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(Chest. 2005;127:1942-1951.)
© 2005 American College of Chest Physicians

Respiratory Complaints in Chinese*

Cultural and Diagnostic Specificities

Jiangna Han, MD; Yuanjue Zhu, MD; Shunwei Li, MD; Xiansheng Chen, MD; Claudia Put, PhD; Karel P. Van de Woestijne, MD and Omer Van den Bergh, PhD

* From the Laboratory of Respiratory Psychophysiology (Drs. Han, Zhu, Li, and Chen), Department of Pneumology, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing China; the Department of Pneumology (Drs. Put and Van de Woestijne), U Z Gasthuisberg, Leuven, Belgium; and the Department of Psychology (Dr. Van den Bergh), University of Leuven, Leuven, Belgium.

Correspondence to: Jiangna Han, MD, Laboratory of Respiratory Psychophysiology, Department of Pneumology, Peking Union Medical College Hospital, Beijing, 100730, China; e-mail: Janet_Han2000{at}hotmail.com


   Abstract
TOP
 Abstract
Introduction
 Subjects and Methods
 Results
 Discussion
 Appendix
 References
 
Study objectives: We investigated the qualitative components of a wide range of Chinese descriptors of dyspnea and associated symptoms, and their relevance for clinical diagnosis.

Measurements: Sixty-one spontaneously reported descriptors were elicited in Chinese patients to make a symptom checklist, which was administered to new groups of patients with different cardiopulmonary diseases, to patients with medically unexplained dyspnea and to healthy subjects.

Results: Test-retest reliability was satisfactory for most of the descriptors. A principal component analysis on 61 descriptors yielded the following eight factors: dyspnea-effort of breathing; dyspnea-affective aspect; wheezing; anxiety; tingling; palpitation; coughing and sputum; and dying experience. Although the descriptors of dyspnea-effort of breathing resembled Western wordings and were shared by patients with a variety of diseases, the descriptors of dyspnea-affective aspect appeared to be more culturally specific and were primarily linked to the diagnosis of medically unexplained dyspnea, whereas wheezing was specifically linked to asthma.

Conclusions: Three factors of breathlessness were found in Chinese. The descriptors of dyspnea-effort of breathing and wheezing appear to be similar to Western descriptors, whereas the dyspnea-affective aspect seems to bear cultural specificity.

Key Words: Chinese • dyspnea • factor analysis • respiratory complaints


   Introduction
TOP
 Abstract
 Introduction
Subjects and Methods
 Results
 Discussion
 Appendix
 References
 
The language of emotion is tightly knit into the language of bodily symptoms and, in particular, into the language of respiratory sensations. For example, one can describe emotional experiences either as breath taking or as suffocating. This shaping of emotional experiences into the language of the body is thought to be particularly sensitive to cross-cultural differences. According to some authors,12 Western people would use more intrapsychic conceptualizations of emotion, whereas Chinese people would be more likely to express emotions in terms of bodily sensations. Anger, for example, would be more frequently experienced in the chest and heart in Chinese people, whereas depression is characterized and phrased as something pressing into the chest. In rural China, emotional reactions may even not be experienced as an emotion, but purely as a medical symptom. This poses a problem in applying Western categories, such as somatization disorder and medically unexplained symptoms, to the Chinese culture.345 Even in the domain of classical medicine, the wordings of symptoms referring to diseases may be also affected by cultural differences. For example, drawing attention to the ethnic/racial difference in the language of dyspnea, Hardie and colleagues6 used methacholine to provoke bronchoconstriction in African Americans and whites with asthma. These investigators found that African-American patients selected "tight throat," whereas whites chose "deep breath." Phankingthongkum et al7 found Thai terminology used by asthmatic children and adolescents to describe wheeze, chest tightness, shortness of breath, and dyspnea. Both studies pointed to important cultural differences in the language of respiratory sensations.

In Chinese, our language of bodily symptom perception and amount of descriptors for dyspnea is extremely limited. The descriptors of breathlessness currently used in the clinical practice, for instance the term breathing difficulty (Figure 2) , are linguistically translated from English, and they do not reflect the cultural and ethnic influences on the symptom perception. Very frequently, Chinese patients would reply with "No, doctor! I don’t have breathing difficulty," and would propose another word.



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  		Figure 2.
 
