Breathlessness, physical activity and sustainability of healthcare.

To the Editor:

We welcome the important paper by Grønseth et al. [1], which used data from the Burden of Obstructive Lung Disease (BOLD) project to highlight the prevalence of breathlessness across the world. As well as being significant because it is a source of suffering that should be ameliorated, we believe that attention to breathlessness, particularly in midlife, has important implications for sustainable healthcare because it allows timely diagnosis, would drive the promotion of physical activity, forms part of a strategy to reduce the burden of comorbidities and would have beneficial environmental effects.

Ensuring that health systems remain sustainable requires the prevention of future ill health [2]. Breathlessness in an individual may or may not indicate the presence of disease, but if it triggers a timely diagnosis of chronic obstructive pulmonary disease (COPD) or other conditions it offers the opportunity to intervene at an early stage with evidence-based therapies including, in COPD, intensive smoking cessation support, influenza vaccination and pulmonary rehabilitation [3]. Late presentation is a major concern in COPD, with many patients not diagnosed until they are admitted to hospital with an acute exacerbation [4].

As the authors note, the data they collected could only account for 13% of the variance in dyspnoea [1]. Other lung function parameters, such as transfer factor, have been shown to wield more prognostic power in COPD than spirometry [5] but, even in an extensively characterised population of COPD patients, lung function and other clinical parameters could explain only 32% of the variance in Medical Research Council score, with transfer factor of the lung for carbon monoxide, residual volume/total lung capacity ratio and exacerbation rate retained in a stepwise regression model [6]. Lung health screening in primary care confirms that breathlessness is common and associated both with reduced self-reported physical activity and reduced quadriceps strength, indicating the presence of deconditioning in healthy individuals as well as those with abnormal spirometry [7]. Increase in physical activity in midlife is associated with improved survival [8] and support to increase physical activity should be part of a structured approach to the management of breathlessness, and given as much importance as the medical management of specific pathologies. An increase in active transport (walking or cycling) is a key tool for promoting fitness and particularly desirable for respiratory health, as increased physical activity may reduce lung function decline [9], while simultaneously reducing the financial and carbon/climate change cost to the environment of transport generally, as well as particulate emissions from car exhausts, which have specific noxious effects on lung health.

Finally, the need for concerted efforts to increase physical activity was highlighted in a recent UK Dept of Health Framework document for the management of comorbidities [10]. Many patients with COPD have comorbidities, including cardiovascular disease, diabetes, osteoporosis and anxiety, all of which may, to an extent, be prevented or reversed by the promotion of physical activity in breathless individuals who have, or may otherwise go on to develop, long-term conditions.

Attention to breathlessness in midlife has the potential to significantly improve the identification of early disease and prevent the development of health problems, and would promote the sustainability at a social, financial and environmental level that is needed to improve patient care today and enable systems to deliver high-quality healthcare tomorrow.