The experience of breathlessness in lung cancer

Episodic and continuous breathlessness: a new categorization of breathlessness

CONTEXT

Unlike pain, where the concept of breakthrough and background pain has been widely characterized and defined, breathlessness as a symptom has not yet been fully explored and has been rarely categorized.

OBJECTIVES

To explore patients' experiences and descriptions of breathlessness to categorize breathlessness.

METHODS

Qualitative study using in-depth interviews with patients suffering from four life-limiting and advanced diseases (chronic heart failure, chronic obstructive pulmonary disease, lung cancer, and motor neuron disease). Interviews were tape-recorded, transcribed verbatim, and analyzed using Framework analysis.

RESULTS

A total of 51 participants were interviewed (mean ± SD age 68.2 ± 11.6 years; 30 of 51 male; median Karnofsky 60%; mean ± SD breathlessness intensity 3.2 ± 1.7 of 10). Episodic breathlessness and continuous breathlessness were the main categories, with subcategories of triggered and non-triggered episodic breathlessness and continuous breathlessness for short and long periods. Episodic breathlessness triggered by exertion, non-triggered episodic breathlessness, and continuous breathlessness for a long period ("constant variable") were the most frequent and important categories with a high impact on daily living. Exertional breathlessness occurred in nearly all participants. Participants could differentiate episodic breathlessness (seconds, minutes, or hours) and continuous breathlessness (days, weeks, or months) by time. Episodic breathlessness occurred in isolation or in conjunction with continuous breathlessness.

CONCLUSION

Participants categorize their breathlessness by time and triggers. The categorization needs further verification, similar to that already established in pain, and can be used as a new evidence-based categorization to advance our understanding of this under-researched, yet high impact, symptom to optimize management.

Episodes of breathlessness: types and patterns - a qualitative study exploring experiences of patients with advanced diseases

BACKGROUND

Despite the high prevalence and impact of episodic breathlessness, information about characteristics and patterns is scarce.

AIM

To explore the experience of patients with advanced disease suffering from episodic breathlessness, in order to describe types and patterns.

DESIGN AND PARTICIPANTS

Qualitative design using in-depth interviews with patients suffering from advanced stages of chronic heart failure, chronic obstructive pulmonary disease, lung cancer or motor neurone disease. As part of the interviews, patients were asked to draw a graph to illustrate typical patterns of breathlessness episodes. Interviews were tape-recorded, transcribed verbatim and analysed using Framework Analysis. The graphs were grouped according to their patterns.

RESULTS

Fifty-one participants (15 chronic heart failure, 14 chronic obstructive pulmonary disease, 13 lung cancer and 9 motor neurone disease) were included (mean age 68.2 years, 30 of 51 men, mean Karnofsky 63.1, mean breathlessness intensity 3.2 of 10). Five different types of episodic breathlessness were described: triggered with normal level of breathlessness, triggered with predictable response (always related to trigger level, e.g. slight exertion causes severe breathlessness), triggered with unpredictable response (not related to trigger level), non-triggered attack-like (quick onset, often severe) and wave-like (triggered or non-triggered, gradual onset). Four patterns of episodic breathlessness could be identified based on the graphs with differences regarding onset and recovery of episodes. These did not correspond with the types of breathlessness described before.

CONCLUSION

Patients with advanced disease experience clearly distinguishable types and patterns of episodic breathlessness. The understanding of these will help clinicians to tailor specific management strategies for patients who suffer from episodes of breathlessness.

Individual experiences and impacts of a physiotherapist-led, non-pharmacological breathlessness programme for patients with intrathoracic malignancy: a qualitative study

BACKGROUND

Non-pharmacological breathlessness management programmes have been shown to be beneficial in the management of lung cancer-related dyspnoea for more than 10 years. What is not so clear is how they work.

AIM

To evaluate how patients with intrathoracic malignancy (lung cancer or pleural mesothelioma) undergoing the non-pharmacological breathlessness management programmes benefited from the programme, using a qualitative methodology.

DESIGN AND SETTING

Consecutive patients completing the programme were invited to be interviewed (semi-structured and audio-recorded) about their experiences of the programme, what had helped them and how. Interviews were transcribed and analysed using interpretative phenomenological analysis.

RESULTS

Nine patients were interviewed. Seven major themes emerged, they are summarised as follows: (1) Mixed prior expectations of the programme, (2) flexibility of delivery and additional support needs, (3) physiotherapist attributes and skills in developing an effective helping relationship, (4) adoption of new techniques, (5) the effects and impact of the programme and new techniques, (6) difficulties and barriers to achieving change and (7) facing an uncertain future beyond the programme.

CONCLUSION

The non-pharmacological breathlessness management programme appears to offer a wide range of benefits to patients, including improving functional capacity, coping strategies and self-control. Such benefits are most likely to be due to a combination of breathing control, activity management and the therapist qualities.

Episodic breathlessness in patients with advanced disease: a systematic review

CONTEXT

Although episodic breathlessness (EB) is reported to be highly prevalent in advanced disease, our understanding about it is limited.

OBJECTIVES

The aim of this study was to systematically review and synthesize the evidence on EB regarding definition, characteristics, and patients' experiences.

METHODS

Systematic review using searches in six databases, hand search, and personal contacts with authors in the field. Search terms included the combination of "episodic" and "breathlessness" (and synonyms) with five different diseases. Selection criteria included patients with advanced disease and information about EB based on original research. All retrieved studies were reviewed by two independent investigators.

RESULTS

Twenty-seven studies (of 7584) were included in this review. Only eight studies explored EB as a primary outcome. EB is poorly defined. It is characterized by high prevalence (81%-85%), high frequency (daily), short duration (often less than 10 minutes), and severe peak intensity. EB either develops without any known trigger or is triggered by physical exertion, emotions, or environmental influences.

