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Validation of a New Dyspnea Measure : The UCSD Shortness of Breath Questionnaire

Elizabeth G. Eakin, Pamela M. Resnikoff, Lela M. Prewitt, Andrew L. Ries and Robert M. Kaplan Chest 1998;113;619-624 DOI 10.1378/chest.113.3.619 The online version of this article, along with updated information and services can be found online on the World Wide Web at: http://chestjournal.chestpubs.org/content/113/3/619

Chest is the official journal of the American College of Chest Physicians. It has been published monthly since 1935. Copyright1998by the American College of Chest Physicians, 3300 Dundee Road, Northbrook, IL 60062. All rights reserved. No part of this article or PDF may be reproduced or distributed without the prior written permission of the copyright holder. (http://chestjournal.chestpubs.org/site/misc/reprints.xhtml) ISSN:0012-3692

as a sub¬ jective symptom. However. Ries. FCCP. University of California San Diego/San Diego State of and University. The results demonstrated that the SOBQ had excellent internal consistency (a=0. Ries). 200 W Arbor Dr. and Department of Family and Preventive Medicine (Dr. 113:619-24) patients with moderate-to-severe lung disease. San Diego. Portland. HL02215 of the National Institutes of Health NHLBI Preventive Pulmonary Academic Award (Dr. Kaplan). CESD Center for Epidemiologic Studies Depression. Conclusions: The SOBQ is a valuable assessment tool in both clinical practice and research in (CHEST 1998. MPH. San Diego = = = es. and postlung transplant (n=17). dyspnea has proved difficult to *From the D yspnea forof the with chronicand disabling symptoms patients lung diseas¬ is one most common September 1994. clarified and undergone a number of revisions that expanded the rating scale measure. PB=perceived breathlessness (modified Borg scale ratings walk post-6MW). MIP. UCSD Medical Center. Ries. shortness of breath Abbreviations: ADL=activity of daily living. and pulmonary func¬ tion and exercise laboratories. BDI Baseline Dyspnea Index. Key words: COPD. Lung. and numeric scales. Eakin). The SOBQ was developed and has been used extensively in the Pulmonary Rehabilitation Program at UCSD to assess shortness of breath with various activities of daily living (ADLs). Design: Patients enrolled in a pulmonary rehabilitation program were asked to complete the SOBQ. the format of which often resulted in a significant number of "not applicable" answers. CHEST / 113 / 3 / MARCH. TLC=total lung capacity.f Pamela M. Kaplan). The SOBQ was also significantly correlated with all validity criteria. such as emergency departments. and by Award No. 1996. and Blood Institute (Dr. Eakin. Setting: University medical center pulmonary rehabilitation program.2 Dyspnea may also be measured in various settings. Resnikoff Ries and Prewitt). Resnikoff. Prewitt. including structured interviews. clinics. Andrew L. the University of California. Kaplan. physicians' offices. N/A=not applicable. San Diego Shortness of Breath Questionnaire (SOBQ).Validation of a New Dyspnea Measure* The UCSD Shortness of Breath Questionnaire Elizabeth G. QWB Breath of Weil-Being. MD. revision accepted September 1997.3 Since its initial the SOBQ has development. Reprint requests: Andrew L. outcomes assessment. Manuscript received June 11. and Robert M. dyspnea. ^Currently at the Oregon Research Institute. PhD Objective: Evaluate the reliability and validity of a new version of the University of California. San Diego (UCSD) Short¬ ness of Breath Questionnaire (SOBQ). and the Divisionand Pulmonary Ms. 1998 619 . cystic fibrosis (n=9). Deo=diffusion of carbon monoxide. MPH. This article de¬ scribes the validation of a new dyspnea measure. Measurements and results: The current version of the SOBQ was compared with the previous version. RV=residual volume. Supported by grants 2RT0268 from the University of California Tobacco Related Disease Research Program. Ore. Critical Care Medicine (Drs. Given the complexity of the symptom and the various approaches to measurement. CA 92103-8377 2. MD. FCCP. Lela M. self-report questionnaires. 