different. The χ2 test criteria for a “word” to be included in the descriptor list were as follows: (1) that not > 20% of observed frequencies could be less than five, and (2) that at least 75% of the subjects in a group used that “word.” To describe their perception of breathlessness at PC30 (Table 3 ), a combined total of 28 distinct word descriptors were used by both groups. These 28 word descriptors were then statistically ranked and ordered according to a similarity of phrasing for each group. Examples of similar phrases that were clustered together during the data analysis are tight throat and throat discomfort. From this clustering of the phrases, 25 distinct word descriptors resulted and these words reflect a shared perception or language of words for each ethnic group (Table 3).

Using the preset criteria for χ2 testing at PC30 resulted in five significantly different word descriptors for each group (Table 3). These significant word descriptors were words that were used only by that particular group. The five distinct word descriptors associated with the African-American group were as follows: tight throat (p < 0.0004), scared-agitated (p < 0.006), voice tight (p < 0.04), itchy throat (p < 0.03), and tough breath (p < 0.04; Table 3). The five distinct word descriptors associated with the white group were as follows: deep breath (p < 0.03), lightheaded (p < 0.03), out of air (p < 0.01), aware of breathing (p < 0.03), and hurts to breathe (p < 0.06). To explain the ethnic differences in the word descriptors, we correlated the word descriptor data with both the absolute change in the FEV1 and with the increasing doses of methacholine. There was a correlation between the absolute decrease in the FEV1 and the use of specific word descriptors for both groups (r = 0.70). That is, as their FEV1 decreased, both groups used word descriptors that reflected more sensory discomfort suggestive of greater airflow obstruction. There was no correlation between the dose of methacholine and the use of specific word descriptors, nor was gender a factor in the word descriptors used by the African-American group.

We also evaluated if any similarities in the language of breathlessness were present between the two ethnic groups and found that only 15% in each group used similar or shared words during the study. We did test participants on different days to prevent any communication or“ sharing of words” between the individuals.

Breathlessness Scores

The mean baseline VAS score for the African-American group was 14.25 mm, whereas the white group was 11.00 mm (Fig 4 ). A one-way ANOVA was used to test for group differences (race) between the two groups at baseline VAS scores (F = 4.39, degrees of freedom: 2, 30; p < 0.04). Race was a factor in the change in the VAS scores for the two groups, from baseline to PC30 (p < 0.000).

The mean Borg scores for the two groups at all testing intervals, 1.09 to 5.25 for African Americans and 0.90 to 4.75 for whites, were not statistically significant (Fig 4). This lack of variability in Borg scores or equal variances between the two groups was documented by the large significance levels (t test) at baseline (p < 0.63) and at PC30 (p < 0.5, repeated measures ANOVA).

The VAS and Borg scores confirmed that both groups correctly perceived the breathlessness induced by acute airflow obstruction at PC30. To assess if the degree of airflow obstruction influenced their perception of breathlessness, we examined the breathlessness scores at PC20 for both groups. We found that at PC20, the African-American group had a significantly lower perception of breathlessness than the white group (p < 0.00), which was not present at PC30. We further analyzed the breathlessness scores of each group to establish if age, race, or gender confounded perception, and were unable to determine any relationships between these variables.

This is the first study to report that words used to describe sensations associated with induced bronchoconstriction differed between African Americans and whites. We found that African-American asthmatic subjects used only upper airway word descriptors to describe their sensations of breathing discomfort, whereas white asthmatic subjects used lower airway word descriptors suggesting chest wall discomfort. It must be acknowledged that provoking airflow obstruction by a methacholine challenge, as a laboratory analog of an asthma exacerbation, may produce different sensations/symptoms than during a spontaneous asthma attack. However, we believe this study provides a beginning step toward a better understanding how ethnicity affects symptom interpretation and, in turn, symptom reporting.

