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Validation of a New Dyspnea Measure*

The UCSD Shortness of Breath Questionnaire

Elizabeth G. Eakin, PhD;f Pamela M.

Resnikoff,

Robert

Andrew L. Ries, MD, MPH, FCCP; and

MD; Lela M. Prewitt;

M. Kaplan, PhD

Objective:

Diego

Evaluate the

Shortness of Breath

reliability

and

validity

of a new version of the

Epidemiologic

perceived

with a

University

of California, San

DepressionScale,

Questionnaire

performing

in

a

a

(SOBQ),

variety

of

a 24-item measure that activities of dailyliving.

program

assesses self-reported

complete

the

shortness of breath while

Design:

SOBQ,

and a

Patients enrolled

the

6-min

Quality

of

walkwith

Setting:University

Patients:

COPD

Thirty-two

pulmonary

scale

rehabilitation

the Center for

ratings

of

female

were asked to

Studies

Weil-BeingScale,

Borg

modified

medical center

male

subjects

fibrosis

breathlessness following thewalk. program.

variety of pulmonarydiagnoses:

with

the previous

answers.

pulmonary

and

22

rehabilitation

subjects

(n=28),cystic

(n=9), and

postlungtransplant(n=17).

the

SOBQ

significant

was

Measurements and

results: The current version of

SOBQ

correlated with all

had

validity

compared

version, the format of which often resulted in a

The results demonstrated thatthe

was also

Conclusions:

number of "not

applicable"

excellentinternal consistency(a=0.96).

criteria.

practice

The SOBQ

significantly

The

SOBQ

is a valuable assessment tool in both clinical

and research in

1998; 113:619-24)

patients with moderate-to-severe lung disease.

(CHEST

Key words: COPD; dyspnea; outcomes assessment; shortness of breath

Abbreviations:

ADL=activity

of

dailyliving;

BDI = Baseline

Dyspnea

Index; CESD Center

for Epidemiologic Studies

expiratory

Borg

(modified

walk

pressure;

ratings

scale

distance

(meters);

Depression; CF=cystic

MIP.maximal

post-6MW);

fibrosis;

Deo=diffusion of carbon monoxide; MEP=maximal

N/A=not

Weil-Being;

applicable;PB=perceived breathlessness

RV=residual

volume;

6MW=6-min

inspiratorypressure;

QWB

Quality

=

of Breath

of

SOBQ=Shortness

Questionnaire;

TLC=total lungcapacity; UCSD = University of California, San Diego

D

es.1

yspnea is one of the most common and

symptoms

Dyspnea

for

is also

patients

an

with chronic

lung

lung

important

primary goal

disabling

diseas¬

outcome variable

diseases

is the reduction and

of breathlessness. However, as a sub¬

jective symptom, dyspnea has proved difficult to

for clinical and research evaluations of

for which a

management

*From the

Eakin),

Joint

Doctoral

Program

in Clinical

Psychology

(Dr.

State

University

of California San

Diego/San Diego

Prewitt),

(Dr.

University,

Medicine

University Department

^Currently

Presented

at the

in

Association of

and the Division

(Drs.

of

of Pulmonary

and Critical Care

and

Resnikoff and

Family

Research

part

at the annual

Cardiovascular and

Portland,

Ore.

Ries and Ms.

and Preventive Medicine

Diego.

Institute,

meeting

Kaplan),

American

of

California, San

Oregon

Eugene.

of the

Pulmonary Rehabilitation,

University

of California

HL34732 from the

Kaplan);

by

and

NHLBI

Supported September1994, by grants

Heart,

Lung,

Award No. HL02215

Preventive

Manuscript

1997.

2RT0268 from the

and Blood Institute

Tobacco Related Disease Research

National

Program;

(Dr.

of the National Institutes

of Health

Pulmonary

received

Academic Award (Dr. Ries).