6MW=6-min of distance (meters). Patients may be asked to give historical reports of dyspnea during a given period of time in the past or to estimate the amount of dyspnea experienced as they perform various tasks. UCSD University California. Patients: Thirty-two male subjects and 22 female subjects with a variety of pulmonary diagnoses: COPD (n=28). Several instruments are available to assess dyspnea. San Diego. Quality SOBQ=Shortness of Questionnaire. and a 6-min walk with modified Borg scale ratings of perceived breathlessness following the walk. Eugene. visual analog. the Center for Epidemiologic Studies Depression Scale. PhD. MEP=maximal expiratory pressure. Joint Doctoral Program in Clinical Psychology (Dr.maximal inspiratory pressure. Presented in part at the annual meeting of the American Association of Cardiovascular and Pulmonary Rehabilitation. the choice of dyspnea measures should be based on information about their reliability and validity. HL34732 from the National Heart.1 Dyspnea is also an important outcome variable for clinical and research evaluations of lung diseases for which a primary goal is the reduction and management of breathlessness. University of California. rehabilitation programs. CF=cystic fibrosis.96). a 24-item measure that assesses self-reported shortness of breath while performing a variety of activities of daily living. the Quality of Weil-Being Scale. MD.

8) 18. % Deo. In addition.100) 11. % pred RV/TLC. m Pulmonary function tests No.3) 54.4had that study.6) FEV^ L FEVl5 % pred FEV/FVC.49) 56 (22) 0. If patients doto estimate the are asked degree of activity.7(1. % pred MIP. Subjects were partici¬ pating in a variety of activities at the Rehabilitation Program. with these poten¬ tially significant changes.5) 65(18) 98 (14) 142 (55) 79(12) 124 (23) 172 (34) expressed as Mean (SD).9) 28.5) 312 (108) 4. mL/min/mm Hg Deo. the Quality of Weil-Being (QWB) Scale.8 (19. the N/A category was replaced by an estimate of anticipated dyspnea because of the fre¬ quency of missing data.not at all. and fear of shortness of breath are included for a total of 24 items (see not routinely perform the Appendix).646(0. Based on the results of that study.28 (0. along with the 6-min walk (6MW) test. 122 of 143 patients (85. range The previous version of the SOBQ.070) 8.5) 21.9(18. pred^predicted.7(8.1 (1.8 (6. pulmonary vascular disease. Clinical 620 Investigations . Subjects ranged in age from The 54 renchymal disease and two patients with pulmonary vascular disease were excluded due to small sample size. L/s FEF25_75%. Of the postlung transplantation patients.03 (0.6) 31. and one each with ct1-antitrypsin deficiency. The SOBQ is scored 24 items responses by summingScores across all to 120. 41% were female (Table 1).7(19.8) 14 1.88) 70 (15) 2.Subject Characteristics* Diagnosis COPD CF Characteristic (n=28) 18/10 (n=9) 7/2 Posttransplant (n 17) = Gender. % pred FVC.65 (0. fear of harm from overexertion.49) 43 (13) 0. M/F Age. cm H20 (at RV) MEP. cm H20 (at TLC) ^Results 36(14) 0.8) 17 2.25) 13(14) 71(10) 7. is described in this article. % FEF25_75%.7 (4. to form a from 0 total score. FEF25_75%=forced expiratory flow rate between 25% and 75% of the FVC. the rating system was changed from rating the frequency of it to a severity scale dyspnea to understand and to makeThe easier for complete. yr QWB PB CESD 6MW. to 5=maximal or unable to do because of breathless¬ ness) during 21 different ADLs associated with levels of exertion.74 (0. sarcoidosis. They completed both the previ¬ ous and the new version of the SOBQ (with the order of administration randomly assigned). n=54. including a standard pulmonary rehabilitation program for pa¬ tients with chronic lung disease (n=21).89 (1.30 (0. they shortness of breath anticipated.66) 55 (42) 46 (17) 20.9) 31 (12) 52 (15) 102 (52) 25(9) 49(8) 0.10) 8(5) 63(8) 16.about limitations due to shortness of breath. which in¬ cluded a "not applicable (N/A)" categoiy and which specific and queried frequency of dyspnea with the activities.8 (2. = Procedures Subjects completed the measures described below as part of their rehabilitation