The upper airway word descriptors (eg, tight throat and voice tight) used by asthmatic African Americans were unique to them. What is unusual about those word descriptors is the absence of the symptom words of wheezing and shortness of breath, as described in other studies on the language of breathlessness.23 None of the asthmatic African Americans used either wheezing or shortness of breath to describe their perception of sensations during induced bronchoconstriction. Only one asthmatic white subject used the term shortness of breath, and this particular person had previous methacholine challenges. It is unusual for the term shortness of breath to be used by a nonhealth professional, and the use of this word likely reflects a learned vocabulary resulting from prior interactions with health professionals. Two white subjects, at PC30, did use terms, whistling and breath catches, that suggest wheezing-like symptoms.

Not only do these word descriptors, voice tight and tight throat, reflect ethnic differences in the qualities of breathlessness, but they also reflect a difference in where the respiratory sensations are felt. The reasons for these differences are not known, but some plausible explanations might be as follows: (1) The mechanisms and the sensations associated with airflow obstruction are different or are mediated through different pathways based on ethnicity.15 If a heightened sensory experience was present, then they may have “felt” their symptoms more intensely in their throat. (2) The throat symptoms described by the African-American group were due to the methacholine solution and not a sensation of breathlessness. However, our belief is that the methacholine solution was not a factor for several reasons. First, we are not aware of any studies validating a relationship between methacholine-induced symptoms and ethnicity. Secondly, but more importantly, the white subjects who inhaled similar doses of methacholine reported no throat sensations. (3) It is possible that the two groups may have interpreted the word descriptor instructions differently. For example, one group could have rated their breathing discomfort, whereas the other group rated their breathlessness. Both groups did receive identical instructions on how to rate their breathlessness, and a standardized verbal and written script was used. (4) Another possibility is that the upper airway symptoms represented vocal cord dysfunction caused by a critical orifice that limited maximal airflow. We did examine several of the flow-volume curves for this group for indications of upper airway obstruction and noted no abnormalities. A direct examination of the vocal cords by endoscope was not performed since we did not expect to find upper airway symptoms. (5) A final consideration is whether the upper airway symptoms represented a different effect of a deep breath on airway function and/or symptoms. For subjects with mild asthma, a deep breath may cause a decrease in airway smooth muscle tone, whereas a deep breath for subjects with moderate to severe asthma has increased muscle tone. The deep breath is part of the FVC test, and thus the test used to detect airflow obstruction may affect the degree of airflow obstruction. To answer this question, future studies need to use body plethysmography and to measure airway resistance.

Another important finding was that, as a group, African Americans required a smaller dose of methacholine to induce a 30% reduction in their FEV1 (p < 0.02). Their lower baseline FEV1, their smaller lung size, and their smaller airway caliber,1011,13 may in part explain why they required a lower dose of methacholine (Fig 2). Another explanation would be if at PC30, the two groups did not have comparable levels of airflow obstruction. When we analyzed the PFT data using the PPFEV1(Table 2), the mean PPFEV1 was 62% for the African-American group and 62.2% for the white group. Future studies conducted in a body box may provide an answer to the why the dose of methacholine varied so greatly between these two ethnic groups.

Several of the word descriptors collected from the African-American group are worth discussing. For example, tight throat was used by 81% of the African-American subjects to describe their sensations of breathing discomfort at PC30. We have anecdotal knowledge of other asthmatic African Americans not enrolled in this study who use the phrase tight throat during acute asthma attacks. When these individuals were asked about this phrase, they stated that tight throat was their primary symptom; they also stated that they did not perceive their asthma sensations in their chest, nor across their chest, nor as chest tightness. Also, it is unlikely that the word descriptors used by the African-American group represent a regional or “street” language, since the participants came from a wide geographic area.

In addition, two of the African-American subjects used only the words itchy throat to describe their breathlessness at PC30. Itchy is not a word normally associated with significantly reduced airflow, and it is reasonable to assume that a health care provider would misinterpret this symptom. As a result, the words that African Americans use to describe their breathing sensations may contribute to an undertreatment of their asthma or lead health professionals to underestimate the severity of an exacerbation, especially if objective measurements of airflow are not made.2In order to ascertain accurate symptoms, health professionals must ask open-ended questions and realize that the standard asthma symptom descriptors (wheezing, chest tightness) presently used by health professionals may not apply across ethnic groups.3,16 Our findings support the National Asthma Education and Prevention Program guidelines that mandate objective measures of lung function to document the severity of airflow obstruction and not to rely on symptoms alone.