CONCLUSION

EB is a common symptom in patients with advanced disease, but information about characteristics and experiences is limited. As there is no common terminology, an agreed definition is needed to foster research to develop effective treatments for EB.

The lived experience of breathlessness and its implications for care: a qualitative comparison in cancer, COPD, heart failure and MND

BACKGROUND

Breathlessness is one of the core symptoms, particularly persistent and frequent, towards the end of life. There is no evidence of how the experience of breathlessness differs across conditions. This paper compares the experience of breathlessness in cancer, COPD, heart failure and MND, four conditions sharing heavy symptom burdens, poor prognoses, high breathlessness rates and palliative care needs.

METHODS

For this qualitative study a purposive sample of 48 patients was included with a diagnosis of cancer (10), COPD (18), heart failure (10) or MND (10) and experiencing daily problems of breathlessness. Patients were recruited from the respective clinics at the hospital; specialist nurses' ward rounds and consultations, and "Breathe Easy" service users meetings in the community. Data were collected through semi-structured, in-depth interviews and participant observation. Breathlessness was compared according to six components derived from explanatory models and symptom schemata, first within groups and then across groups. Frequency counts were conducted to check the qualitative findings.

RESULTS

All conditions shared the disabling effects of breathlessness. However there were differences between the four conditions, in the specific constraints of the illness and patients' experiences with the health care context and social environment. In cancer, breathlessness signalled the (possible) presence of cancer, and functioned as a reminder of patients' mortality despite the hopes they put in surgery, therapies and new drugs. For COPD patients, breathlessness was perceived as a self-inflicted symptom. Its insidious nature and response from services disaffirmed their experience and gradually led to greater disability in the course of illness. Patients with heart failure perceived breathlessness as a contributing factor to the negative effects of other symptoms. In MND breathlessness meant that the illness was a dangerous threat to patients' lives. COPD and heart failure had similar experiences.

CONCLUSION

Integrated palliative care is needed, that makes use of all appropriate therapeutic options, collaborative efforts from health, social care professionals, patients and caregivers, and therapies that acknowledge the dynamic interrelation of the body, mind and spirit.

The lived experience of breathlessness and its implications for care: a qualitative comparison in cancer, COPD, heart failure and MND

BACKGROUND

Breathlessness is one of the core symptoms, particularly persistent and frequent, towards the end of life. There is no evidence of how the experience of breathlessness differs across conditions. This paper compares the experience of breathlessness in cancer, COPD, heart failure and MND, four conditions sharing heavy symptom burdens, poor prognoses, high breathlessness rates and palliative care needs.

METHODS

For this qualitative study a purposive sample of 48 patients was included with a diagnosis of cancer (10), COPD (18), heart failure (10) or MND (10) and experiencing daily problems of breathlessness. Patients were recruited from the respective clinics at the hospital; specialist nurses' ward rounds and consultations, and "Breathe Easy" service users meetings in the community. Data were collected through semi-structured, in-depth interviews and participant observation. Breathlessness was compared according to six components derived from explanatory models and symptom schemata, first within groups and then across groups. Frequency counts were conducted to check the qualitative findings.

RESULTS

All conditions shared the disabling effects of breathlessness. However there were differences between the four conditions, in the specific constraints of the illness and patients' experiences with the health care context and social environment. In cancer, breathlessness signalled the (possible) presence of cancer, and functioned as a reminder of patients' mortality despite the hopes they put in surgery, therapies and new drugs. For COPD patients, breathlessness was perceived as a self-inflicted symptom. Its insidious nature and response from services disaffirmed their experience and gradually led to greater disability in the course of illness. Patients with heart failure perceived breathlessness as a contributing factor to the negative effects of other symptoms. In MND breathlessness meant that the illness was a dangerous threat to patients' lives. COPD and heart failure had similar experiences.

CONCLUSION

Integrated palliative care is needed, that makes use of all appropriate therapeutic options, collaborative efforts from health, social care professionals, patients and caregivers, and therapies that acknowledge the dynamic interrelation of the body, mind and spirit.

Using laboratory models to test treatment: morphine reduces dyspnea and hypercapnic ventilatory response

RATIONALE

Opioids are commonly used to relieve dyspnea, but clinical data are mixed and practice varies widely.

OBJECTIVES

Evaluate the effect of morphine on dyspnea and ventilatory drive under well-controlled laboratory conditions.

METHODS

Six healthy volunteers received morphine (0.07 mg/kg) and placebo intravenously on separate days (randomized, blinded). We measured two responses to a CO(2) stimulus: (1) perceptual response (breathing discomfort; described by subjects as "air hunger") induced by increasing partial pressure of end-tidal carbon dioxide (Pet(CO2)) during restricted ventilation, measured with a visual analog scale (range, "neutral" to "intolerable"); and (2) ventilatory response, measured in separate trials during unrestricted breathing.

MEASUREMENTS AND MAIN RESULTS

We determined the Pet(CO2) that produced a 60% breathing discomfort rating in each subject before morphine (median, 8.5 mm Hg above resting Pet(CO2)). At the same Pet(CO2) after morphine administration, median breathing discomfort was reduced by 65% of its pretreatment value; P < 0.001. Ventilation fell 28% at the same Pet(CO2); P < 0.01. The effect of morphine on breathing discomfort was not significantly correlated with the effect on ventilatory response. Placebo had no effect.

CONCLUSIONS

(1) A moderate morphine dose produced substantial relief of laboratory dyspnea, with a smaller reduction of ventilation. (2) In contrast to an earlier laboratory model of breathing effort, this laboratory model of air hunger established a highly significant treatment effect consistent in magnitude with clinical studies of opioids. Laboratory studies require fewer subjects and enable physiological measurements that are difficult to make in a clinical setting. Within-subject comparison of the response to carefully controlled laboratory stimuli can be an efficient means to optimize treatments before clinical trials.