assessment. cystic fibrosis (CF) (n=9). Diagnostic breakdown follows: COPD (n=28). SOBQ (old) SOBQ (new) 64(12) 0.3%) at least a single N/A answer.96) 68 (25) 72 (17) 1. modified Borg scale ratings of perceived breathless¬ ness (PB) following the 6MW test.79 (0.114) 7. and the Center for Epidemiologic Studies Depres¬ sion (CESD) Scale. The new SOBQ asks patients to indicate the severity of shortness of breath experienced on a six-point scale (0. validation patients of the new version of the SOBQ.5) 504 (162) 2.573 (0. and postlung transplantation reha¬ bilitation (n 17).22) 30 (17) 23(9) 0.95 (0.8) 458 (106) 4. L FVC. was validated in a study examining reliability In validity of six commonly used dyspnea measures. rehabilitation prior to lung transplantation (n=16).4) 61.9(17. Three patients with restrictive pa¬ subjects in this study were a convenience sample of at the University of California.2 (14.20) 7/10 48 (14) 0.3(1. San Diego Pulmonary Rehabilitation Program. Three additional of the Materials and Methods Subjects patients evaluated was as questions 12 to 82 years.1 (1. and postlung transplant (n=17).1) 1. however. Data on pulmonary function testing were 1. The five double-lung transplant recip¬ ients had underlying CF and the three heart-lung transplant recipients had Eisenmenger's syndrome.4 (16. the single lung transplant recipients included five with emphysema.2 (7. Table varying original instrument.624 (0.69 (0. and idio¬ pathic pulmonary fibrosis.

SOBQ scores correlated positively with Borg scale ratings of PB following the 6MW.001.001.89. p<0.87. hopelessness. Because of time constraints in this study protocol. but found to have no significant correlation with SOBQ scores. For the 38 patients with available pulmonary function test results.0 (for optimum function). Test-retest correlations are good for a test designed to assess fluctuations in mood (r=0.10 Guyatt and colleagues11 demonstrated a learning effect across subsequent trials of this test and recom¬ mend two practice tests prior to actual test administration. Figure 1 shows the correlation of the total SOBQ scores for the old and new versions for each diag¬ nostic group. we used one practice test. This was due to the inability of some patients to tolerate body plethysmography and the routine use of abbreviated pul¬ monary function testing for postlung transplant patients. These were associated with lower 6MW distances. An internal consistency criterion of 0. and Borg ratings of PB after the 6MW. Only those tests per¬ formed at UCSD Medical Center were accepted. Statistical Analyses The SOBQ was evaluated for reliability and validity. or the extent to which the different items on the questionnaire measure the same construct.57). posttransplant: 0. and depression. health-related quality of life. The weights are obtained from indepen¬ dent samples of judges who rate the desirability of the observable health status. and the reliability and validity have been replicated across various normal and clinical samples. All testing and quality control procedures were done according to standard and recommended methods.001). with lower QWB scores. Second. validity data for patients with COPD have been published. with scores >16 indicative of clinically significant levels of depressive symptoms in adults. The choice of variables against which we evaluated the validity of the SOBQ was based on clinical judgment and a review of the literature that indicated some empirical support for the relationships of dyspnea with exercise tolerance. with slightly higher mean values on the new version.taken from patients' medical records.57 Measures 6MW Test: The 6MW is a standard measure of exercise tolerance used frequently with lung and heart disease popula¬ tions. Itemtotal correlations ranged from 0. Radloff16 has presented extensive data on the reliability and validity of the CESD. and maximal expiratory pressure (MEP) (at total lung capacity [TLC]) to assess respiratory muscle strength were performed in 68% of the pulmonary function tests (79% of COPD patients. appetite loss. First. from a list of 24 clusters