The lower airway word descriptors (eg, need to take a deeper breath) used by the white group are consistent with the findings of other studies of white cohorts.23,17 To illustrate this point, Elliott and colleagues 3 found that certain word descriptors (eg, aware of breathing, need to take a deep breath, and not enough air) reflected mechanical or chest sensations. In turn, Simon and colleagues,2 found similar word descriptors (eg, being out of air and breath stops) were used by normal volunteers to describe their chest tightness.

It is possible that the symptoms experienced at PC30 may have been exaggerated, since some subjects in both groups experienced airflow reduction > 30%. However, comparable levels of airflow obstruction did occur in both groups (Fig 1): mean FEV1 reduction was 32% for African Americans and 34% for whites. Thus, it is reasonable to assume that the symptoms experienced were similar (Table 2). However, to verify if these two ethnic groups actually shared a similar symptom experience is difficult to determine, since comparable studies using a PC30 are lacking.

Whether or not culture or ethnicity affected how the VAS and Borg scale was scored was not assessed. It would, however, be valuable to determine if the words or the numerical values on the Borg scale are used differently by different cultural and racial groups. We assumed, because the Borg scores did not differ, that the two groups interpreted the scale similarly. However, it is possible that one group used the word ratings on the Borg scale, while the other group used the numerical ratings. For example, 5 and severe are paired as a rating on the Borg scale; for some individuals, when their asthma symptoms become severe, this is when they decide go to the emergency department for treatment.1819 Thus, by selecting the term severe, an underestimation of breathlessness could have occurred. The Borg scale is recognized as a valid measure of dyspnea intensity or magnitude during exercise in patients with COPD; however, it is unclear if asthma patients perceive or sense their breathlessness as intensity.,6,18,2021

In our study, we found that the VAS, an interval measurement (Fig 4), to be a more sensitive measure to assess the changes in the perception of breathlessness.6,18,22 We believe that the openness or the lack of words on the VAS allowed the two ethnic groups more control over how they rated their sensations. Furthermore, it is this subjective assessment of the symptoms reflecting the sensory experience of breathlessness that may more clearly define or explain the perception of breathlessness in asthmatics.6,2324

A final concern was that several subjects in both groups had breathlessness symptoms at baseline (Fig 4). On the day of the visit, a subject’s asthma had to be in “good” control. Those individuals with the higher baseline breathlessness scores were novices to the methacholine challenge procedure, and their anxiety about the procedure may have been a contributing factor. Conversely, we were concerned that those subjects who had prior methacholine challenges rated their breathlessness differently. Nineteen of the 32 subjects were novices to methacholine procedure. In the future, the data will be analyzed to determine if having prior methacholine challenges influenced how a subject scored his or her breathlessness.

In summary, clinicians need to be aware that the report of upper airway symptoms by African Americans with asthma may be a very typical presentation of acute airflow obstruction, and to acknowledge the significance of these symptoms. Word descriptors reflect the distinct qualities of the language of breathlessness, and as health professionals, we must ask the correct symptom questions to determine the appropriate interventions. Applying these ethnic language descriptors to symptom monitoring, especially in the area of emergency care, has the potential to reduce the present rise in asthma mortality in asthmatic African Americans. A requirement for effective symptom monitoring, assessment, and management is a clear, understandable, and culturally sensitive dialog between health care professionals and their patients. Educating health professionals about the unique ethnic language of breathlessness may prevent the undertreatment of asthmatic African Americans during acute asthma episodes.

Abbreviations: ANOVA = analysis of variance; PC20 = provocative concentration of methacholine causing a 20% fall in FEV1; PC30 = provocative concentration of methacholine causing a 30% fall in FEV1; PFT = pulmonary function testing; PPFEV1 = percent predicted FEV1; VAS = visual analog scale

Supported by a UCSF Graduate Research Award; a Nurse Training Grant in Symptom Management, T32-NR07088–01; and the American Nurses Foundation, R#29.

