The COVID-19 pandemic has resulted in the widespread use of facemasks globally. Facemasks contribute to the protection against contamination of the people wearing them and those in close proximity, and they also protect against the fear of contamination. Wearing facemasks is, however, associated with a series of material constraints: you have to think about the mask, to have it with you, to pay for it, to change it, or to wash it frequently. Facemasks are also associated with marked sociological inconveniences, obstructing verbal communication (eg, muffled voice, invisible lip movements) and hindering non-verbal communication by making facial expressions hard to read. Facemasks can also be uncomfortable to wear. Primarily, being slightly resistive to airflow and a possible source of carbon dioxide rebreathing, they change our relationship with our own breathing. We suddenly become consciously aware of our respirations, and many of us find this unsettling. What if there was a sociological upside to this particular consequence of wearing protective masks? What if this could make us more attentive to the predicament of patients with chronic breathing problems? Ordinarily, the continual neural bombardment from respiratory-related afferents that our brain receives is fully gated out, and, once passed the trial of our very first breath, breathing comes naturally and we are not consciously aware of it, even when it is disturbed by mild exercise or speech. But disease-related alterations of the respiratory system arising from lung, heart, or neuromuscular abnormalities can put an end to this so-called respiratory felicity. These alterations can result in breathing becoming faster, shallower, laboured, noisy, or associated with the abnormal use of certain muscles. Most importantly, they can result in dyspnoea, namely breathing becoming a conscious act (sensory dimension) and an emotionally disturbing one (affective dimension). This multidimensional negative respiratory experience, of which the felt intensity can be disconnected from the extent of the underlying respiratory abnormalities, is a symptom—an alarm signal. But beyond that, it is a life-altering existential experience, with psychological, behavioural, and social consequences. This is especially true when dyspnoea cannot be improved by treatments to correct its causative pathophysiological abnormalities, a situation termed chronic breathlessness or persistent dyspnoea. In such cases, the ever-present awareness of breathing becomes a permanent threat, a permanent reminder of impending mortality. The impact of dyspnoea on the lives of those affected is further aggravated by the invisibility that unfortunately characterises the experience. Even though observing acute dyspnoea in others is associated with negative feelings, dyspnoea is not only under-diagnosed and associated with delayed diagnosis but also under-evaluated, under-addressed, and often associated with an apparent lack of empathy from others. This invisibility impedes access to appropriate care and raises a human rights issue. It is explained, in part, by the disconnection of the dyspnoeic experience lived by the patients from the respiratory measurements performed by physicians. Also, the experience of dyspnoea, with the inherent sense of powerlessness that accompanies it, is not one that is universal, in contrast with pain and other common discomforts that everybody has experienced and can easily empathise with. Not having lived with dyspnoea presumably limits the ability of others to sympathise and empathise with patients, which probably goes some way to explain avoidance behaviours that are sometimes observed in persons confronted with dyspnoeic patients, and sometimes even in caregivers. Patients are well aware of the invisibility of dyspnoea, and remarks such as, "They should have doctors experience these symptoms, especially dyspnoea, so they understand what patients are going through" are not uncommon. Yet, the experiential learning theory suggests that personally experiencing dyspnoea could be useful in changing one's perception of it. This has not been formally studied, but is supported by anecdotal evidence. Similarly, Robert Lansing and colleagues report the post-hoc verbatim of a healthy person submitted to an air hunger inducing experiment: "If I felt I had to live my life feeling like that, I would jump out of the window". Submitted for the first time to a similar type of experiment, one of us (AG), a respiratory intensivist, exclaimed that he would "never again tell an agitated [dyspnoeic] mechanically ventilated patient to calm down". So, wearing a facemask to fight the circulation of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) makes breathing a conscious experience that can be unsettling or oppressive. This dyspnoea is mild at rest and is in no way comparable to patients' experiences. However, it can become sufficiently disturbing—when climbing stairs, when talking while walking, when in confined or crowded spaces, or in reaction to heightened emotional states—for people to seek respiratory relief by removing their masks, at the price of trangressing hygiene recommendations. This amounts to regaining control, an option not available to dyspnoeic patients, and illustrates the truly dyspnogenic effect of face masks. We submit that the respiratory discomfort induced by facemasks could be considered as a form of mass experiential learning liable to bring a great many people to discover the overlooked existential experience of dyspnoeic patients. We believe that this offers a unique opportunity to raise public awareness of what it means to be constantly aware of, and bothered by, one's own breathing. This phenomenon could be leveraged by foundations and charities that promote lung health or by teams engaged in the field of disability studies as a communication tool about the dyspnoeic experience that is lived by patients afflicted by chronic respiratory diseases, to, in the end, achieve better levels of comprehension and empathy. Meanwhile, let us have a thought for these patients when breathing through a facemask bothers us. TS reports personal fees from AstraZeneca France, Boerhinger Ingelheim France, GSK France, TEVA France, Chiesi France, Lungpacer Inc, ADEP Assistance, personal fees and non-financial support from Novartis France, and grants from Air Liquide Medical Systems, outside of the submitted work. All other authors declare no competing interests.