of symptoms and problems. the time between pulmonary function testing and questionnaire administration was pacity (Deo).1314 In addition. The SOBQ scores corre¬ lated negatively with physiologic measures of disease severity (percent predicted FVC and FEV1? Deo. each patient selects.12 QWB Scale: The QWB is a comprehensive measure of healthrelated quality of life that includes several components. All of these correlations were in the expected direc¬ tion. On break¬ down by diagnosis.91.9 with moderate correlations with tests of pulmonary function and maximum exercise capacity. Mean scores on the old and new versions of the SOBQ were similar for each group. p<0.96. the two versions . SOBQ. with higher scores indicating better life quality. Data from the longer of the two walks were used. if available. on a scale ranging from 0 (for dead) to 1.2 was RESULTS 28 the utility for the state. health-related quality of life (QWB). the observed level of function and the days (mean±SD). and social activ¬ ity. or scores on the CESD. and energy level. The subjects with COPD were older and had higher COPD. 59% of posttransplant patients). it obtains observable levels of functioning at a point in time from three separate scales: mobility. lung func¬ tion. followed by at least 10 min of rest and then a second test. The CESD discriminates between clinical and normal populations. The timed distance walk test has been shown to be highly reliable.70 was chosen as good evidence for reliability. SOBQ scores for COPD patients correlated significantly only with 6MW distance CHEST/113/3/MARCH. This system has been used exten¬ sively in a variety of medical and health services research studies.96) and for each group (COPD: Subject characteristics are shown in Table 1. MEP was also evaluated. pulmonary function tests included spirometric measure¬ ments of vital capacity and expiratory flow rates. MIP. Reliability assessed by calculation of coefficient a. Pulmonary function testing for posttransplant patients was retrieved with the additional criterion of same surgical status (posttransplant) as on the date of questionnaire completion. As seen in Table 2. Patients are asked to report how often they experienced a particular symptom during the past week on a four-point scale subjective symptomatic complaint are weighted by preference. FEV1? Deo. Using this system. 71% of CF patients. Subjects rated their dyspnea using the modified Borg scale at the end of each walk. Lung volumes measured by body plethysmography. those that they had experienced over the last 6 days.49 to 0. p<0. CF: 0.18 The SOBQ demon¬ strated excellent internal consistency (a=0. Next. a statistic used to evaluate internal consistency. single-breath diffusing ca¬ 14±45 All ranging from rarely or none of the time to most or all of the time. and MEP. Total score on the CESD ranges from 0 to 60.17 The validity of the SOBQ was evaluated by examining its correlations with variables with which it is assumed to be related. The scale includes 20 items and taps dimensions of depressed mood. CESD Scale: The CESD is of the SOBQ showed a similar pattern of correlations with the validity criteria. with RV/TLC and with depression (CESD). and exercise tolerance (6MW). indicating that each item contributed to the overall reliability of the instrument. Subjects were asked to walk as far as possible in 6 min. sleep disturbance. physical activity. Kaplan and coworkers15 reported that the QWB was substantially correlated with both performance and physiologic variables relevant to the health status of patients with a general measure of depression that has been used extensively in epidemiologic studies. within 6 months of the rehabilitation assessment. 1998 621 0. it is possible to place the general health status of any individual on the continuum between death and optimal functioning for any point in time. and MIP). maximal inspiratory pressure (MIP) (at residual volume [RV]).96). The correlation of the versions was excellent overall (0.8 The test was conducted in an area free from distractions with standardized encouragement provided by the staff.