Exercise intervention to improve exercise capacity and health related quality of life for patients with Non-small cell lung cancer: a systematic review

CONTEXT

The role of exercise intervention for patients with Non-small cell lung cancer (NSCLC) has not been systematically reviewed to date.

OBJECTIVE

To identify, evaluate and synthesize the evidence examining (1) the effect of exercise intervention on exercise capacity, health related quality of life (HRQoL), physical activity levels, cancer symptoms and mortality for patients with NSCLC; and (2) the safety and feasibility of exercise intervention for a population with NSCLC.

DATA SOURCES

A systematic review of articles using the electronic databases MEDLINE (1950-2010), CINAHL (1982-2010), EMBASE (1980-2010), TRIP (1997-2010), Science Direct (1994-2010), PubMed (1949-2010), Cochrane Library (2010), Expanded Academic ASAP (1994-2010), Meditext Informit (1995-2010), PEDRO (1999-2010) and DARE (2010). Additional studies were identified by manually cross referencing all full text reports and personal files were searched. No publication date restrictions were imposed. ELIGIBILITY CRITERIA FOR STUDY SELECTION: Randomised controlled trials (RCTs), case-control studies and case series assessing exercise intervention to improve exercise capacity, HRQoL, level of daily physical activity, cancer symptoms or mortality of patients with NSCLC were included. Only articles available in English and published in a peer reviewed journal were included.

DATA EXTRACTION

A data collection form was developed by one reviewer and data extracted. Data extraction was cross checked by a second reviewer. RESULTS AND DATA SYNTHESIS: 16 studies on 13 unique patient groups totalling 675 patients with NSCLC met the inclusion criteria. The majority of studies were case series (n=9) and two RCTs were included. Studies exercising participants pre-operatively reported improvements in exercise capacity but no change in HRQoL immediately post exercise intervention. Studies exercising participants post-treatment (surgery, chemotherapy or radiotherapy) demonstrated improvements in exercise capacity but conflicting results with respect to the impact on HRQoL immediately post exercise intervention. Heterogeneity among studies was observed and a meta-analysis was deemed inappropriate. PRISMA guidelines were followed in reporting this systematic review.

CONCLUSION

Exercise intervention for patients with NSCLC is safe before and after cancer treatment. Interventions pre-operatively or post-cancer treatment are associated with positive benefits on exercise capacity, symptoms and some domains of HRQoL. The majority of studies are small case series therefore results should be viewed with caution until larger RCTs are completed. Further research is required to establish the effect of exercise during and after cancer treatment and in the advanced stage of disease, the optimum type of exercise training and the optimum setting for delivery.

Dyspnea in lung cancer patients: a systematic review

Dyspnea is a common and distressing symptom experienced by 19%-51% of patients with advanced cancer. Higher incidences are reported in patients approaching end of life. While the prevalence of dyspnea has been reported to be as frequent as pain in people with lung cancer, less attention has been paid to the distress associated with dyspnea. This review of the literature was undertaken to investigate how dyspnea has been assessed and whether breathlessness in people with lung cancer is distressing. Using a predetermined search strategy and inclusion criteria, 31 primary studies were identified and included in this review. Different outcome measures were used to assess the experience of dyspnea, with domains including intensity, distress, quality of life, qualitative sensation, and prevalence. Overall, the studies report a high prevalence of dyspnea in lung cancer patients, with subjects experiencing a moderate level of dyspnea intensity and interference with activities of daily living. Distress associated with breathing appears to be variable, with some studies reporting dyspnea to be the most distressing sensation, and others reporting lower levels of distress. However, taking into account the prevalence, intensity, and distress of dyspnea, the general consensus appears to be that the experience of dyspnea in people with lung cancer is common, with varying degrees of intensity, but involves considerable unpleasantness. Thus, if dyspnea and pain are both distressing sensations for people with lung cancer, this has potential implications for both clinical and academic areas with regards to both management strategies and further research.

Quality of life and non-pain symptoms in patients with cancer

To measure the prevalence of non-pain physical symptoms and psychological symptoms in patients with cancer, to investigate the impact of physical and psychological symptoms on their quality of life (QoL), and to inquire whether treatment had been received for the complaints/symptoms, a representative sample of 1,429 cancer patients were recruited and classified according to tumor type and treatment status [i.e., (1a) curative treatment >6 months ago, (1b) curative treatment <or=6 months ago, (2) palliative antitumor treatment, and (3) treatment no longer feasible]. QoL and non-pain symptoms were measured by the European Organisation for Research and Treatment of Cancer (EORTC)-C30 version 3. We added two items: (1) Did you have a dry mouth? and (2) Did you feel listless? We also asked whether the patients had received treatment for their symptoms. Depression and anxiety were measured by the Dutch version of the Hospital Anxiety and Depression Scale. One-way analysis of variance (ANOVA) was used to detect differences in global QoL between patients with different types of cancer. When ANOVA was significant, post hoc tests (Tukey) were performed to identify significant differences among cancer types. Linear regression analyses (forced entrance procedure) were performed to investigate the influence of physical and psychological symptoms on global QoL. The prevalence of moderate-to-severe symptoms increased significantly with each disease group. Vomiting and irritability were the least prevalent symptoms, and fatigue and worries were the most prevalent symptoms in all groups. Patients in Group 1 (curative treatment) experienced symptoms that were independent of cancer type. Patients in Group 2 (palliative treatment) experienced symptoms that varied with cancer type. QoL decreased significantly each step from Group 1 through 3. Fatigue, appetite loss, constipation, dry mouth, depression, and anxiety had independent negative influences on QoL. Patients with gastrointestinal cancer, malignant lymphoma, and other hematological malignancies had significantly poorer QoL than patients with prostate cancer. In 45%-90% of patients, symptoms remained untreated. Non-pain physical symptoms and psychological symptoms are frequent in patients with cancer at all disease phases. Many symptoms remain untreated. Systematic recording of symptom intensity should be mandatory, irrespective of the phase of disease.

