KARLA KENDRICK's ARTICLE !

Can a self-rating 0 to 10 scale for dyspnea yield a common language that is understood by ED Nurses, patients, and their families?

I have been in several emergency departments, not only as an emergency nurse, but also as an asthmatic patient. I cannot recall anyone asking me, either as a child or as an adult, to rate my dyspnea on any of those occasions. Nor can I recall my mother, who was an emergency nurse in the 1950s, being asked to rate or interpret my breathing difficulties on any scale.

Before age 5 years, asthmatic children might need a parent to rate their dyspnea, and parents of asthmatic children generally become quite skilled at interpreting their child's varying degrees of dyspnea. My mother always seemed to know if I had run home, based on my exertional dyspnea. She also knew if I was lying about holding a furry animal at school, based on my sighing dyspnea. My mother even knew if I was having respiratory difficulties in the middle of the night, based on my paroxysmal dyspnea. By the age 8 years, I myself would have been knowledgeable and developmentally capable of expressing my breathing difficulty using a system that associates numbers or colors with the severity of my breathing.

As an adult asthma patient, I have faced the repeated challenge of trying to express my degree of dyspnea so that the ED nurses and physicians could be quickly alerted to the severity of my breathing difficulty. As an emergency nurse, I have searched for ways to help patients express the degree of dyspnea they are experiencing. I have often learned that personal experience leads to both knowledge and understanding.

Here is an exercise that will help illustrate my point. You will need a thin red plastic coffee stirrer, the type with 2 compartments inside the "straw"; be sure the stirrer is patent.

For the next 5 minutes, while in a sitting position, start breathing through one end of the stirrer and only through the stir "straw." Keep track of your time. For the first minute, you will find the task simple enough as you concentrate on moving air in and out through the "straw." By the end of 2 minutes you will experience pressure within your lungs' and will find this pressure somewhat uncomfortable, but you can still move air in and out through the "straw" without much difficulty. Four minutes into the exercise, you will be watching the clock anxiously, anticipating the end of 5 minutes. You will find it is taking a great effort to move air in and out through the "straw." You cannot talk because the only air you are receiving is now through that "straw." Now, stand and walk around your chair once and sit down.

Imagine that you are at the ED triage desk and the nurse assesses you and determines that you are dyspneic. The nurse notes that you are able to move air in and out through the "straw" with moderate persistent difficulty, your color is good, and you are not using accessory muscles to breath, although you appear anxious. Your respiratory rate is rapid, but within acceptable parameters, and you are not audibly wheezing. The triage nurse is not aware of the tremendous effort you are using just to breathe through the "straw," nor is the nurse aware of the pressure you are experiencing because you are unable to expand your lungs as a result of the narrow "airway" you have to breathe through.

Now suppose that the triage nurse hands you a 0 to 10 breathing scale and asks you to rate your sensation of dyspnea. The numbers on the scale correlate to the description of progressive increased difficulty in breathing (Figure 1).

Look at this scale and rate your breathing difficulty by choosing a number that most represents how you perceive your dyspnea. Based on that number and presenting symptoms, were you triaged to the treatment area and given a respiratory treatment, or were you told to sit in the waiting room?

You have experienced, first hand, the sensation of what it is like to have an asthma attack. Now, remove the "straw" and take in a deep breath. Rate yourself again using the same scale after 1 minute. That number may be the equivalent number a patient might use to rate his or her breathing after a couple of respiratory treatments.

What have you learned from this exercise?

For patients seeking relief for their asthma, the modified Borg scale is a simple, quick, easy tool that can be used to relate important information while conserving energy to breath. The modified Borg scale also helps parents of an asthmatic child articulate how they perceive their child's breathing.

For the ED nurse, the modified Borg scale is a valuable clinical indicator that quantifies in measurable terms such illusory expressions as "I feel short of breath," "I am having trouble breathing," or "My child isn't breathing very well." For the ED physician, the modified Borg scale could offer good baseline data to measure the effectiveness of respiratory treatments.

The 1 to 10 pain scale is being used increasingly in the emergency department and is recognized as a reliable scale to measure the intensity of pain. A similar scale that measures the varying degrees of dyspnea may be even more important. Determining the degree of pain a patient is experiencing is difficult for the ED staff. Some patients are more stoic or too afraid to complain of pain. Furthermore, it is difficult for ED staff to determine how much effort and energy it is taking for an asthmatic patient to breathe through narrowing airways. Even worse, we may force such patients to exhaust what little oxygen reserves they may have by asking them several questions regarding their dyspnea.

Try using the modified Borg scale with adult asthmatic ED patients, and ask parents to co-rate their asthmatic child. Then record your respiratory assessment on the basis of signs, symptoms, and sensory perceptions of dyspnea. You will find that the modified Borg scale is a quick, easy, and accurate new tool. (See the article on page 216 for additional information about the modified Borg scale.)

SCALE	SEVERITY
0	Nothing At All
0.5	Very Very Slight (Just Noticeable)
1	Very Slight
2	Slight
3	Moderate
4	Some What Severe
5	Severe
6
7	Very Severe
8
9	Very Very Severe (Almost Maximum)
10	Maximum

Modified Borg scale, From Burdon JGW,Juniper EF,Killian KJ,Hargrave FE,Campbell EJM

The perception of breathlessness in asthma. Am Rev Respir Dis 1982;126:825-8.

Karla R. Kendrick, San Diego County Chapter, is a Staff Nurse III and Quality Improvement Facilitator for the Emergency Department and Urgent Care Clinic, Veterans Administration San Diego HealthCare System, San Diego, Calif

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