47* -0.67* -0." to "much .42f +0.51f -0. but also on the measure. individual goals for the program.91.49f -0. As a clinical tool. p<0.35* -0. SEE=8.Validity Correlations of the Two Versions of the SOBQ* SOBQ (Previous) QWB CESD 6MW PB FVC. 0.68* +0.0. % > 5 + /.21-23 However. Dyspnea is a primary symptom and an important outcome measure in chronic evaluating patients with measure lung diseases. SEE=7.40f 0. Clinical Investigations .89. Only in recent years.0. a change of 4% of worse predicted FEVt was required to change the rating.64 for the older and newer versions. cm H20 (at RV) *For pred -0. it was used for the rehabil¬ primarily in the screening evaluation associated with itation program to assess dyspnea specific ADLs. fAA . *p<0.4 The new version of the SOBQ corre¬ lates well with the previous version (Fig 1). scores for the old and and evaluate the SOBQ as an outcome measure of studies. % pred MIP.96. Dyspnea by the BDI measure has also been correlated with percentTable study and our previous experi¬ valid instrument that can be used to assess dyspnea associated with ADLs in patients with moderate-tosevere chronic lung disease.48* -0. Recently. see text and Table 1 footnotes.96. however.361 -0. DISCUSSION Correlations between ratings of dyspnea and phys¬ observed previously.05. Correlation of the total SOBQ versions for each diagnostic group.68* +0. A ¦ Cystic Fibrosis: r=0.001. Although the current study is limited by its small sample size and the use of a convenience sample of patients. reliability and validity of theused earlier versions of We have developed and the SOBQ in our pulmonary rehabilitation program for nearly 30 years. SEE=5. SEE=7. respectively. p=0. and nonsignificant correlations with QWB and CESD scores. Redelmeier et al25 investigated the change in FEVX associated with a change in subjective dyspnea rating on a 7-point scale from "much better.05).92 60 80 100 120 COPD: r=0.. % Deo. Posttransplant patients also showed a significant correlation between SOBQ scores and 6MW distance (r=. % pred FEV^FVC.41f 0.69* -0.62 ~T- 20 40 Previous Version Total Score new Figure 1.44 Post-Transplant: r=0. FEVX FVC have been cor¬ patients related with the Baseline Dyspnea Index (BDI).44f +0.19-20 The choice ofa dyspnea depends not only on the purpose of the application. explanation of abbreviations. and PB.47 and . It should be noted that this study included not only 28 patients with COPD." Using this scale.37f -0.80 Overall: r=0. we have made a series of the rating and used in the questionnaire to minimize scoring system missing responses for specific daily activities that are N/A or no longer performed by individual subjects. This suggests that the instrument has validity for dyspnea symptoms in different lung diseases. Because dyspnea in researchmodifications in of this.64§ fp<0. (r=. MIP.50f -0. We have found this information useful in the screening process to better understand the impact of lung disease on a person's life and also to help set specific.45* -0.42 for the older and newer ver¬ sions.50f -0.42f -0. Patients with CF showed nonsig¬ nificant correlations with percent-predicted Deo.01. *p<0.60* 52 52 52 52 38 38 38 38 26 29 30 FEF25-75%> RV/TLC. respectively.. In iologic parameters have beenand with COPD. % SOBQ (New) -0.29).006).36* -0. the results are consistent with those from a previous study in which an older version of the SOBQ was evaluated on a larger sample of patients with COPD. with mild correlation (r=0. % pred FEV!. did we begin to use The results of this ence4 indicate thatthe UCSD SOBQ is a reliable and 622 2. Wolkove et al24 did not find a significant correlation between Borg scores of dyspnea and FEVX and FVC in patients with COPD. 0.64 and . but also 9 patients with CF and 17 patients after lung transplantation. The number of patients in each subgroup was not large enough to reach statis¬ tical significance for many of the individual correla¬ tions.120 .