Table Graphic Jump Location
Table 1. Sample Characteristics
* 

Every 1 to 2 mo.

 

All PFT data have been corrected for race and body size.

 

p<0.02; p value reported as ANOVA.

Figure Jump LinkFigure 1. Methacholine challenge: differences in FEV1 from baseline to PC30 by ethnicity.Grahic Jump Location
Table Graphic Jump Location
Table 2. Methacholine Challenge Results*
* 

FEV1 reported in liters; all PFT data corrected for race and body size.

 

p values that were significant.

 

p values reported as ANOVA repeated measures.

Figure Jump LinkFigure 2. Differences in the dose of methacholine at PC30 by ethnicity. McH = methacholine chloride.Grahic Jump Location
Figure Jump LinkFigure 3. Correlation of change in FEV1 with mean VAS scores by group: baseline to PC30 (n = 32).Grahic Jump Location
Table Graphic Jump Location
Table 3. Word Descriptors Used at PC30 by Ethnicity*
* 

p values by χ2 test.

 

75% of the subjects in each group had to use the word to be included in the cluster analysis.

Figure Jump LinkFigure 4. Breathlessness scores: Borg scale and VAS from baseline FEV1 to FEV1 at PC30.Grahic Jump Location
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Belman, M, Brooks, L, Ross, D, et al Variability of breathlessness measurement in patients with chronic obstructive pulmonary disease.Chest1991;99,566-571. [PubMed]
 
Roisman, G, Peiffer, C, Lacronique, J, et al Perception of bronchial obstruction in asthmatic patients: relationship with bronchial eosinophilic inflammation and epithelial damage and effect of corticosteroid treatment.J Clin Invest1995;96,12-21. [PubMed]
 
Cournoyer, I, Boulet, L-P, Deschesnes, F, et al Perception of airflow obstruction and breathlessness in normals and asthmatics: correlation with anxiety and bronchodilator needs.J Allergy Immunol1993;91,267-269
 
Mador, M, Kufel, T Reproducibility of visual analog scale measurements of dyspnea in patients with chronic obstructive pulmonary disease.Am Rev Respir Dis1992;146,82-87. [PubMed]
 

Figures

Figure Jump LinkFigure 1. Methacholine challenge: differences in FEV1 from baseline to PC30 by ethnicity.Grahic Jump Location
Figure Jump LinkFigure 2. Differences in the dose of methacholine at PC30 by ethnicity. McH = methacholine chloride.Grahic Jump Location
Figure Jump LinkFigure 3. Correlation of change in FEV1 with mean VAS scores by group: baseline to PC30 (n = 32).Grahic Jump Location
Figure Jump LinkFigure 4. Breathlessness scores: Borg scale and VAS from baseline FEV1 to FEV1 at PC30.Grahic Jump Location

Tables

Table Graphic Jump Location
Table 1. Sample Characteristics
* 

Every 1 to 2 mo.

 

All PFT data have been corrected for race and body size.

 

p<0.02; p value reported as ANOVA.

Table Graphic Jump Location
Table 2. Methacholine Challenge Results*
* 

FEV1 reported in liters; all PFT data corrected for race and body size.

 

p values that were significant.

 

p values reported as ANOVA repeated measures.

Table Graphic Jump Location
Table 3. Word Descriptors Used at PC30 by Ethnicity*
* 

p values by χ2 test.

 

75% of the subjects in each group had to use the word to be included in the cluster analysis.

References

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Cournoyer, I, Boulet, L-P, Deschesnes, F, et al Perception of airflow obstruction and breathlessness in normals and asthmatics: correlation with anxiety and bronchodilator needs.J Allergy Immunol1993;91,267-269
 
Mador, M, Kufel, T Reproducibility of visual analog scale measurements of dyspnea in patients with chronic obstructive pulmonary disease.Am Rev Respir Dis1992;146,82-87. [PubMed]
 
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