Self-management for breathlessness in COPD: the role of pulmonary rehabilitation

Most of the effort of controlling breathlessness happens at home. Therefore, it is important to explore how patients and carers respond to breathlessness, what their self-care entails and what they experience as helpful. Data were collected from a purposive sample of 18 chronic obstructive pulmonary disease patients through participant observation during outpatient consultations and in-depth interviews at a large hospital and in the community in London. Data were analysed with the Grounded Theory approach. As information regarding the management of breathlessness was lacking and access to treatment was difficult, patients reverted to alternative strategies. Some patients developed considerable expertise and managed their symptoms competently within the limits of current care. Patients who coped successfully were involved in pulmonary rehabilitation and had adopted this as a way of life. Benefits and challenges to participation in these programmes were identified. Those patients who self-manage maintain an acceptable quality of life through self-acquired expertise relating to symptoms, medication and help-seeking. Well-being needs to be understood not as the end point, but as a precarious balance needing skilful maintenance and hard work. The findings have implications for notions such as adherence, patient involvement and responsibility in the management of chronic obstructive pulmonary disease.

Lung cancer: challenges and solutions for supportive care intervention research

Lung cancer is the leading cause of cancer death. It is associated with a high level of morbidity, particularly fatigue, pain, breathlessness, and coughing. These symptoms can have a substantial impact on psychosocial functioning. It is critical to have effective interventions demonstrated to improve quality of life particularly for those with advanced disease. However there is a paucity of high quality intervention research to guide practice in this area. This article discusses the challenges in conducting supportive care research in this group, including the patient's level of literacy in English, poor performance status, rapidly fluctuating health status, and familial or professional "gate-keeping." Many of these challenges can be overcome by broadening eligibility criteria, permitting some flexibility in relation to recruitment and data collection procedures, working closely with the treatment team, involving the patient's family, minimizing practical difficulties associated with intervention delivery, and reducing study burden in other ways, such as limiting the amount of data collected from the patient and shortening follow-up time intervals. We explore these potential solutions drawing on the experience of conducting a randomized controlled trial of a support intervention for people with lung cancer and their family.

Dyspnea experience and management strategies in patients with lung cancer

OBJECTIVE

The aim of this paper was to describe lung cancer patients' experience of dyspnea and their strategies for managing the dyspnea.

METHODS

Semi-structured interviews with two main questions about dyspnea experiences and management were conducted with 20 patients with lung cancer, not amenable to curative treatment, who had completed life prolonging treatments. Data analysis was made with a descriptive, qualitative content analysis.

RESULTS

The two questions resulted in two domains with 7 categories and subcategories. The experience of dyspnea included four categories: 'Triggering factors' included circumstances contributing to dyspnea, which comprised physical, psychosocial and environmental triggers. Bodily manifestations were considered to be the core of the experience. 'Immediate reactions' concerned physical and psychological impact. The long-term reactions included limitations, increased dependence and existential impact concerning hope, hopelessness and thoughts of death. The experience of managing dyspnea included three categories: 'Bodily strategies', 'psychological strategies' and 'medical strategies'.

CONCLUSION

Dyspnea experience is a complex experience which influences the life of the patients both with immediate reactions and long-term reactions concerning physical, emotional and existential issues in life and patients address this experience with managing strategies in order to take control of their situation, although they do not seem to be able to meet the existential distress they experience.

The multiple dimensions of dyspnea: review and hypotheses

Although dyspnea is a common and troubling symptom, our understanding of the neurophysiology of dyspnea is woefully incomplete. Most measurements of dyspnea treat it as a single entity. Although the multidimensional dyspnea concept has been mentioned for many decades, only recently has the concept been the subject of experimental tests. Emerging evidence has begun to favor the hypothesis that dyspnea comprises multiple dimensions or components that can be measured as different entities. Most recently, studies have begun to show that there is a separable 'affective dimension' (i.e. unpleasantness and emotional impact). Understanding of the multidimensional measurement of pain is far in advance of dyspnea, and has enabled progress in the neurophysiology of pain, including identification of separate neural structures subserving various elements of pain perception. We propose here a multidimensional model of dyspnea based on a state-of-the-art pain model, and review existing evidence in the light of this model.

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.

The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy

Intractable breathlessness is a common, devastating symptom of advanced cancer causing distress and isolation for patients and families. In advanced cancer, breathlessness is complex and usually multifactorial and its severity unrelated to measurable pulmonary function or disease status. Therapeutic advances in the clinical management of dyspnea are limited and it remains difficult to treat successfully. There is growing interest in the palliation of breathlessness, and recent work has shown that a systematic, evidence-based approach by a committed multidisciplinary team can improve lives considerably. Where such care is lacking it may be owing to therapeutic nihilism in clinicians untrained in the management of chronic breathlessness and unaware that there are options other than endurance. Optimum management involves pharmacological treatment (principally opioids, occasionally oxygen and anxiolytics) and nonpharmacological interventions (including use of a fan, a tailor-made exercise program, and psychoeducational support for patient and family) with the use of parenteral opioids and sedation at the end of life when appropriate. Effective care centers on the patient's needs and goals. Priorities in breathlessness research include studies on: neuroimaging, the effectiveness of new interventions, the efficacy, safety, and dosing regimens of opioids, the contribution of deconditioning, and the effect of preventing or reversing breathlessness.

Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)

GOALS/OBJECTIVES: To review the scientific evidence on symptoms and specific complications that are associated with lung cancer, and the methods available to palliate those symptoms and complications.

METHODS

MEDLINE literature review (through March 2006) for all studies published in the English language, including case series and case reports, since 1966 using the following medical subject heading terms: bone metastases; brain metastases; cough; dyspnea; electrocautery; hemoptysis; interventional bronchoscopy; laser; pain management; pleural effusions; spinal cord metastases; superior vena cava syndrome; and tracheoesophageal fistula.

RESULTS

Pulmonary symptoms that may require palliation in patients who have lung cancer include those caused by the primary cancer itself (dyspnea, wheezing, cough, hemoptysis, chest pain), or locoregional metastases within the thorax (superior vena cava syndrome, tracheoesophageal fistula, pleural effusions, ribs, and pleura). Respiratory symptoms can also result from complications of lung cancer treatment or from comorbid conditions. Constitutional symptoms are common and require attention and care. Symptoms referable to distant extrathoracic metastases to bone, brain, spinal cord, and liver pose additional problems that require a specific response for optimal symptom control. There are excellent scientific data regarding the management of many of these issues, with lesser evidence from case series or expert opinion on other aspects of providing palliative care for lung cancer patients.

CONCLUSIONS

Palliation of symptoms and complications in lung cancer patients is possible, and physicians who provide such care must be knowledgeable about these issues.

Quality of life in elderly cancer patients

The incidence of most types of cancer is age-dependent and progressive ageing is rapidly increasing the number of elderly people who need treatment for cancer. Elderly patients (older than 70 years) present particular characteristics that make the choice of the correct treatment more difficult; for this reason, these patients are often undertreated and largely underrepresented in cancer trials making the experimental evidence on this topic even weaker. Only relatively recently has Health-Related Quality of Life (HRQoL) begun to be considered as one of the hard end-points for clinical cancer research in the elderly. Treatment of elderly cancer patients represents a typical situation where its assessment is particularly useful because of the expected toxicity of treatment and several unresolved methodological problems (higher frequency of illiteracy, worse compliance with the questionnaires, concomitant diseases, use of instruments not validated in the aged population). The aim of this review is to underline the importance detected by the too small number of studies on elderly QoL evaluation and the need in future trials either to improve QoL assessment in this subcategory of patients undergoing treatment for cancer or not, or find specific assessment tools to do it.

Speaking-related dyspnea in healthy adults

PURPOSE

To reveal the qualities and intensity of speaking-related dyspnea in healthy adults under conditions of high ventilatory drive, in which the behavioral and metabolic control of breathing must compete.

METHOD

Eleven adults read aloud while breathing different levels of inspired carbon dioxide (CO(2)). After the highest level, participants provided unguided descriptions of their experiences and then selected descriptors from a list. On a subsequent day, participants read aloud while breathing high CO(2) as before, then rated air hunger, physical exertion, and mental effort (with definitions provided). Recordings were made of ventilation (with respiratory magnetometers), end-tidal partial pressure of CO(2), transcutaneous PCO(2), oxygen saturation, noninvasive blood pressure, heart rate, and the speech signal.

RESULTS

Unguided descriptions were found to reflect the qualities of air hunger, physical exertion (work), mental effort, and speech-related observations. As CO(2) stimulus strength increased, participants experienced increased perception of air hunger, physical exertion, and mental effort. Simultaneous increases were observed in ventilation, tidal volume, end-inspiratory and end-expiratory volumes, expiratory flow during speaking, nonlinguistic junctures, and nonspeech expirations.

CONCLUSION

Two qualities of speaking-related dyspnea--air hunger and physical exertion--are the same as those reported for many other types of nonspeech dyspnea conditions and, therefore, may share the same physiological mechanisms. The mental effort quality associated with speaking-related dyspnea may reflect a conscious drive to balance speech requirements and ventilatory demands. These findings have implications for developing better ways to evaluate and manage clients with respiratory-based speech problems.

Perceptions of Dyspnea and Helpful Interventions During the Advanced Stage of Lung Cancer

Dyspnea is a distressful but neglected symptom in oncology practice and research. The aim of this study was to describe the experience of dyspnea and helpful interventions in Chinese patients with advanced lung cancer admitted in the palliative care unit in 1 region in Hong Kong. A qualitative description approach using in-depth interviews was used to guide this study. Eleven participants agreed to be interviewed with age ranging from 51 to 80 years. They have been diagnosed with lung cancer from 1 to 12 months, and all required oxygen therapy from dyspnea. The results of content analysis revealed 4 main themes: (1) characteristics of dyspnea, (2) impact of dyspnea, (3) strategies used to manage dyspnea, and (4) nurses' role in managing dyspnea. Patients in this study found no Chinese words to adequately define and describe dyspnea and relied on sensations they experienced during the dyspnea episode. The impact of dyspnea was multidimensional, and patients used various strategies to manage dyspnea, including avoiding triggers and utilizing traditional Chinese medicine. Healthcare professionals were perceived to play a very inadequate role in assisting patients with dyspnea, and participants suggested that they should take a more active role in educating and supporting patients with dyspnea.

Measurement of breathlessness in advanced disease: A systematic review

BACKGROUND

There is a plethora of assessment tools available to measure breathlessness, the most common and disabling symptom of advanced cardio-respiratory disease. The aim of this systematic review was to identify all measures available via standard search techniques and review their usefulness for patients with advanced disease.

METHODS

A systematic literature search was performed in Medline. All studies focusing on the development or evaluation of tools for measuring breathlessness in chronic respiratory disease, cardiac disease, cancer, or MND were identified. Their characteristics with regard to validity, reliability, appropriateness and responsiveness to change were described. The tools were then examined for their usefulness in measuring significant aspects of breathlessness in advanced disease.