June 11, 1996; revision

Andrew L.

acceptedSeptember

UCSD

2,

Reprint Medical Center, requests:

Ries, MD, MPH, FCCP,

200 W Arbor Dr, San Diego, CA 92103-8377

measure. Several instruments are available to assess

dyspnea,including

questionnaires,

Dyspnea may

to

give

period

structured interviews,

analog,

self-report

visual

and numeric scales.2

settings,

also be measured in various

such as

clinics,rehabilitation tion and exercise laboratories. programs,

departments,physicians'offices,

and

pulmonary

may

be

func¬

asked

Patients

reports of dyspneaduring

past or

to estimate

as

a

given

the amount

various

and the

they perform

symptom

the

emergency

historical

of time in the

of

tasks.

dyspnea experienced

their

approaches complexity of the

Given the

to measurement,

measures

reliability

and

validity.

of a new

various

dyspnea

about

choice of

should be based on information

This article de¬

measure, the

scribes the validation

University

ness of

The

extensively

at

dyspnea

Diego

of California, San

in

developed

was

the

Pulmonary

(UCSD) Short¬

Breath Questionnaire (SOBQ).

SOBQ

and has been used

Program

Rehabilitation

UCSD to assess

shortness of breath with various

activities of

development,

revisions that

daily living

the

SOBQ

(ADLs).3 Since its initial

has

undergone

a number of

clarifiedand expanded the rating scale

CHEST / 113 /3 /MARCH, 1998

619

of the

patients

original

instrument. The new

severity

SOBQ

asks

to indicate the

experienced

on a

of shortness of

breath

to 5=maximal or unable to do because of breathless¬

six-point

scale (0.not at all,

21 different ADLs associated with

about

harm from overexertion, and fear of shortness of

breath are included for a total of 24 items

of

shortness of breath

ness)

during

varying

levels of exertion. Three additional

limitations due to shortness of breath,

If patients

are

do not

questions

fear

of

(see

the

scored to form a

which in¬

and which

activities,

and

Appendix).

routinelyperform degree

The

the

SOBQ

is

activity, they

by

total

The

cluded

asked to estimate

anticipated.

across

summing responses

score. Scores

previous

a "not

all 24 items

range from 0 to 120.

version

of

the SOBQ,

categoiy

specific

the

applicable(N/A)"

of

dyspnea

queriedfrequency

was

validated

in

a

validity

that

at least a

that

study,

of six

with

studyexamining

used

reliability

commonly

122

dyspnea

measures.4 In

had

results of

an

of the fre¬

rating

however,

single

the N/A

of 143

patients(85.3%)

on the

replaced by

because

N/A answer. Based

was

study,

category

estimate

of anticipateddyspnea

missing

data.

from

changed

severity

In

quency of

system

dyspnea

patients

of

was

addition, the

the

rating

of

for

The validation

frequency

to a

scale to

and

make it easier

with these

to understand

complete.

SOBQ,

the new version of the

poten¬

tiallysignificantchanges, is

described in this article.

Materials and Methods

Subjects

The 54

patients

Pulmonary

12

to

in this

evaluated at the

subjects

study

were a convenience

(Table1).

cystic

fibrosis

patients

with

single sample lung transplant

size.

and one each with

vascular disease,

sample

of

University

Program.

of California, San

Subjectsranged

Diagnostic

in

age

Diego

Rehabilitation

82 years; 41% were female

was as follows: COPD (n=28),

from

breakdown

(CF) (n=9), and

with restrictive

pulmonary

Of the

pa¬

vascular

postlung

recipients

ct1-antitrypsin

and idio¬

postlungtransplant

renchymal

(n=17). Three

patients

disease and two

disease were excluded due to small

transplantation patients,

included fivewith

deficiency,

pathicpulmonary

ients had

the

emphysema,

sarcoidosis,

recipients

pating

in

including

tients

pulmonary

The

five

fibrosis.

double-lungtransplantrecip¬

heart-lung transplant

Subjects

were

partici¬

underlying

had

CF and the three

Eisenmenger's syndrome.

lung

a variety

a

standard

of activities at the Rehabilitation Program,

pulmonary

rehabilitation

disease (n=21), rehabilitation

program

for

pa¬

prior

to

reha¬

with chronic

lungtransplantation(n=16), and postlungtransplantation

bilitation

(n

=

17).

