The potential role of the anterior insular cortex and interoception on dyspnea in chronic obstructive pulmonary disease

Dyspnea (the perception of breathing discomfort) can be an immensely debilitating symptom for people with chronic obstructive pulmonary disease (COPD) and is not fully reflective of physiological measures of disease severity. We propose that the anterior insular cortex (AIC) and its key role in interoception (the perception of signals from within the body) are important mediators of dyspnea symptomology. Interoception encompasses respiratory motor drive, corollary discharge, sensory afferents, central neural integration, error signal generation, gating, decision processing and behavioral adaptation. Neuroimaging evidence supports this notion as decreased AIC activity in people with COPD is associated with heightened dyspnea, and respiratory interoceptive attention tasks have been shown to increase activation in this area of the brain. Therefore, activity in the AIC within the interoceptive processing pathway may explain some of the variability in symptom burden in people living with COPD. We explore these theories in the context of the current knowledge on the physiology and neuroscience of dyspnea, drawing on the implementation of interoceptive measures in other respiratory and mental health conditions. Given the evidence that the AIC has a key role in interoception and is a likely mediator within dyspnea symptomology, advances in our understanding of the role of interoceptive processing on symptom burden in people living with COPD, as well as appropriate methods to measure and treat it, should be research priorities.