Abstract Background Dyspnea conveys an upsetting or distressing experience of breathing awareness. It heavily weighs on chronic respiratory disease patients, particularly when it persists despite maximal treatment of causative abnormalities. The physical, psychological and social impacts of persistent dyspnea are ill-appreciated by others. This invisibility constitutes a social barrier and impedes access to care. This study aimed to better understand dyspnea invisibility in patients with chronic obstructive pulmonary disease (COPD) through quantitative discourse analysis. Methods We conducted a lexicometric analysis (lemmatization, descending hierarchical classification, multicomponent analysis, similarity analysis) of 11 patients' discourses (6 men, severe COPD; immediate postexacerbation rehabilitation) to identify semantic classes and communities, which we then confronted with themes previously identified using interpretative phenomenological analysis (IPA). Results Class#1 ( "experience and need for better understanding"; 38.9% of semantic forms, 50% of patients ) illustrates the gap that patients perceive between their experience and what others see, confirming the importance of dyspnea invisibility in patients' concerns. Class#2 ( "limitations"; 28.7% of forms) and Class#3 ( management"; 13.1% of forms) point to the weight of daily limitations in performing basic activities, of the need to accept or adapt to the constraints of the disease. These three classes matched previously identified IPA-derived themes. Class#4 (" hospitalization "; 18.2% of forms) points to the importance of interactions with the hospital, especially during exacerbations, which constitutes novel information. Conclusions Lexicometry confirms the importance of dyspnea invisibility as a burden to COPD patients.
In contrast with pain, dyspnoea is not visible to the general public, who lack the corresponding experiential baggage. We tested the hypothesis that the generalised use of face masks to fight severe acute respiratory syndrome coronavirus 2 dissemination could change this and sensitise people to respiratory health.General population polling (1012-person panel demographically representative of the adult French population, quota sampling method; 517 (51%) female). 860 (85%) answered "no" to "treated for a chronic respiratory disease" ("respiratory healthy"), and 152 answered "yes" ("respiratory disease"). 14% of respiratory healthy respondents reported having a close family member treated for a chronic respiratory disease (RH-family+ ). Respondents described mask-related attitudes, beliefs, inconveniencies, dyspnoea and changes in their respiratory health vision . RESULTS: Compliance with masks was high (94.7%). Dyspnoea ranked first among mask inconveniencies (respiratory disease 79.3%, respiratory healthy 67.3%; p=0.013). "Air hunger" was the main sensory dyspnoea descriptor. Mask-related dyspnoea was independently associated with belonging to RH-family+ (OR 1.85, 95% CI 1.16-2.98) and removing masks to improve breathing (OR 5.21, 95% CI 3.73-7.28). It was negatively associated with considering masks effective to protect others (OR 0.42, 95% CI 0.25-0.75). Half the respondents were more concerned with their respiratory health since wearing masks; 41% reported better understanding patients' experiences.Wearing protective face masks leads to the mass discovery of breathing discomfort. It raises public awareness of what respiratory diseases involve and sensitivity to the importance of breathing. These data should be used as the fulcrum of respiratory health oriented communication actions.