UCSD SOBQ breathlessness on a scale between zero and five where 0 is not at all breathless and 5 is maximally breathless or too breathless to do the activity. While eating 012345 7. Please respond to all items. Doing dishes 012345 14. similar relation¬ ships were seenofin the current study for the 6MW. At rest. 0 1 2 3 4 Anne has never mowed the lawn before but estimates that she Example 2: (5) would have been too breathless to do this week. Interestingly. Read the two examples below then turn the page to begin the questionnaire. health-related quality of life. Walking up a hill. thus. If the activity is one which you do not perform. How short of breath do you get while: 2. for the CF group.. the BDI. please give your best estimate of breathlessness. we believe that the self-report nature of the SOBQ makes it particularly useful for research and clinical applications. done as an evaluation of the SOBQ. As seen in Table 2. Walking on a level with others your age 4. Picking up and straightening 13.96) and moderate-to-strong correlations with exercise tolerance. Borg scale ratings of dyspnea following a 6MW. For example. although not significantly. we compared the previous version of the SOBQ with these other dyspnea measures in terms of its reliability. In this study. Mahler et al21 found a strong correla¬ tion between a 12-min walk distance and the BDI scores (r=0. and ease of adminis¬ tration. Timed walk distances have also been correlated with dyspnea. please rate your UCSD Medical Center Severely Maximally or unable to do because of breathlessness Example 1: How short of breath do you get while: 1. The SOBQ can be completed quickly and easily by patients with little applications. research SOBQ to be a useful clinical instrument to assess Appendix. Sweeping/vacuuming 012345 . 5... and depression for various disease processes.. Dressing 012345 12. In a previous study.6). Your responses should be for an "average" day during the past week. We have also found the dyspnea during common ADLs in order to set goals for improvement in specific activities through pulmonary rehabilitation or other inter¬ ventions. 0 1 2 (3) 4 5 Harry has felt moderately short of breath during the past week while brushing his teeth and so circles a three for this activity. Brushing teeth 012345 9. disease severity. While clinicians experienced in evaluating patients with lung disease may find the interviewer-administered BDI easy to complete. the SOBQ demonstrated excellent internal consistency (a 0. Walking on a level at your own pace 3.which factors the most The be used as a tool to further evaluate SOBQ may these relationships in future studies. most commonly in COPD.. with contributions from oxygen and acid-base abnormal¬ ities.27 and the Oxygen Cost Diagram28). Its high levels of reli¬ ability and validity make it an excellent tool for = previous findings.. and psychological factors. mechanical factors such as expiratory flow limitation and lung hyperinflation. In the current study. 0 Not at all 1 2 3 4 5 Pulmonary Rehabilitation Shortness-of-Breath Questionnaire Program ©1995 The Regents of the University of California Instructions: For each activity listed below. Shaving and/or brushing hair 10. we feel our instruction or supervision. 012345 012345 0 1 2 3 4 5 012345 ' 012345 012345 012345 CHEST/113/3/MARCH. 2.68). The SOBQ is a relative newcomer among the group of commonly used dyspnea measures (ie... SOBQ scores and percent-predicted Deo appear to corre¬ late best..96). Showering/bathing 012345 11. validity. and the correlation between the previous and current versions of the SOBQ (r=0. She circles a five for this activity. adds to the growing literature examining determinants of the question of but does dyspnea. Brushing teeth. Standing up from a chair 8. 0 Not at all 1 2 3 4 Severely 5 Maximally activity during the past unable to do because of breathlessness How short of breath do you get: or " 1. it pro¬ vides more detailed information than the global scores obtained from the American Thoracic Society Dyspnea Scale and Oxygen Cost Diagram. Walking up stairs 012345 6. Mowing the lawn. Which of these contribute the most in any particular disease remains poorly defined. The causes dyspnea are multifactorial.. no correlation was seen for the COPD group.contribute not answer in each disease.4 The SOBQ demonstrated higher levels of reliability than the other measures evaluated.21 the American Thoracic Society Dyspnea Scale. This study.confident that the SOBQ is a reliable and valid measure of dyspnea. Given the replication of predicted Deo in 37 patients with chronic airflow limitation26 (r=0. 1S 623 . It is the only one of these instruments that evaluates dyspnea in relation to specific ADLs.

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