Procedures

Subjectscompleted

(6MW) test, modified

ness (PB)

(QWB)

following

Scale,and

the

the measures described below as

Theycompleted

SOBQ

both the

part

previ¬

of

their rehabilitation assessment.

ous and the new version of the

administration

(with the order of with the 6-min walk

perceived

Quality

of

Studies

breathless¬

Weil-Being

Depres¬

were

randomly assigned), along

Borg

scale

ratings

the

6MW test,

of

the Center for

Epidemiologic

sion (CESD) Scale. Data on pulmonary

function testing

Characteristic

Gender, M/F

Age, yr

QWB

CESD

6MW, m

PB

SOBQ (old)

SOBQ (new)

Pulmonary function tests

No.

FVC, L

FVC, %

FEV^ L

FEVl5 %

FEV/FVC,

FEF25_75%, L/s

FEF25_75%, % pred

pred

pred

%

RV/TLC, %

Deo, mL/min/mm Hg

Deo, % pred

MIP, cm H20 (atRV)

MEP, cm H20 (atTLC)

Table 1.Subject Characteristics*

Diagnosis

COPD

CF

(n=9)

Posttransplant

(n = 17)

(n=28)

18/10

7/2

7/10

64(12)

23(9)

48

(14)

0.573 (0.100)

0.624 (0.070)

0.646(0.114)

11.7(8.5)

8.2 (7.8)

7.8 (6.5)

312 (108)

458 (106)

504 (162)

4.3(1.3)

4.1

(1.9)

2.7(1.8)

54.8 (19.4)

28.2

(14.6)

18.4

(16.5)

61.9(18.8)

31.9(17.1)

21.7(19.8)

14

17

1.95 (0.49)

1.65

(0.49)

2.74

(0.88)

56

(22)

43 (13)

70

(15)

0.69

(0.22)

0.79 (0.20)

2.03

(0.96)

30 (17)

25(9)

68

(25)

36(14)

49(8)

72

(17)

0.30

(0.25)

0.28 (0.10)

1.89

(1.66)

13(14)

8(5)

55

(42)

71(10)

63(8)

46 (17)

7.1 (1.9)

16.8

(2.5)

20.7

(4.6)

31

(12)

65(18)

79(12)

52

(15)

98 (14)

124

(23)

102

(52)

142 (55)

172

(34)

^Results expressed as Mean (SD); n=54; pred^predicted;FEF25_75%=forced expiratory flow rate between 25% and 75% of the FVC.

620

Clinical Investigations

taken from months of the

patients'

medical records, if available, within 6

Only those tests per¬

accepted. Pulmonary

rehabilitation assessment.

formed at UCSD Medical Center were

function testing for posttransplantpatients was retrievedwith the

additional criterion of same surgical status (posttransplant) as on

the date

available

pulmonary function testing and questionnaire administration was

pulmonary function test results, the time between

of questionnaire completion. For the 38 patients with

14±45 days (mean±SD).

All pulmonary function tests included spirometric measure¬

ments of vital capacity and expiratory flow rates. Lung volumes

measured by body plethysmography, single-breath diffusing ca¬

pacity (Deo), maximal inspiratory pressure (MIP) (at residual

volume [RV]), and maximal

expiratorypressure (MEP) (attotal

lungcapacity[TLC]) to assess respiratory muscle strength were

performed in 68% of the pulmonary function tests (79% of

posttransplant

COPD

testing

patients,

71% of CF

patients,

59% of

patients).

bodyplethysmography

monary function testing for postlung transplant patients. All

were done according to

This

was due to the inability

and

quality

control

recommended

of some patients

to tolerate

and the routine use of abbreviated pul¬

procedures

methods.57

standard and

Measures

6MW Test: The 6MW is a standard measure of exercise

tolerance used frequently with lung and heart disease popula¬

tions.8 The test was conducted in an area free from distractions

with standardized

reliable,9 with moderate

correlations with tests of pulmonary function and maximum

demonstrated a

trials of this test and recom¬

encouragement provided by

possible

in

highly

6 min.

the staff.

Subjects

were asked to walk as far as

The timed distance

walk test has been shown to be

exercise

capacity.10 Guyatt

and

learning effect across subsequent

mend two practice tests prior

colleagues11

to actual test administration.

