抽象的
基于谨慎的认知治疗可以改善COPD患者的福祉超出通常的治疗措施:这是慢性呼吸困难的整体方法的额外证据http://ow.ly/Dz2630irqvR
一世n healthy people, breathing is the most natural thing in the world. No need to think about it. No need to be concerned about it. It is not even the object of conscious perception. But when breathing becomes difficult, when it produces suffering, nothing else matters一种。L.ife discolours and shrinks around an act of breathing that has become elusive and uncertain, but pervasive. Disability ensues, which adds “a variety of adverse psychosocial, spiritual, or other consequences” to the respiratory-related physical limitations [1]。R.espiratory suffering, be it called dyspnoea, breathlessness or by any other name, is therefore a major (and probably often the main) driver of impaired quality of life in patients afflicted with chronic respiratory diseases (and also cardiac diseases, neuromuscular diseases and severe obesity). To put things more bluntly, not being able to breathe freely is probably the worst thing that can happen to a human being. Dyspnoea has long been compared to pain [2]一种nd has a lot of neurophysiological similarities with it [3.那4.]。Yet in many ways dyspnoea is probably worse than pain. Indeed, acute dyspnoea goes hand in hand with fear, the fear of dying, which is not systematically the case with pain. And, not being a universal experience like pain, dyspnoea might be less susceptible than pain to induce reactions and empathy from those who witness it. Trained healthcare professionals dealing with respiratory distress on a daily basis fail to correctly evaluate the dyspnoea of their patients [5.]尽管最近的证据表明,诸如类似于替代痛苦的方式确实存在替代呼吸困难[6.[慢性疾病的呼吸困难趋于看不见的护理人员[7.]。这可能是因为对呼吸困难的医疗反应不太编纂和效率低于对疼痛的反应,但这种现象只能放大呼吸困难对经历它的人心理的负面后果[7.那8.]。然而,正如B强调的那样一种şoğlu[8.]在最近的编辑中,未能询问,评估和适当地治疗呼吸性,如专业临床指南所述,是违反临床医生的道德和患者的法律责任(另见[9.])。在这种临床重要性之上,呼吸痛苦是收敛点和一系列疾病的最终途径,有时常见,并且专家可能无法互相理解。换句话说,呼吸困难是呼吸医学的“联合机”,其所有多样性。出于所有这些原因,呼吸困难应该是所有医疗保健专业人员的最重要关注点,临床研究中的主要标准以及特定多学科研究努力的重点。幸运的是,有迹象表明,这是在全球范围内成为这种案例,欧洲呼吸协会(ERS)在这一运动中发挥着重要作用,如众多类型的所有类型的出版物所证明的188bet官网地址E.uropean Respiratory Journal[1那8.那10-14.]和E.uropean Respiratory Monographseries [15.]那一种nd the endorsement by the ERS of the Dyspnea 2016 meeting organised by the International Dyspnea Society (www.dyspnea2016inparis.fr/sponsors/endorsement).
