Breathlessness in advanced disease. 2: Patient assessment and management

This second of a two part unit on breathlessness addresses patient assessment and management, including common treatments. Interventions that can be taught to, and used independently by, patients and carers are explored.

High-flow oxygen therapy in acute respiratory failure

OBJECTIVE

To compare the comfort of oxygen therapy via high-flow nasal cannula (HFNC) versus via conventional face mask in patients with acute respiratory failure. Acute respiratory failure was defined as blood oxygen saturation < 96% while receiving a fraction of inspired oxygen > or = 0.50 via face mask.

METHODS

Oxygen was first humidified with a bubble humidifier and delivered via face mask for 30 min, and then via HFNC with heated humidifier for another 30 min. At the end of each 30-min period we asked the patient to evaluate dyspnea, mouth dryness, and overall comfort, on a visual analog scale of 0 (lowest) to 10 (highest). The results are expressed as median and interquartile range values.

RESULTS

We included 20 patients, with a median age of 57 (40-70) years. The total gas flow administered was higher with the HFNC than with the face mask (30 [21.3-38.7] L/min vs 15 [12-20] L/min, P < .001). The HFNC was associated with less dyspnea (3.8 [1.3-5.8] vs 6.8 [4.1-7.9], P = .001) and mouth dryness (5 [2.3-7] vs 9.5 [8-10], P < .001), and was more comfortable (9 [8-10]) versus 5 [2.3-6.8], P < .001). HFNC was associated with higher P(aO(2)) (127 [83-191] mm Hg vs 77 [64-88] mm Hg, P = .002) and lower respiratory rate (21 [18-27] breaths/min vs 28 [25-32] breaths/min, P < .001), but no difference in P(aCO(2)).

CONCLUSIONS

HFNC was better tolerated and more comfortable than face mask. HFNC was associated with better oxygenation and lower respiratory rate. HFNC could have an important role in the treatment of patients with acute respiratory failure.

Folate intake associated with lung function, breathlessness and the prevalence of chronic obstructive pulmonary disease

A case-control study was conducted in central Japan to investigate the relationship between dietary intake of folate and lung function, breathlessness and chronic obstructive pulmonary disease (COPD). A total of 278 referred patients (244 men and 34 women) aged 50-75 years with COPD diagnosed within the past four years and 340 community-based controls (272 men and 68 women) were assessed for dyspnoea and undertook spirometric measurements of lung function. A structured questionnaire was administered face-to-face to obtain information on demographics, lifestyle and habitual food consumption. Folate intake was derived from the Japanese food composition tables. The COPD patients had significantly lower habitual intake of folate (mean 231, SD 90 microg/day) than control subjects (mean 261, SD 110 microg/day), p<0.001. Lung function measures were found to be positively associated with dietary folate level. Reductions in prevalence of COPD and especially breathlessness were observed, the respective adjusted odds ratio (OR) being 0.74 (95% confidence interval (CI) 0.35 to 1.58) and 0.43 (95% CI 0.21 to 0.91) for the highest versus lowest quartile of folate intake. The corresponding tests for linear trend were also significant (p<0.05). In conclusion, an inverse association was evident between dietary folate intake and the prevalence of breathlessness for Japanese adults, together with a significant dose-response relationship for the COPD risk. Moreover, increased folate intake might be beneficial to lung function.

Principles to effectively manage people with interstitial lung disease in the community

This article examines the problems of caring for people with interstitial lung disease in primary care. It describes simple strategies that can support people to remain at home during the end stage of their illness. The diagnosis and investigations of ILD have been covered in previous Nursing Times articles (Duck, 2007a; 2007b).

[Effect of proactive use of inhaled procaterol on dyspnea in daily activities and quality of life in patients with chronic obstructive pulmonary disease]

AIM

To examine the effects of inhaled procaterol (Meptin Air : MA), a short-acting beta2-agonist, for proactive use rather than rescue use in dyspnea and health-related quality of life in patients with chronic obstructive pulmonary disease (COPD), who complained of dyspnea in daily activities despite treatment with long-acting bronchodilators.

METHODS

Patients with moderate to most severe COPD who were on maintenance therapy with tiotropium and other long-acting bronchodilators were studied. Severity of dyspnea was evaluated with the Shortness of Breath Questionnaire (SOBQ) and patients were recommended to use MA on an as-needed basis before daily activities which had caused dyspnea. The effects of MA were evaluated with the St. George's Respiratory Questionnaire (SGRQ) and MRC dyspnea scale. Baseline and post-administrative lung functions and exercise capacity (6-minute walking test) were measured.

RESULTS

SOBQ revealed that all patients still had dyspnea in daily activities despite maintenance therapy. Inhalation of MA to prevent dyspnea in daily activities on an as-needed basis significantly improved QOL in SGRQ, lung function and MRC scales. Six-minute walking distances showed a tendency to improve.

CONCLUSION

Proactive use of MA as needed (assist use) improved QOL and continuing dyspnea despite maintenance drugs. Assist use of MA before effort improved exercise capacity, suggesting that it might improve the ability of activity of daily living (ADL).