Systematic investigation of the language of dyspnea and associated symptoms in Chinese is in an urgent need for the simple reason that a patient’s description of a subjective experience may help the physician to identify the specific cause of breathlessness.8910 This would be similar to a physician asking a patient with chest pain to describe the quality and characteristics of chest pain in order to determine the etiology. The present study was designed to answer the following questions: What are the descriptors used by Chinese patients to describe their respiratory sensations? To what extent are they related to a clinical diagnosis? In view of the assumed Chinese cultural tendency to express emotional experiences in bodily symptoms,2 it was of particular interest to find out how Chinese patients with medically unexplained respiratory symptoms would describe their symptoms differently from patients with a clearly defined pathology.

The following three stages were involved in the present study: (1) the initial collection of a wide range of spontaneously reported descriptors of respiratory symptoms from interviewing a variety of patients presenting dyspnea; (2) the administration of the symptom checklist, incorporating those descriptors into a 5-point scale of frequency of occurrence, to new groups of patients with dyspnea and healthy subjects; and (3) the derivation of symptom factors measuring different qualitative components of dyspnea by a principal component analysis, and the separation of the clinical groups in terms of these symptom factors by a variance analysis with Duncan grouping.


   Subjects and Methods
TOP
 Abstract
 Introduction
 Subjects and Methods
Results
 Discussion
 Appendix
 References
 
Subjects
The following two populations of subjects were studied: 232 patients presenting with dyspnea as a chief complaint; and 96 healthy subjects. With one exception, they were all Mandarin speakers.

Patients were recruited from the following three hospitals in the Beijing area: Peking Union Medical College Hospital; Fu Wai Hospital & Cardiovascular Institute; and Railway General Hospital. Among the patients, 153 (66%) were from Beijing, and 74 (32%) were from the other parts of northern China. The other five patients (2%) were from southern China. The geographic distribution of the patients is shown in Figure 1 . According to the etiology of their dyspnea, the patients were further classified into the following five groups: organic lung diseases except for asthma; asthma; congestive heart failure; medically unexplained dyspnea; and pregnancy. Their age, gender distribution, and level of education are shown in Table 1 .



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  		Figure 1. The geographic distribution of the 232 patients who were recruited for the present study.

 

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  		Table 1. Characteristics of Each Diagnostic Grouping*

 
Organic Lung Diseases:
A total of 48 patients with a variety of lung diseases other than asthma were grouped into this category. Among them, 11 patients had interstitial lung diseases, 9 had pulmonary emboli, 8 had COPD, 5 had bronchiectasis, 3 had lung cancer, 3 had spontaneous pneumothorax, 3 had tuberculous pleural effusions, 2 had primary pulmonary hypertension, 1 had an upper airway obstruction, 1 had alveolar proteinosis, 1 had bronchial tuberculosis, and 1 had pulmonary venoocclusive disease.

Asthma:
A total of 42 patients with asthma were classified into a group separated from other organic lung diseases.

Congestive Heart Failure:
A total of 35 patients with congestive heart failure were grouped into this category. The underlying diseases of cardiac failure were valvular heart disease (18 cases), dilated cardiomyopathy (8 cases), and coronary artery disease (8 cases). In one patient, the underlying cause was undetermined at the time of the study.

Medically Unexplained Dyspnea:
This group consisted of 54 patients who complained of dyspnea that could not be explained by the presence of an organic disease. The diagnosis was based on the combination of respiratory complaints, specifically dyspnea, the absence of any disability that might explain these complaints, and, additionally, a high level of anxiety.11 Organic diseases as a cause of dyspnea were excluded.

Pregnancy:
A total of 53 women who had been pregnant for 20 to 40 weeks were included in the present study.

Healthy subjects were all citizens of Beijing. They were paid volunteers. They had no complaints of dyspnea or symptoms suggestive of the presence of any disease.

Methods
Development of the Respiratory Symptom Checklist:
As a first step in the development of the respiratory symptom checklist, a large pool of Chinese descriptors of breathlessness and associated symptoms were assembled. Inpatients (n = 40) and outpatients (n = 31) with dyspnea were individually interviewed, and were asked to cite as many subjective expressions associated with dyspnea as possible. These interviews produced 60 descriptors. Then, these 60 spontaneously reported descriptors were evaluated by eight respiratory and cardiac physicians and by two psychologists. They were asked to add possible missing descriptors and to eliminate the descriptors either because of their close similarity to other descriptors or because they were judged to be potentially too difficult for some patients to understand. After the individual evaluation, a small group participated in a consensus meeting. Eight spontaneous descriptors were eliminated because of redundancy. Nine descriptors from classic textbooks were added, as follows: "difficult to breathe out" (DL38); "coughing" (DL54); "mucus congestion" (DL55); "chest pain" (DL56); "expectoration" (DL57); "hemoptysis" (DL58); "my breathing stopped" (DL59); "I cannot walk on level or up the stairs" (DL60); and "I cannot lie down" (DL61). This process resulted in a total of 61 descriptors (Table 2 ).