如何解决Dyspnoea?清楚地,通过校正致病肺病(“治疗肺部”而导致的生理异常)。这一领域有很多研究,许多成功,但也有很多挫折,因为许多病变和呼吸系统的功能障碍都不完全可逆。值得注意的是,肺不是唯一一个靶向与慢性呼吸系统疾病相关的生理异常的器官。例如,在运动肌肉方面实现这一问题一直是康复的开发和成功,作为慢性呼吸系统疾病患者的关注的组成部分。附上还有,仍然存在在“病理生理学”治疗领域的途径,而无需新分子或新发现,而是通过一些“横向思维”。例如,随着呼吸阻抗的增加在呼吸困难的发病机制中发挥着重要作用,即使所选择的手段不是疾病特异性,即使所选择的手段也是有用的,通过任何方法降低其可能是有用的。支气管扩张剂即使在正常科目中也减少了呼吸阻抗:它们对“非支气管疾病”呼吸困难的推定益处可能值得探索[16.]。
D.yspnoea can also be addressed by targeting the brain. After all, no brain, no dyspnoea. So, when respiratory system physiological abnormalities have been corrected or cannot be further corrected (“chronic breathlessness” [1]或“持久性呼吸困难”[17.]), it is logical to turn to the brain (“fool the brain”). Benefits can be achieved pharmacologically through direct action on brain receptors involved in the pathogenesis of dyspnoea. Opioids are currently the only such approach of somewhat proven efficacy [18.]但虽然有一些争议(总结在[19.])和相应的证据需要加强。最近在一份编辑中强调的E.uropean Respiratory Journal(E.R.j) [20]那it is also possible to alleviate dyspnoea by pharmacological or non-pharmacological interventions aimed at rebalancing the respiratory-related brain efferent output with the corresponding afferent input (load-capacity balance/corollary discharge theory [21])。L.ikewise, nebulised furosemide is thought to relieve dyspnoea [22]by enhancing the afferent traffic from the respiratory system through direct stimulation of tracheobronchial slowly adapting stretch receptors [23.]。T.here are many research avenues in this direction, from simple actions (stimulation of trigeminal afferents by use of portable fans [24.])更复杂的(诱导呼吸道神经塑料[25.]by analogy with an approach that has proven useful in certain types of pain [26.那27.])。
B.ut “treating the lung” and “fooling the brain” can, in the current state of our research and knowledge, fail to relieve dyspnoea sufficiently to make life acceptable again. This is true for the dyspnoea that stems from chronic diseases with identified lesions or organ dysfunction, but is also true for certain unexplained dyspnoeas (e.g.in patients with the chronic hyperventilation syndrome, where there is no organic disorder to correct but that still qualifies as a disease and a disability according to World Health Organization principles). Are there other approaches, and are they available today? In this issue of theE.R.j那Farver-V.estergaard等等。[28.]present the results of a cluster randomised controlled trial of mindfulness-based cognitive therapy in chronic obstructive pulmonary disease (COPD). The primary objective of this study was to test the efficacy of a combined mindfulness and cognitive therapy approach on psychological distress as assessed using the hospital anxiety and depression scale (HADS). This is in line with the currently accepted multidimensional model of dyspnoea [29.]from which it is clear that anxiety and depression are the ineluctable consequences of dyspnoea when the behavioural changes that it induces fail to correct or to prevent it. The rationale behind the choice of intervention stemmed from data showing that psychosocial interventions can be effective in COPD patients [3.0-3.2]那particularly when they incorporate a cognitive dimension [3.3.]那一种nd from data pointing at the putative interest of meditative techniques in the same context [3.4.]。正念与认知的结合一种pproach (building on data suggesting the interest of cognitive behavioural therapy [3.5.]) was therefore logical. Farver-V.estergaard等。[28.]found that mindfulness-based cognitive therapy as an add-on to pulmonary rehabilitation resulted in a statistically and clinically significant improvement of the HADS score and more specifically of its “depression” dimension. Strikingly, the effect was durable and still present after 6 months. These are very important results that should raise hope in our capacity to improve the well-being of patients that have often lost hope and feel helpless. To speak bluntly again, these results tell us that there is still hope after “optimal bronchodilation”. As always, the study by Farver-V.estergaard等。[28.]has limitations, which are clearly discussed in the article. The evolution of inflammatory markers before and after the interventions in the two treatment arms are not easy to interpret (e.g.肿瘤坏死因子-α的显着增加在肺恢复的肺恢复和缺乏肺部恢复和谨慎的基础认知治疗中的缺乏。结果与以前的思维态度的研究差异差异,这是在COPD中未能享有福利的思维 - 身体干预措施[3.6.那3.7.],这有点麻烦但是作者合理解释。该研究如何在实践中翻译仍有待观察。如何选择将从此处受益的患者或其他思维身体方法中受益,这将是一个挑战来确定。实际上,对于新的细节,很容易将每种类型的心态或心理社会干预放入同一个锅中,但它们之间存在显着差异(不仅在正念的认知治疗和谨慎的基于思想的压力减少之间存在显着差异[28.]那but even more obviously when cognitive behavioural therapy, hypnosis, coping skills therapy or other approaches are considered): caution will be needed in evaluating and then choosing the best approaches. Nevertheless, the major merit of this study is that it introduces a novel approach in the care of COPD patients with persistent dyspnoea, and we do need novelties in this field. Of note, Farver-V.estergaard等。[28.提供完整的治疗手册中使用他们study as an online supplement to their article. This is a remarkable document that will be of major use for those willing to follow suit.