RESULTS

Thirty-five tools were initially identified, two were excluded. Twenty-nine were multidimensional of which 11 were breathlessness-specific and 18 disease-specific. Four tools were unidimensional, measuring the severity of breathlessness. The majority of disease-specific scales were validated for chronic obstructive pulmonary disease (COPD), few were applicable in other conditions. No one tool assessed all the dimensions of this complex symptom, which affects the psychology and social functioning of the affected individual and their family--most focused on physical activity.

CONCLUSION

As yet there is no one scale that can accurately reflect the far-reaching effects of breathlessness on the patient with advanced disease and their family. Therefore, at present, we would recommend combining a unidimensional scale (e.g. VAS) with a disease-specific scale (where available) or a multidimensional scale in conjunction with other methods (such as qualitative techniques) to gauge psychosocial and carer distress for the assessment of breathlessness in advanced disease.

A Qualitative Study of the Experiences During Radiotherapy of Swedish Patients Suffering From Lung Cancer

PURPOSE/OBJECTIVES

To describe experiences during radiotherapy of patients suffering from lung cancer.

DESIGN

Inductive, qualitative.

SETTING

A radiotherapy department in the south of Sweden.

SAMPLE

15 patients with lung cancer undergoing their second week of radiotherapy.

METHODOLOGIC APPROACH

Interviews were conducted in a hospital setting, transcribed, and content analyzed.

MAIN RESEARCH VARIABLES

Experiences during radiotherapy.

FINDINGS

The patients' experiences fall into four categories: fatigue, physical distress, managing disease- and treatment-related issues, and obstacles to managing. Fatigue was a major experience expressed in terms of low energy levels and low fitness, sometimes leading to social isolation.

CONCLUSIONS

Nurses need to implement interventions to minimize side effects of radiotherapy and maximize patients' abilities to manage the disease and the treatment.

INTERPRETATION

Informing and educating patients about pretreatment and assessing fatigue as well as implementing interventions (e.g., nurse-patient interaction, support, information, encouragement, focus on the patients' own resources) may lead to improved comprehensive care during radiation therapy.

Assessing Coughing and Wheezing in Lung Cancer: A Pilot Study

PURPOSE/OBJECTIVES

To establish reliability and validity of two self-report questionnaires, the Lung Cancer Cough Questionnaire and the Lung Cancer Wheezing Questionnaire.

DESIGN

Prospective, exploratory pilot study.

SETTING

Clinical oncology settings in the southern United States.

SAMPLE

31 adult women with lung cancer.

METHODS

Content validity of both questionnaires was assessed through a comprehensive literature review and an expert judge panel. Concurrent validity was established by Spearman rank correlation coefficients and Wil-coxon Rank Sum tests with items from other valid tools. Test-retest reliability was assessed by percent agreement, kappa, paired t tests, and correlations. Internal consistency was determined by Cronbach's alpha.

MAIN RESEARCH VARIABLES

Cough, wheeze.

FINDINGS

Cronbach's alpha showed excellent internal consistency and percent agreement, and kappa showed similarity of item responses across test-retest administrations. Nonsignificant paired t tests indicated similar mean scores, and significant test-retest correlations supported test-retest reliability.

CONCLUSIONS

Preliminary testing indicates good reliability and validity for both questionnaires. Both instruments can identify people with problems of coughing and wheezing and have the potential for monitoring these symptoms over time and determining effectiveness of interventions.

IMPLICATIONS FOR NURSING

Assessment of coughing and wheezing is an important component of monitoring respiratory symptoms of lung cancer. Both of these symptoms can be amenable to interventions. Further research is needed to confirm psychometrics and sensitivity of these tools.

Patient reporting and doctor recognition of dyspnoea in a comprehensive cancer centre

The aim of this study was to examine different aspects of dyspnoea in an Australian acute cancer care population, specifically prevalence, recognition, reporting, symptom control methods and prognostic significance. Patients and treating hospital medical officer were concurrently asked to evaluate the experience of dyspnoea. The prevalence of dyspnoea was 33%, with discrepancies observed between patient and doctor reporting of the presence of dyspnoea (P = 0.021), as well as its intensity and distress. Symptomatic methods for the relief of cancer-related dyspnoea are underused, particularly opioids. The medical underestimation of dyspnoea is consistent with previous studies and potentially detracts from effective management of this symptom.

Cigarette smokers views on their habit and the causes of their illness following lung cancer diagnosis: a clinical-qualitative study

CONTEXT AND OBJECTIVE

Lung cancer is the commonest malignant tumor and is increasing in incidence by 2% a year. In 90% of diagnosed cases, it is associated with tobacco product consumption. It is the greatest cause of mortality among cancer types in Brazil. Knowledge of patients psychological representations is needed for evaluating treatments and educating patients. The aim here was to interpret how smokers with lung cancer interpret the possible causes of their illness and to understand their perceptions regarding cigarette use.

DESIGN AND SETTING

Clinical-qualitative study (exploratory, non-experimental) at the Pulmonary Disease Service, General Hospital, Universidade Estadual de Campinas.

METHODS

An intentional small sample of cancer inpatients was recruited. The group was closed with 11 subjects, following attainment of data saturation from interviews. These interviews were semi-directed, with in-depth open-ended questions on interviewees observations, applied in a confidential setting using a tape recorder. Interviewees responses were categorized using qualitative content analysis and the results were assessed using interdisciplinary theoretical concepts, particularly from medical psychology.

RESULTS

Six males and five females aged between 46 and 68 years who presented diverse clinical conditions were interviewed.