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  		Table 2. Descriptors in the Respiratory Symptom Checklist (n = 328)

 
In the second step, the respiratory symptom checklist incorporating the 61 descriptors was developed on a 5-point scale of frequency of occurrence over the past 1 month (0, never occurring; 1, rare; 2, sometimes; 3, often; 4, very often). Four different ordered versions of 61 descriptors were produced by randomization.

Administration of the Respiratory Symptom Checklist:
The respiratory symptom checklist was administered to new groups of 232 patients and 96 healthy subjects. They filled out the checklist during a consultation or during hospitalization. Each subject completed two different versions on two occasions that were separated by at least 2 h. Family members were not present, and subjects were left alone and given as much time to finish the checklist as they needed. Most subjects needed between 10 and 15 min. The subject rated the frequency with which he/she experienced each descriptor during the last month by marking the appropriate point on the 5-point scale. When assistance was requested, the investigators took care not to suggest any answers. After the completion of each checklist, the subjects were asked to check any missing item and to complete it.

Statistical Analysis
The first step in the statistical analysis was to compute the mean and SD for a particular item from the data on 328 subjects who had completed the symptom checklist a first time (Table 2). The mean values for each item would provide an estimate of the frequency of occurrence of each descriptor in the studied population.

To investigate the qualitative components of the descriptors of dyspnea and associated symptoms, a principal component analysis was performed on 61 descriptors with orthogonal varimax rotation.1213 The basic idea of this analysis was to classify this wide range of 61 descriptors into a number of clinically meaningful and interpretable symptom factors that would capture the unique qualitative components of dyspnea. This analysis yielded 12 consecutive and uncorrelated factors based on the minimal eigenvalue criterion (> 1). With varimax rotation, a pattern of loadings was obtained (ie, factors marked by high loadings for some descriptors and low loadings for others). From this pattern of loadings, each factor was identified by high loadings of a unique set of descriptors, arriving at a classification of 61 descriptors into 12 symptom factors. However, the minimal eigenvalue criterion sometimes retains too many factors. An additional criterion (ie, the extent to which a solution is interpretable) was used. We ended up with eight factors that made the best "sense."

The internal consistency of each factor was examined by the Cronbach {alpha} coefficient. The validity of the factors was examined by a variance analysis providing Duncan grouping on different groups of patients and healthy subjects. The test-retest reliability of each descriptor was evaluated by calculating the Spearman {rho} value for 328 subjects who had completed the checklist on two occasions. All analyses were performed with a statistical software package (SAS; SAS Institute; Cary, NC).

Translation and Validation of Descriptors From Chinese into English
The respiratory symptom checklist was originally developed in the Chinese language. To facilitate the communication with and the comparison to the existing descriptors in English,8910 these 61 descriptors were translated into English by one of the authors. To ensure the reliability of the wording used, they were back-translated to Chinese by another professional translator. The 61 descriptors in the original Chinese and their corresponding English translation are presented in the Appendix.


   Results
TOP
 Abstract
 Introduction
 Subjects and Methods
 Results
Discussion
 Appendix
 References
 
Structure of the Respiratory Symptom Checklist
Twelve factors were derived based on the minimal eigenvalue criteria (> 1) by the principle component analysis on the 61 descriptors, explaining 67.8% of the total variance. The pattern of loadings for 61 descriptors on each factor derived from varimax rotation is illustrated in Table 3 . A cutoff loading of > 0.40 was required in the item classification. As shown in Table 3, there were six descriptors with loading of < 0.40, namely, dizziness, shaking or trembling, cold hands or feet, flushing to the head, sudden hot or cold, and chest pain. In the case of crossloading, a difference of < 0.20 between the highest loading on one factor and the next highest on the other factor was required to consider the item to be shared on two different factors. Ten descriptors reached loadings of > 0.40 on two factors, and 9 of them were shared on factor 1 and other factors. Compressed chest and chest tightness were on factors 1 and 6. Oppressive chest was on factors 1 and 5. Gasping, breathing more, breathing fast, exhaling more, and rapid respiration were shared on factors 1 and 2. An inability to breathe in and out was on factor 1 and 8. Fatigue was on factor 3 and 5.