f的态度为基础的认知治疗方法是否使用arver-V.estergaard等。[28.]help the patients enrolled in the trial with their dyspnoea? This was not specifically assessed, but there was no significant improvement in the COPD assessment test. It would have been of the utmost interest to know what the effects of the therapeutic intervention under scrutiny were on a multidimensional assessment of dyspnoea like the Multidimensional Dyspnoea Profile or the Dyspnoea-12 [10那3.8.那39]。一世n COPD outpatients, it has been shown that the affective dimension of dyspnoea was more marked in patients exhibiting signs of depression [13.]。因此,可以通过思维身体类型的方法减少心理困扰,也可以通过“情感”途径来改善呼吸困难;或者改善呼吸困难的情感尺寸可以抑制心理困扰;或两者。无论如何,对于那些热衷于将治疗干预的影响与可观察效果相关,有一种逻辑可以使用思维身体治疗呼吸困难。实际上,呼吸困难的发病机制严重涉及包括凸出的脑网络的脑网络。insula是在二氧化碳刺激诱导的持续实验呼吸困难期间强烈激活的大脑区域之一[4.0]一种nd inspiratory mechanical loading [4.1]。一世t is activated as soon as breathing is made difficult by experimental loading (and actually from the first breath on, see [4.2])。在慢性呼吸系统疾病的患者中通过仅预期呼吸困难的患者激活[4.3.那4.4.]。Yet mindfulness training has been associated with modulation of the activity of the insula in response to an aversive respiratory stimulus [4.5.],它可以在某些情况下解释其具有可能的“呼吸组分”的某些情况[4.6.]。We do not know if the mindfulness-based cognitive intervention modulated the functioning of the insula in the patients studied by Farver-V.estergaard等。[28.]那一种nd it seems that these patients did not experience dyspnoea relief. But they did feel better. They were less depressed. They could live better with their dyspnoea. They had gained control. Their mind was appeased even though their body had not experienced dramatic improvements [4.7.]。这是一个重大结果。
总之,越来越清楚的是,需要多方面,多学科和多维患者的慢性或持续的呼吸困难患者的方法:换句话说整体[4.8.](see also the recent correspondence from Faull.等。[4.9.]in theE.R.j). The encouraging results obtained by the “breathlessness intervention service” approach (improved quality of life, reduced symptom impact, lessened carers burden [5.0])证明这假设的有效性,在“生命结束”背景下,将支持性护理与治疗项目方式相结合的功效[5.1那5.2]。综合方法有助于“古典”结果,但它们也积极影响尊严[5.3.]那一种fundamental element of humanity that should never be denied to sick patients because of their sickness. The study of Farver-V.estergaard等。[28.]表明,在这种角度来看,在护理呼吸困难的照顾中融入思想的关心是很重要的,因此要整体治疗人,而不仅仅是他/她的肺部或他/她的大脑。换句话说,不仅考虑慢性或持续的呼吸性,不仅是症状,而不仅仅是作为综合征,而且在最后,作为一个独立的全包条件,保证我们的未分开和“初级”的关注。
承认
T.he author is grateful to Miriam J. Johnson for her critical appraisal of the manuscript and her help improving it.
脚注
Conflict of interest: T. Similowski reports personal fees from AstraZeneca, Boerhinger Ingelheim France, GSK, Lungpacer Inc., TEVA, Chiesi, Pierre Fabre, and Invacare; and personal fees and non-financial support from Novartis, all outside the submitted work. In addition, T. Similowski has a patent concerning a “brain–ventilator interface to improve the detection of dyspnea” licensed to Air Liquide Medical Systems and MyBrainTechnology.
↵一种T.his text is derived from a passage in the foreword of the first edition of a document published in 2013 by the Forum of International Respiratory Societies, and this concept has become the “motto” of the French “Fondation du Souffle” (www.lesouffle.org).
- R.eceivedFebruary 12, 2018.
- 公认2018年2月13日。
- 复制right ©ERS 2018