CONCLUSIONS

A broader approach towards the psychological comprehension of such patients is needed, considering that cigarette consumption involves conscious and unconscious motivations, sociocultural and educational factors, the glamour of tobacco advertising, and problems with psychophysical dependence. Such an approach would avoid the perception among patients that the healthcare team are "inquisitors". This would lead to better adherence to treatment and better quality of life.

Validation of a Swedish version of the Cancer Dyspnea Scale

The Cancer Dyspnea Scale (CDS) is a multidimensional measure of dyspnea experience, with three subscales related to sense of effort, sense of anxiety and sense of discomfort, and a total score. In this study, we evaluated the validity and reliability of a Swedish version, the CDS-S, in 99 patients with advanced lung cancer who were not receiving curative or life-prolonging treatments. Criterion-related validity was demonstrated by significant group differences in CDS-S scores when patients were stratified by dyspnea intensity, as measured by a visual analogue scale (VAS-D). Correlations between the total CDS-S score and other dyspnea scales varied between 0.63 and 0.68. Convergent validity was shown by comparing the CDS-S subscales with conceptually related measures of physical and emotional function and discomfort, and correlations ranged from 0.34 to 0.57. The CDS-S captured the psychological dimension of dyspnea better than did the VAS-D. Internal consistency of the CDS-S scales was confirmed by Cronbach's alpha coefficients ranging from 0.81 to 0.90. The CDS-S was well received by the patients and completed in 2 minutes. This study supports the CDS as a valid and reliable instrument to measure dyspnea experience in a palliative setting, well suited for use in research as well as in clinical practice.

We need a new symptom measurement and intervention paradigm

As we move into an era of performance accountability widespread use of singular numeric symptom-severity rating scales, as a standard for symptom measurement, is common. While these scales are important for population comparisons, the use of a singular measure does not reflect the multidimensional nature of symptoms, ignores distress as a distinct dimension, and does not take into account the role of interpretive processes, such as meaning of illness, on an individual’s view of symptoms.

Comprehensive Symptom Management in Patients with Advanced-Stage Non–Small-Cell Lung Cancer

Although we have made steady improvements in the survival rates of patients with advanced-stage lung cancer, the majority of patients still experience distress and suffering. Although the symptom burden is greatest in patients in the end stages of life, many patients living with lung cancer suffer from troubling symptoms and side effects of therapy. Even long-term survivors with early-stage non-small-cell lung cancer (NSCLC) often experience respiratory symptoms, such as dyspnea and cough. Because of the high prevalence of NSCLC and the frequency with which it presents in an incurable stage, symptom management is a large component of the care of these patients. Dyspnea, cough, fatigue, anorexia/cachexia, and pain are the most common symptoms in patients with advanced-stage NSCLC. Cancer-directed therapy can improve some of these symptoms but often incompletely and temporarily. Therefore, comprehensive care of patients with advanced-stage NSCLC must include therapies targeted at these difficult and distressing symptoms.

Mesothelioma from the Patient's Perspective

This study reports findings from qualitative semi-structured interviews with 15 patients who suffered from mesothelioma. The results are described under four headings that reflect the main themes that arose from the data: coping with symptoms (particularly breathlessness and pain), finding out about mesothelioma and its implications, the trauma of medical interventions, and psychosocial issues. The results illustrate the severe disease burden that is borne by people who have mesothelioma. It is hoped that a greater understanding of mesothelioma from a patient's perspective could inform the response of health care professionals.

Non-invasive interventions for improving well-being and quality of life in patients with lung cancer—A systematic review of the evidence

Despite advances in lung cancer treatment, the outlook for most patients remains grim. Many of them face a short survival time during which they may suffer physical and psychological problems related with the cancer and the treatment side-effects. There is a need for a high quality care to support patients and reduce symptoms as much as possible. This systematic review found that a specialised nursing programme to reduce breathlessness was effective and that after patients' treatment had finished, those cared by nurses did as well or even better than those cared by doctors.

Symptoms in patients with lung carcinoma

BACKGROUND

The patient perspective on distress associated with lung carcinoma is important, yet understudied. Previous research on symptom experience generally had not differentiated the dimension symptom intensity/frequency from which symptoms are associated with most distress. The objective of the current study was to determine whether patterns of symptom intensity were similar to patterns of symptom distress, whether patterns were consistent at different time points, whether patterns varied by subgroups, and whether high symptom intensity was equivalent to distress.

METHODS

Four hundred adults who were newly diagnosed with inoperable lung carcinoma completed a measure of symptom intensity/frequency and a new measure of distress associated with symptoms at six time points during the first year after diagnosis. These data were supplemented by field notes by research nurses and by less structured, qualitative interviews.

RESULTS

The mean ranking of distress in the total group and in all subgroups remained constant at all time points, with breathing, pain, and fatigue associated with the most distress. In contrast, the pattern of mean rank order of symptom intensity showed little consistency; however, fatigue had the highest intensity scores at all time points.

CONCLUSIONS

The current data challenged the uncritical use of summated scores of different symptom items in the context of lung carcinoma. Breathing and pain appeared to function as icons representing threats associated with lung carcinoma, with distress described as related to the past and the present and to expectations for the future. One of the most promising implications of these data was in fostering a preventive paradigm for symptom palliation.

Palliative care for patients with cancer: district nurses' experiences

AIM

This paper reports a study exploring district nurses' experiences of providing palliative care for patients with cancer and their families.

BACKGROUND

There is an increasing demand for palliative care in the community, as many patients wish to die at home. District nurses are central to providing palliative care in the community, but there is a dearth of literature on district nurses' experiences in palliative care.

METHOD

A Husserlian phenomenological approach was adopted with a purposive sample of 25 female district nurses. Data were collected using unstructured, tape-recorded interviews and analysed using Colaizzi's seven stages of data analysis.