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  		Table 3. The Pattern of Loadings for 61 Descriptors on Each Factor Derived From Varimax Rotation in 328 Subjects*

 
The inspection of the loadings on each factor from the rotated factor pattern (Table 3) suggested that there was no item loading high enough for factor 11 and only one defining item of hemoptysis for factor 12. Therefore, no internal consistency was calculated. Factors 9 and 10 were composed of three items of poor conceptual clarity. Accordingly, the internal consistency of these two factors was poor (Cronbach {alpha}: factor 9, 0.49; factor 10, 0.50). In contrast, factors 1 to 8 were conceptually clear. They appeared to have fairly high internal consistency (Cronbach {alpha}: factor 1, 0.96; factor 2, 0.88; factor 3, 0.84; factor 4, 0.75; factor 5, 0.79; factor 6, 0.85; factor 7, 0.75; and factor 8, 0.72). Therefore, factors 1 to 8 were retained and defined, in order of importance according to the proportion of eigenvalues, as follows:
  1. Dyspnea (effort of breathing encompassed 19 descriptors): attempt to breathe in with much effort; being suffocated; shortness of breath; oppressive chest; sighing; my breathing needs conscious help; inability to breathe in deeply enough; difficult to breathe out; my breath does not go in all the way; I cannot breathe enough; desperate for breath to come; my breath does not go out all the way; breathing fast; breathing with difficulty (with effort); I cannot breathe in; hunger for more air; a need to take a deep inspiration; rapid respiration; and I cannot breathe out.
  2. Wheezing: gasping; whistling while breathing; whistling in throat; whistling in exhalation; breathing more; exhaling more.
  3. Anxiety: nervousness; irritated; a restless heart; restless.
  4. Tingling: tingling fingers or arms; tingling legs or feet; tingling face; tingling head or body.
  5. Palpitation: palpitation; fatigue; pounding heart; I cannot walk on level or up the stairs.
  6. Dyspnea-affective aspect: compressed chest; blocked chi in the chest; tight or lump throat; blocked chi in the throat; chest tightness.
  7. Coughing and sputum: blurred vision; coughing; mucous congestion; and expectoration.
  8. Dying experience: experiencing the agony of dying; inability to breathe in and out; my breathing stopped.

Reproducibility of the Descriptors
Retesting of the subjects on two occasions separated by at least 2 h revealed fairly high reliability. In 51 descriptors, the test-retest coefficients reached 0.70 to 0.91, as shown in Table 3. The other 10 descriptors had relatively lower stability from one administration to another. They were compressed chest ({rho} = 0.69), blackness before eyes ({rho} = 0.66), stiff fingers, arms or legs ({rho} = 0.52), feeling faint ({rho} = 0.58), out of control or getting crazy ({rho} = 0.60), I cannot breathe enough ({rho} = 0.67), my breath does not go out all the way ({rho} = 0.69), I cannot breathe in ({rho} = 0.69), inability to breathe in and out ({rho} = 0.66), and I cannot breathe out ({rho} = 0.61).

Validity of the Symptom Factors
A variance analysis with Duncan grouping was used to compare the scores of the healthy subjects and the different categories of patients on the eight symptom factors. As shown in Table 4 , it appears that these symptom factors were able to separate clearly different types of patients with dyspnea. The factors of dyspnea-effort of breathing, wheezing, and palpitation turned out to be the most important factors in variance analysis with R2 values of 0.30, 0.34 and 0.28, respectively.


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  		Table 4. Variance Analysis on Symptom Factors for Five Groups of Patients and Healthy Subjects

 
For the symptom factor of dyspnea-effort of breathing, the Duncan test separated medically unexplained dyspnea from asthma, organic lung diseases, and congestive heart failure, with the highest mean scores achieved in the group of patients with medically unexplained dyspnea. The factor of wheezing appeared most often in asthmatic patients, followed by organic lung diseases and congestive heart failure. The symptoms of palpitation showed up most frequently in patients with congestive heart failure and organic lung diseases, and to a lesser frequency, in those with medically unexplained dyspnea. The scores of coughing and sputum (R2 = 0.13) were the highest in patients with organic lung diseases, followed by asthma patients. Factors of anxiety (R2 = 0.06), tingling (R2 = 0.12), and dying experience (R2 = 0.06) were unique for patients with medically unexplained dyspnea, and clearly distinguished those patients from healthy subjects and other patients with dyspnea. The dyspnea-affective aspect appeared to be primarily linked to the diagnosis of medically unexplained dyspnea, and, to a lesser extent, to the diagnosis of asthma (R2 = 0.08).