Because of time constraints in this studyprotocol, we used one

practice test,followed by at least 10 min of rest and then a second

test. Data from the longer of the two walks were used. Subjects

rated their

each walk.12

the modified Borg scale at the end of

dyspneausing

QWB Scale: The QWB is a

ity. Second, separate

symptoms

the last

and

6 days.

scales:

comprehensive measure of health-

at a point in time from

experienced

over

related quality of life that includes several components. First, it

obtains observable levels of

three

and social activ¬

each patient selects, from a list of 24 clusters of

mobility,physicalactivity, functioning

those that

they

had

problems,

Next,

the observed level of function and the

are

weighted by preference,

or

subjectivesymptomaticcomplaint utility

(foroptimumfunction).The weights

the

forthe state, on a scale ranging from 0 (fordead) to 1.0

are obtained from indepen¬

dent samples of judges who rate the desirability of the observable

health status. Using this system, it is possible to place the general

health status of

individual on the continuum between death

higher

scores

used exten¬

indicating optimalfunctioning quality.

and

better life

sively in a variety

been published.Kaplan

was

substantially

QWB

physiologic variables

COPD.

any

for anypoint in time, with

This

system has been

correlated with both

of medical and health services research

data for

patients with COPD

reported

that the

and

with

performance

patients

and coworkers15

studies.1314 In addition, validity

have

relevant to the health status of

CESD Scale:

The CESD is a general measure of

extensively in epidemiologic

depression

thathas been used

studies. The scale

includes 20 items and

energy Patients are asked to report how often they experienced a

the past week on a four-point scale

particularsymptom during

taps dimensions of depressed mood,

loss,

sleepdisturbance, and

level.

hopelessness,appetite

ranging from rarely

or none of the time to most or all of the time.

from 0 to 60, with scores >16

Total score on the CESD ranges

depressivesymptoms reliability good

for a

and validity of the CESD. Test-retest correlations are

test designed to assess fluctuations in mood (r=0.57). The CESD

discriminates between clinical and normal populations, and the

indicative of clinicallysignificant levels of

in

adults. Radloff16 has presented extensive data on the

reliability and validity have been replicated across various normal

and clinical samples.

Statistical Analyses

The SOBQ

items on the

validity

of the

was

evaluatedfor reliability and calculation of coefficient a, a

consistency,

by

examining

validity.Reliability

statistic used to

was assessed by

evaluate internal

or the extent to which the different

measure the same construct.17 The

its correlations

questionnaire

SOBQ

was evaluated

judgment

with variables with which it is assumed to be related. The choice

of variables against which we evaluated the validity of the SOBQ

and a review of the literature that

was based on clinical

indicated some empiricalsupport forthe

relationships of dyspnea

life, lung func¬

with exercise tolerance,

tion, and depression.2

health-related quality of

RESULTS

Subject

characteristics are shown in Table 1. The

subjects with COPD were older and had higher

of PB

28

scores on the CESD, SOBQ, and

Borgratings

afterthe 6MW, with lower associated with lower 6MW

MIP, and MEP. Mean scores on the old and new

These were

QWB scores.

distances, FEV1? Deo,

versions of the SOBQ were similar for each group,

mean values on the new version.

with slightlyhigher

An internal

consistency

criterion of 0.70 was chosen

consistency(a=0.96).

Item-

as good evidence for reliability.18 The SOBQ demon¬

strated excellent internal

total correlations ranged from 0.49 to 0.87, indicating

that each item contributed to the overall reliability of

the instrument.

Figure 1 shows the correlation of the total SOBQ

scores for the old and new versions for each

nostic

The correlation of the versions

excellent group. overall (0.96) and for

diag¬

was

each group (COPD:

0.89, p<0.001; CF: 0.91, p<0.001; posttransplant:

0.96, p<0.001). As seen in Table 2, the two versions

of the

SOBQ

showed a similar

criteria. The

pattern

of correlations

with the

lated negatively validity with physiologic

severity (percentpredicted

SOBQ scores corre¬

measures of disease

FVC and FEV1? Deo,

and MIP), health-related quality of life (QWB), and

exercise tolerance

(6MW).

SOBQ

scores correlated

of PB following the

positively with Borg scale ratings

tion.

6MW, with RV/TLC and with depression (CESD).