The patient with cancer-related dyspnea

Dyspnea can be challenging to manage because it often is exacerbated by anxiety. Patient positioning and relaxation and breathing techniques can help.

End stage chronic obstructive pulmonary disease

Many patients with chronic obstructive pulmonary disease (COPD) die each year as those with lung cancer but current guidelines make few recommendations on the care for the most severe patients i.e. those with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages III and IV with chronic respiratory failure. Only smoking cessation and long term oxygen therapy (LTOT) improve survival in COPD. Although non invasive positive pressure ventilation (NPPV) may have an adjunctive role in the management of chronic respiratory insufficiency there is little evidence for its use in the routine management of stable hypercapnic COPD patients. At difference, several prospective, randomised, controlled studies, systematic reviews and meta-analyses show good level of evidence for clinical efficacy of NPPV in the treatment of acute on chronic respiratory failure due to acute exacerbations of COPD. NPPV is also alternative to invasive ventilation for symptom relief in end stage COPD. Surgical interventions for end stage COPD like bullectomy, different modalities of lung volume reduction surgery and lung transplantation are likely to be of value to only a small percentage of patients. Nevertheless, there are specific indications, which, when added to pulmonary rehabilitation will further advance exercise capacity and quality of life. As in other chronic diseases when severity of disease increases along the natural history, therapy aimed to prolong life becomes less and less important in comparison to palliative therapy aimed to relieve symptoms. The most effective treatments for dyspnoea are bronchodilators, although also opiates may improve dyspnoea. Supplemental oxygen reduce exertional breathlessness and improve exercise tolerance in hypoxaemic COPD patients. There are difficulties in treating with antidepressant the frail and elderly COPD patients. Good clinical care can prevent or alleviate suffering by assessing symptoms and providing psychological and social support to the patients and their families.

Palliative sedation in a specialized unit for acute palliative care in a cancer hospital: comparing patients dying with and without palliative sedation

Palliative sedation is undergoing extensive debate. The aims of this study were to describe the practice of palliative sedation at a specialized acute palliative care unit and to study whether patients who received palliative sedation differed from patients who did not. We performed a systematic retrospective analysis of the medical and nursing records of all 157 cancer patients who died at the acute palliative care unit between 2001 and 2005. Palliative sedation, defined as continuous deep sedation prior to death, was used for 43% of all deceased patients. In 87% of the sedated patients, it was started in the last two days before death. Sedated and nonsedated patients did not differ in survival after admission (eight days vs. seven days, P=0.12). Sedated patients were younger (55 years vs. 59 years, P=0.04) and more often had malignancies of the digestive tract (P<0.01). In both groups, common symptoms at admission were pain (79% vs. 87%, P=0.23), constipation, (40% vs. 48%, P=0.46), and dyspnea (32% vs. 29%, P=0.77). On the day that palliative sedation was started, sedated patients more often suffered from dyspnea and delirium than nonsedated patients at a comparable day before death. The most important indications for palliative sedation were terminal restlessness (60%) and dyspnea (46%). We conclude that at the studied acute palliative care unit, patients who ultimately received palliative sedation did not have symptoms different than nonsedated patients at admission, but on the day at which the sedation was started, they suffered more often from delirium and dyspnea.

Relief of incident dyspnea in palliative cancer patients: a pilot, randomized, controlled trial comparing nebulized hydromorphone, systemic hydromorphone, and nebulized saline

Acute episodic breathlessness in patients receiving palliative care is a distressing symptom with little evidence-base to inform management. This pilot, double-blind, controlled, crossover study compared the effects of nebulized hydromorphone, systemic hydromorphone and nebulized saline for the relief of episodic breathlessness in advanced cancer patients. On three occasions of acute breathlessness, patients randomly received either nebulized hydromorphone, a systemic breakthrough dose of hydromorphone or nebulized saline together with a blinding agent. Breathlessness was scored before and 10, 20, 30, and 60 minutes post-treatment completion using a 100 mm visual analog scale. Twenty patients completed the trial. Ratings did not differ significantly across pretest treatments. Change in ratings from pretest to 10 minutes after completion of nebulization (about 20 minutes after administration of systemic hydromorphone) indicated that each of the treatments resulted in statistically significant improvements in breathlessness, with no significant differences between treatments. Over time, breathlessness decreased significantly for all treatments, with no significant differences between treatments. Only nebulized hydromorphone produced a rapid improvement in breathlessness that reached a magnitude considered to be clinically important. Interpretation of these results is considered in relation to our definition of clinical significance, the dose of hydromorphone used and the possibility of a placebo effect. This study can serve to inform the design of future trials to investigate the management of incident breathlessness.