   Discussion
TOP
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
Appendix
 References
 
In the present study, spontaneously reported descriptors of dyspnea and associated symptoms were elicited in Chinese patients to make a symptom checklist. This was used to collect frequency evaluations in new groups of Chinese patients with different cardiopulmonary diseases and medically unexplained dyspnea, and in healthy subjects. Test-retest reliability in these 328 subjects was satisfactory for most of the descriptors. A principal component analysis on 61 Chinese descriptors yielded eight factors. The descriptors of dyspnea were separately allocated to the following three factors: dyspnea-effort of breathing; dyspnea-affective aspect; and wheezing. The other five factors grouped the associated symptoms of dyspnea, namely, anxiety, tingling, palpitation, coughing and sputum, and dying experience. To what extent are the Chinese descriptors different from those in Western cultures?

The Descriptors of Breathlessness in Chinese
Dyspnea-Effort of Breathing:
Simon et al14 initially studied the language of breathlessness and solicited 19 phrases describing respiratory discomfort from patients with cardiopulmonary diseases. These investigators administered a list of these phrases to 53 patients with breathlessness due to pregnancy and a variety of cardiopulmonary disorders, and found that certain descriptors were associated with breathlessness in different disease conditions.8 The association of specific descriptors with different pathophysiologic conditions was further replicated in a large sample of patients with a diagnosis of COPD, asthma, interstitial lung disease, congestive heart failure, cystic fibrosis, deconditioning, and neuromuscular disease,10 and in healthy subjects.15

It is difficult to compare our results with the results of those studies for a number of reasons. First, compared to the present study, these investigators collected a much smaller set of descriptors, prompted by a more specific question ("describe the sensations associated with uncomfortable awareness of breathing"). Second, the studies mentioned collected dichotomous judgments (ie, the descriptor was or was not applicable), whereas we used retrospective frequency-of-occurrence judgments over the past month. Third, they used cluster analysis to group the descriptors, whereas we used principal-component analysis. Fourth, either healthy individuals or patient groups were used as subjects, whereas in our study, grouping was done in a mixed group of patients and healthy subjects.

Despite all of these differences, the terms used in Chinese and Western subjects to describe breathing discomfort overlapped considerably with factor 1, which was defined as dyspnea-effort of breathing in the present study. As shown in Table 5 , in 11 of 15 English descriptors,810 identical phrases were found in factor 1. It is likely that common physiologic processes, related to respiratory effort, chemoreceptor stimulation, mechanical stimuli arising in the lung and chest wall receptors, and the processing of respiratory-related afferent information, as suggested by Manning and Mahler,16 contribute to the perception of these sensations in similar ways in both cultures. It might be possible that the techniques used in the studies of Simon et al8 and Mahler et al10 have resulted in more fine-grained clusters along the dimensions of "depth and frequency of breathing," "perceived need or urge to breathe," and "difficulty breathing and phase of respiration."15


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  		Table 5. Comparison Between Descriptors Proposed by Simon et al8 and Those in the Present Study*

 
Dyspnea-Affective Aspect:
However, not all phrases of dyspnea were allocated to the factor of dyspnea-effort of breathing in the present principal-component analysis. The descriptors of chest tightness, compressed chest, tight throat or lump in the throat, blocked chi in the chest, and blocked chi in the throat were grouped into another factor (factor 6), which was defined as dyspnea-affective aspect. It appeared that some descriptors unique for Chinese emerged in this factor, for example, blocked chi in the chest or in the throat. According to the concept of traditional Chinese medicine, chi is the living energy circulating along specific channels in human body. If chi is blocked in the pathway, disorders of body function will emerge. In this factor, the other concomitant descriptors included chest tightness and tight throat or lump in the throat. The former could be found in the 15 descriptors of breathlessness given by Simon et al,8 and the latter was often used by patients with anxiety and somatoform disorders.17 The fact that the descriptors of dyspnea were grouped separately into two distinct factors suggests that dyspnea, like pain, is a multidimensional experience encompassing not only effort of breathing but also an affective aspect.1819 This latter component appears to be more sensitive to cultural and emotional meanings.