All of these correlations were in the expected direc¬

MEP was also evaluated, but found to have no

significant correlation with SOBQ scores. On break¬

down by diagnosis, SOBQ scores for COPD patients

correlated significantly

only with 6MW distance

CHEST/113/3/MARCH, 1998 621

>

5

120

20

+

/.

fAA

~T-

40

.

.

A

¦

%

COPD: r=0.89, SEE=8.62

Cystic

Post-Transplant: r=0.96, SEE=5.80

Overall: r=0.96, SEE=7.92

Fibrosis: r=0.91, SEE=7.44

6060

80

100

Previous Version Total Score

120

Figure 1. Correlation of the total SOBQ scores for the old and new versions for each diagnosticgroup.

(r=. 0.47 and .0.42 for the older and newer ver¬

sions,

respectively,p<0.05).Posttransplantpatients

significant

correlationbetween

SOBQ

and

versions,

respectively,

QWB

nonsignificant

correlationswith

nonsig¬

Deo,

alsoshowed a

scores and 6MW distance (r=. 0.64 and .0.64 for

the older and newer

p=0.006),

and CESD scores. Patients with CF showed

nificant

correlations with percent-predicted

MIP, and PB.

DISCUSSION

The results of this

study

and our

SOBQ

previousexperi¬

is

a

reliable and

dyspnea

ence4indicatethatthe

valid instrument that can be used

associated with ADLs in

UCSD

to assess

patients

with moderate-to-

severe chronic

symptom

evaluating

lung

disease.

important

Dyspnea is a primary

outcome measure

in

diseases.19-20

not

only

and an

patients

with chronic lung

measure

The choice of a

on the

purpose

and

reliability

We have

the

dyspnea

of the

validity

developed

our

years.

depends

but

application,

also on the

of the measure.

and used earlier versions of

program

clinical tool, it was used

in the screening evaluation forthe rehabil¬

associated with

ADLs. We have found this information

to better understand

lifeand also

SOBQ in

30

pulmonary

As a

rehabilitation

primarily nearly

for

itation

specific

useful

the

program

in the

to assess

dyspnea

screeningprocess

specific, lung

of

disease

on a

individual

impact

set

person's

Only help

to

goals did we begin

forthe

program.

to use

in recent

years, however,

622

and evaluate the

dyspnea in research studies.

SOBQ

as an outcome measure of

Because of this, we have

the rating

to

and

subjects.

by

its

small

of

sample

patients

corre¬

should

made

series of modifications in

used in the

for

a

scoringsystem

questionnaire

minimize

activities that are

missingresponses

N/A

or no

Although

sample

size

SOBQ

patients,

previous study

with

lateswellwith the be noted that this

with COPD, but

patients

the

different

each

tical

tions.

instrument has

lung

subgroup

specificdaily

longer performed by

the

and the use of

current

study

a

is

individual

limited

convenience

the results are consistent with those

was

evaluated on a

largersample

of

the

COPD.4 The new version

previous

study

version

after

of

from a

in which an older version of the

SOBQ

(Fig1). only

28

It

included not

patients

patients

17

that

in

in

statis¬

also 9

with CF and This

suggests

to reach

lungtransplantation.

validity

for

dyspneasymptoms

patients

diseases.

was not

The number of

largeenough

of the

significance for many

individual correla¬

Correlationsbetween

ratings

of

dyspnea previously.

and

phys¬

In

iologicparameters

patients

FEVX and FVC in

Redelmeier et al25 associatedwith a

on a 7-point

worse

."

predicted

havebeen observed

with COPD, FEVX and FVC have

Dyspnea

Index

Borg

patients

scores of

been cor¬

(BDI).21-23

significant

relatedwith the Baseline

However, Wolkove et al24 did not find a

correlation between

dyspnea Recently,

in

and

FEVX

with COPD.

the

change

investigated

change

in

from "much

scale,

subjectivedyspnearating

better

a change change

to

Dyspnea

"

to "much of 4% of

the

by the

rating,

BDI

percent-

scale

Using this

FEVt

was

required

(r=0.29).

with mildcorrelation

measure has also been correlated with

Table 2.Validity Correlations of the Two Versions of

the SOBQ*

SOBQ (Previous)