Chronic obstructive pulmonary disease (COPD) is a disabling condition that affects around 10% of the world population [1]. Limited efficacy of etiopathogenic treatments often leaves patients with persistent dyspnoea [2] and handicap. This makes symptomatic treatments a priority. Opiates are sometimes beneficial, but often difficult to use. Finding new treatments thus appears of paramount importance. In this frame, medical hypnosis, recently shown as very effective at alleviating various types of experimental dyspnoea in healthy humans [3], may provide a promising approach. It is safe, cheap and it can improve various pathological conditions [4, 5] especially pain, either acute or chronic [6, 7]. Footnotes This manuscript has recently been accepted for publication in the ERJ Open Research . It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJOR online. Please open or download the PDF to view this article. Conflict of interest: The authors have no conflict of interest to report regarding this work. Gladys Beuze reports no conflict of interest at all. Outside this work and over the last 3 years, Christian Straus reports grant and support to his department from Centre Hospitalier de Lille and CARMAT. Sophie Lavault reports personal fees for consulting and teaching activities from Chiesi France. Antoine Guerder reports personal fees for consulting and teaching activities from Epione Santé, ASV Santé, Glaxosmith Kline and for travel and congress expenses from Chiesi and Sanofi. Capucine Morélot-Panzini reports personal fees for consulting and teaching activities from AstraZeneca France, Chiesi France, Sanofi France, Novartis France, GlaxiSmithKline France, Menarini France, ResMed, Löwenstein, Breas, Fisher & Paykel, ADEP, Isis, Orkyn, SOS oxygène, Air Liquide Santé International. Jesus Gonzalez-Bermejo reports personal fees for expert boards from Beas company and Lowenstein, and for teaching from Oxylis and Air Liquide. Thomas Similowski reports, personal fees for consulting and teaching activities from AstraZeneca France, Chiesi France, Hephaï, KPL consulting, Lungpacer Inc., OSO-AI, TEVA France, Vitalaire. He is a stock shareholder of startups Hephaï and Austral Dx. He is listed as inventor on issued patents (WO2008006963A3, WO2012004534A1, WO2013164462A1) describing EEG responses to experimental and clinical dyspnea.
In healthy humans, inspiratory threshold loading deteriorates cognitive performances. This can result from motor-cognitive interference (activation of motor respiratory-related cortical networks vs. executive resources allocation), sensory-cognitive interference (dyspnea vs. shift in attentional focus), or both. We hypothesized that inspiratory loading would concomitantly induce dyspnea, activate motor respiratory-related cortical networks, and deteriorate cognitive performance. We reasoned that a concomitant activation of cortical networks and cognitive deterioration would be compatible with motor-cognitive interference, particularly in case of a predominant alteration of executive cognitive performances. Symmetrically, we reasoned that a predominant alteration of attention-depending performances would suggest sensory-cognitive interference. Twenty-five volunteers (12 men; 19.5-51.5 yr) performed the Paced Auditory Serial Addition Test (PASAT-A and B; calculation capacity, working memory, attention), the Trail Making Test (TMT-A, visuospatial exploration capacity; TMT-B, visuospatial exploration capacity, and attention), and the Corsi block-tapping test (visuospatial memory, short-term, and working memory) during unloaded breathing and inspiratory threshold loading in random order. Loading consistently induced dyspnea and respiratory-related brain activation. It was associated with deteriorations in PASAT-A [52 [45.5;55.5]; (median [interquartile range]) to 48 [41;54.5], P = 0.01], PASAT-B (55 [47.5;58] to 51 [44.5;57.5], P = 0.01), and TMT-B (44 s [36;54.5] to 53 s [42;64], P = 0.01), but did not affect TMT-A and Corsi. The concomitance of cortical activation and cognitive performance deterioration is compatible with competition for cortical resources (motor-cognitive interference), whereas the profile of cognitive impairment (PASAT and TMT-B but not TMT-A and Corsi) is compatible with a contribution of attentional distraction (sensory-cognitive interference). Both mechanisms are therefore likely at play.NEW & NOTEWORTHY To our knowledge, this is the first study exploring the interferences between inspiratory loading and cognition in healthy subjects with the concomitant use of neuropsychological tests and electroencephalographic recordings. Inspiratory loading was associated with dyspnea, respiratory-related changes in brain activation, and a pattern of deterioration of neuropsychological tests suggestive of attentional disruption. Inspiratory loading is therefore likely to impact cognitive performances through both motor-cognitive interference (engagement of cortical networks) and sensory-cognitive interference (dyspnea-related shift in attentional focus).
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