Caring for critically ill patients with advanced COPD at the end of life: a qualitative study

Providing expert critical care for the high acuity patient with a diagnosis of COPD at the end of life is both complex and challenging. The purpose of this descriptive study was to examine intensive care unit (ICU) clinicians' perspectives on the obstacles to providing quality care for individuals with COPD who die within the critical care environment. Transcripts of three focus groups of ICU clinicians were analyzed using thematic analysis. The three themes of "managing difficult symptoms", "questioning the appropriateness of life-sustaining care" and "conflicting care priorities" were noted to be significant challenges in providing high quality end of life care to this population. Difficulties in palliating dyspnea and anxiety were associated with caregiver feelings of helplessness, empathy and fears about "killing the patient". A sense of futility, concerns about "torturing the patient" and questions about the patient/family's understanding of treatment pervaded much of the discourse about caring for people with advanced COPD in the ICU. The need to prioritize care to the most unstable ICU patients meant that patients with COPD did not always receive the attention clinicians felt they should ideally have. Organizational support must be made available for critical care clinicians to effectively deal with these issues.

Patients Reported Health-Related Quality of Life Five Years Post Coronary Artery Bypass Graft Surgery – A Methodological Study

Background: The number of individuals undergoing Coronary Artery Bypass Graft Surgery (CABGS) to treat coronary artery disease is steadily increasing.

Aim: The purpose of the study was to describe the cohort's characteristics, their angina and breathless symptoms and report health-related quality of life (HRQoL) five years after CABGS.

Methods: One hundred and twenty-eight patients participated in the follow-up study using the quality of life Short-Form 36 (SF-36) questionnaire. Angina and breathless symptoms were also recorded.

Results: One hundred and nine patients were interviewed (face-to-face) and 19 completed postal questionnaires. The SF-36 component summaries of the face-to-face patients indicated that their physical (PCS) and mental (MCS) health was relatively good (45.8 and 53.6, respectively, with 0 = worst health and 100 = best health and 50 being the mean score), compared to the postal patients' mean PCS of 30.8 ( p < .001). The postal MCS was also lower but not statistically significant (49.6, p = .081). At follow-up, the majority of patients were asymptomatic in terms of angina and breathlessness compared to their pre-operative status.

Conclusion: The findings demonstrate that patient perceived HRQoL five years after CABGS is generally good and patients remain relatively asymptomatic although data collection methods highlight differences in physical HRQoL.

Understanding palliative nursing care

Palliative care is care that is given to patients and their significant others who are experiencing life-threatening or life-altering illnesses by providing emotional, spiritual, and physical support. Patients can continue to receive aggressive medical treatment while receiving palliative care and recovery is possible. Pain control is a top priority in palliative care. Non-pharmacological interventions have also been shown to be effective in palliative care as well. Palliative care is truly a holistic, collaborative practice engaging many disciplines in the care of the patient and their love ones.

Research-as-if-practice: a study of family nursing partnership with couples experiencing severe breathing difficulties

Living with the symptoms of lung disease is challenging. The impact difficult breathing has on individuals and their families is frequently underestimated, with health care limited to managing physical manifestations of the origins of difficult breathing. This study describes a distinct approach to family nursing practice named partnership, which is based on a participatory worldview. Five couples in which the wife had severe breathing difficulties participated in the study. The research process is described as as-if-practice. The partnership process was illustrated in the theme "finding coherence in life with symptoms and treatment regimens." The outcome of the process was illustrated in the interrelated themes of "living life fully and taking things as they come" and "efficient use of health care." The study shows how the meaning that unfolded in the process reveals the insights of all participants into the families' health predicaments and what can be done with that insight.

The effects of exercise training on fatigue and dyspnea in heart failure

BACKGROUND

Physiological benefits of exercise training for heart failure (HF) patients have been demonstrated, however little is known about the effects of training on the symptoms of fatigue and dyspnea.

AIM

The purpose of this study was to examine HF symptoms of fatigue and dyspnea in response to a 24-week exercise training intervention.

METHODS

This pilot study was a randomized, two-group repeated measures design. Fifteen subjects in the intervention group completed a combination of aerobic and resistance training three times per week in a standard cardiac rehabilitation setting. The control group consisted of 6 subjects who were instructed not to begin any formal exercise program during the 24-week intervention.

RESULTS

Subjects (19 males and 2 females) had a mean age of 66.2+/-10.2 years and mean ejection fraction (EF) of 28.4+/-7.4%. Non-parametric Friedman Analysis of Variance by Ranks showed the exercise group significantly decreased sensory fatigue (Piper Fatigue Scale) over time (chi(2)=6.49, p=.04) while the control group did not change (chi(2)=0.93, p=.63). Dyspnea showed a non-significant decrease over time for the exercise group (chi(2)=4.16, p=.13) while the control group showed a decrease from baseline to 12 weeks but an increase to above baseline values by week 24 (chi(2)=0.18, p=.91).

CONCLUSION

These results provide support for the beneficial effects of exercise training on symptoms of fatigue and dyspnea in HF patients. Larger studies to evaluate symptom response to exercise are needed.

Palliation of tracheobronchial carcinoma: the role of cryosurgery

Bronchoscopy is a common day case procedure that can aid in the diagnosis and treatment of tracheobronchial disorders. The controlled application of extreme cold through a bronchoscope to endobronchial lesions (malignant and benign) is known as endobronchial cryosurgery. This procedure improves respiratory function and reduces shortness of breath and is performed in a cycle of three treatments. This article describes the instrumentation required, how cryosurgery is performed and how endobronchial cryosurgery can improve the patient's functional status and survival.