SOBQ (New)

QWB

CESD

6MW

PB

FVC, %

FEV!, %

FEV^FVC,

FEF25-75%>

RV/TLC, %

pred

pred

%

Deo, % pred

MIP, cm

H20

(atRV)

pred

52

52

52

52

38

38

38

38

26

29

30

-0.40f

0.35*

-0.68*

+0.42f

-0.36*

-0.49f

-0.50f

-0.42f

+0.48*

-0.69*

-0.64§

-0.41f

0.37f

-0.68*

+0.45*

-0.361

-0.50f

-0.51f

-0.44f

+0.47*

-0.67*

-0.60*

*For explanation of abbreviations, see text and Table 1 footnotes.

fp<0.01.

*p<0.001. *p<0.05.

Clinical Investigations

predicted Deo in 37 patients

with chronic airflow

limitation26 (r=0.68). In the current study, SOBQ

scores and percent-predicted Deo appear to corre¬

late best, although not significantly, for the CF

group. Interestingly,

no correlation was seen forthe

Timed walk distances have also been

correlated group. with

COPD

dyspnea,

most

commonly in COPD.

for the 6MW.

For example, Mahler et al21 found a strong correla¬

between a 12-min walk distance and the BDI

tion

scores (r=0.6). As seen in Table 2, similar relation¬

ships

were seen in the

current study

are

The causes of

dyspnea

multifactorial, with

contributions from

ities, mechanical factors oxygen such as

limitation and

factors. Which of these contribute the most

and acid-base abnormal¬

expiratory

flow

psychological

and

in

any

defined. This

adds to

SOBQ,

lunghyperinflation,

particular study,

the

disease remains

poorly

done as an evaluation of the

literature

examining

the

growing

determinants of

of which

dyspnea,

SOBQ

The

but does not answer

may

relationships

SOBQ

of

is a

question

factors contribute the most in each disease. The

be used as a tool to further evaluate

these

in future studies.

relative

used

dyspnea

Cost

the

newcomer among

measures

In

the

commonly

(ie, the

group

BDI,21 the American Thoracic

Society Dyspnea

Diagram28).

previous

a

version of

measures in

Scale,27 and

previousstudy,

the

SOBQ

terms of its

tration.4 The

reliability

dyspnea only

the

Dyspnea

BDI

easy

the Oxygen

we

compared

with these other

reliability,validity,

SOBQ

dyspnea

and

ease of adminis¬

higher

levels of

thus, it

pro¬

global

Society

self-report

useful for

SOBQ

can be

with little

findings,

and

we feel

demonstrated

other measures

evaluated. It is

one of these instruments that evaluates

than the

in relation to

specificADLs;

vides

scores obtained from the American Thoracic

more detailed information than the

Scale and

Oxygen

in

Cost

Diagram.

experienced

evaluating patients

to

may

complete,

SOBQ

we believethatthe

makes it

particularly

The

applications.

While

with

find the interviewer-administered

clinicians

lung disease

nature of the

research and clinical

completedquickly

instruction or

Given the

and

easily by patients

of our

previous

supervision.

replication

and the correlation between the

current versions of the SOBQ

confident that the

measure of

SOBQ

In

dyspnea.

demonstrated

is a

this

(a = 0.96) and

with exercise

dyspnea

previous

(r=0.96),

reliable

study,

and valid

the

SOBQ

consistency

correlations

ratings

of

severity,

excellent internal

moderate-to-strong

tolerance,

a

Borg

6MW,

scale

disease

following

health-related

various disease

quality of life, and depression

processes.

Its

high

for

levels of reli¬

make it an excellent tool for

ability and validity

research applications.

SOBQ to be a useful

dyspnea during

We have also found the

clinical instrument to assess

common ADLs in order to set

goals for improvement in specific activities

through pulmonary

ventions.

rehabilitation or other inter¬

Appendix.UCSD SOBQ

UCSD Medical Center

Program

The

©1995

Pulmonary

Rehabilitation

California

Shortness-of-Breath

Questionnaire

of

Regents of the University

Instructions: For each

activity.

giveyour

be for an

all items.

begin

0

1

2

3

4

the