Wheezing:
Wheezing, as a classical medical term, means breathing hard with whistling and indicates the presence of the airway obstruction, especially in patients with asthma.122021 Reported wheezing in the patient’s history is considered to be one of the important criteria for the diagnosis of asthma.21 In the factor analysis of the present study, the phrases gasping, breathing more, exhaling more, whistling while breathing, whistling in the throat, and whistling in exhalation were grouped under factor 2, which was defined as wheezing. In fact, the meaning of gasping and whistling used in Chinese is not different from that used in Western cultures. It is possible that the perception of wheezing, similar to the other descriptors in dyspnea-effort of breathing, is mainly influenced by the physiologic change (eg, the airflow obstruction), rather than by cultural factors. Therefore, wordings indicating the same meaning could be identified not only in Western and Chinese cultures but also by people in Thailand, as evidenced by the study of Phankingthongkum et al7 on Thai terminology of wheezing. To what extent are the factors differentially related to diagnostic categories?

The Relation of the Dyspnea Language and the Clinical Diagnosis
The ability of the symptom descriptions to differentiate diseases is considered to be an evidence of construct validity.22 For this purpose, a variance analysis with Duncan grouping was used to compare the scores of the symptom factors in different categories of patients and in healthy subjects. As shown in Table 4, the factor of dyspnea-effort of breathing was shared by different categories of patient, with the highest scores attributed to patients with medically unexplained dyspnea. This component of effortful breathing may imply both a dynamic aspect, which may be obvious in patients having to overcome pulmonary malfunction such as asthmatic patients, and a static component related to hyperinflation, which may be particularly prominent in patients with medically unexplained dyspnea.23

The factors of dyspnea-affective aspect and wheezing appeared to be primarily linked to the diagnosis of medically unexplained dyspnea and asthma. However, wheezing characterized asthma and was not present in patients with medically unexplained dyspnea. In that respect, the symptom factors could make a meaningful contribution to the differential diagnosis. For instance, if a patient reports wheezing, a diagnosis of medically unexplained dyspnea is very unlikely. On the other hand, anxiety, tingling, and dying experience seemed to be unique for patients with medically unexplained dyspnea. This would mean that in a patient complaining of, for instance, compressed chest or blocked chi, dyspnea would be likely to be nonorganic in origin if, in addition, the patient is clearly anxious and is presenting symptoms of tingling in the body. For patients with dyspnea, the occurrence of coughing, sputum, and hemoptysis would direct the physician’s attention to the organic lung diseases, whereas the presence of effortful breathing combined with palpitation (factor 5) may point to a cardiac origin of dyspnea.

In the present study, the descriptors of breathlessness were investigated mainly in Mandarin speakers living in northern China (Fig 1). One may question the generalizability of the results to other dialects used in southern China, for instance, Cantonese and Shanghaihua. Indeed, it is quite difficult for the speakers of different dialects to understand each other. It all depends on the tone of voice that each dialect uses. At times, in one sentence, each word has a different tone, so that the same word might mean one thing in one dialect and another thing in another dialect. However, the writing language is the same. Although they cannot understand each other’s speech, they can well understand each other when they put words on paper, for example, in a written questionnaire. Even so, further validation of the present results in Canton and Shanghai is needed before clinical application in those areas

In summary, the following three factors of breathlessness were found in Chinese subjects: dyspnea-effort of breathing; dyspnea-affective aspect; and wheezing. The descriptors of dyspnea-effort of breathing and wheezing appear to be similar to those in Western studies, whereas the descriptors of dyspnea-affective aspect seem to bear cultural specificity. Although the descriptors of dyspnea-effort of breathing are shared by patients with a variety of diseases, the descriptors of dyspnea-affective aspect and wheezing are unique to a particular clinical condition.


   Appendix
TOP
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 Appendix
References
 
Appendix: Descriptors in Original Chinese and Their English Translations



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   Acknowledgements
 
We thank Dr. Zheng Hu for providing us with the opportunity to collect data in Railway General Hospital. We thank Dongmei Luo for her high-quality work on data management. We also thank Dr. Andrew Harver for stimulating our interest in this topic through his excellent work and for his valuable comments during the preparation of the manuscript.


   Footnotes
 
This research was supported by grant BIL01/05 of the Bilateral Scientific and Technological Cooperation between Belgium (Flanders) and China.

Received for publication May 26, 2004. Accepted for publication November 16, 2004.


   References
TOP
 Abstract
 Introduction
 Subjects and Methods
 Results
 Discussion
 Appendix
 References
 

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