FINDINGS

Four themes were identified: the communication web; the family as an element of care; challenges for the district nurse in symptom management and the personal cost of caring.

CONCLUSIONS

District nurses' experiences of providing palliative care to family units was challenging but rewarding. The emotive nature of the experience cannot be under-estimated, as many district nurses were touched by the varying situations. Whilst acknowledging the need to maintain an integrated approach to care, district nurses should be identified as the key workers in the complex situation of palliative care.

Control of common, non-pain cancer symptoms

Despite major advances in cancer biology and therapeutics, cancer and its treatment continue to cause devastating suffering. Patients with advanced cancer most often experience multiple physical and psychological symptom concurrently. We review here some of the common non-pain cancer symptoms, focusing on the assessment and treatment of fatigue, anorexia and cachexia, dyspnea, and symptoms common near the end of life.

Low dose diamorphine reduces breathlessness without causing a fall in oxygen saturation in elderly patients with end-stage idiopathic pulmonary fibrosis

There is very little evidence regarding the safety and efficacy of opioids for the control of dyspnoea in the terminal stages of idiopathic pulmonary fibrosis (IPF). We conducted an open case series study of 11 elderly opioid-naive patients referred for management of severe breathlessness before and after their first injection of 2.5 mg diamorphine subcutaneously. Subjective breathlessness, measured by a 100 mm visual analogue scale, fell by a mean of 47 mm in the first 15 min (P < 0.0001) and the mean heart rate fell by 12/min (P = 0.007). There were small non-significant falls in the mean respiratory rate (2/min), systolic blood pressure (6 mmHg) and oxygen saturation (1%). These changes were maintained at 30 min. Follow up treatment with oral morphine remained effective in reducing the symptom of breathlessness and no patient showed signs of respiratory depression. Low dose opioids are effective and safe in the palliative management of IPF in frail elderly patients.

Clinical practice guidelines for the psychosocial care of adults with cancer

Clinical practice guidelines are increasingly being developed in medical settings to provide evidence-based recommendations to guide the clinical care of patients. The development of Clinical practice guidelines for the psychosocial care of patients with medical illness is a newer initiative, and more complex as the target audience includes health care professionals from diverse backgrounds. In Australia, the National Breast Cancer Centre and National Cancer Control Initiative have collaborated to develop Clinical practice guidelines for the psychosocial care of adults with cancer, funded by the Australian Government Department of Health and Ageing. This paper outlines the development of these guidelines in the international context, gives an overview of their content, and describes strategies for their implementation and evaluation.

Patient descriptions of breathlessness in heart failure

OBJECTIVE

To explore patient experience of breathlessness in heart failure.

METHODS

Semi-structured interviews were undertaken with 27 patients with chronic heart failure and were analysed using a constant comparative approach.

RESULTS

The patients had a mean age of 69 (range 38-94 years). All had chronic heart failure with a mean left ventricular ejection fraction of 33.1%. The patient narratives suggested three dominant experiences of breathlessness, "everyday", "worsening" and "uncontrollable". These descriptions predominantly focused on physical functioning, relating to patients' ability to manage breathlessness on a day to day basis. Patients were able to accommodate everyday breathlessness, using a number of coping strategies. In most cases this experience of breathlessness came to be accepted as "normal". Worsening breathlessness was a symptom that patients were unable to manage and that prompted a hospital admission, whereas uncontrollable breathlessness was experienced as a symptom that even health care professionals struggled to control.

CONCLUSIONS

Patients' descriptions of breathlessness are distinct from medical terminology and more clearly relate to physical adaptations to breathlessness. Further research is required to identify whether heart failure patients' descriptions of breathlessness are different to those of cancer patients, and to establish whether the categories generated from this data set are applicable to other heart failure patients in other settings.

Quality of life of elderly persons with newly diagnosed cancer

The aim was to investigate quality of life (QoL) in elderly persons newly diagnosed with cancer (65+ years) in relation to age, contact with the health-care system, ability to perform activities of daily living (ADL), hope, social network and support, and to identify which factors were associated with low QoL. The sample consisted of 101 patients (75 women and 26 men) newly diagnosed with cancer. EORTC QLQ-C30, Nowotny's Hope Scale, Katz ADL and the Interview Schedule for Social Interaction (ISSI) were used. The analysis was carried out in four age groups and revealed no significant differences in QoL. Compared with the other age groups, those of a high age (80+ years) more often lived alone, used more home-help service and had a smaller social network. Factors associated with low QoL were 'no other incomes than retirement pension', 'low level of hope' and 'lung cancer'. In addition, 'being told that the cancer disease has not come to an end', 'needing more help in activities of daily living', 'getting help from grown-up children' and 'needing help with PADL' were associated with low QoL. Those at risk of inferior QoL, that is, having poor economy, low level of hope and lung cancer need special attendance and specific interventions to improve QoL.

A prospective study to determine the association between physical symptoms and depression in patients with advanced cancer

Depression is a common symptom in patients with advanced cancer and patients who are depressed may also have physical symptoms which are difficult to palliate and which improve as their depression is appropriately treated. This study was carried out to determine if there was an association between depression and physical symptoms in patients with advanced cancer and to establish whether a seven-item verbal rating scale asking patients to verbally rate the severity of physical symptoms together with low mood could be used to screen for depression. The scale was validated against a semi-structured clinical interview according to DSM IV criteria. Seventy-four patients participated with an age range of 28-92 years. All patients had an ECOG performance status of two or three. The prevalence of major depression in this study was found to be 27% (95% C.I. 17-37%). The mean score on the verbal rating scale was 28.77 (median score 29.5) (95% C.I., 26.23 - 31.31; range 0-65). A cut-off of > or = 30 gave a sensitivity of 65% and specificity of 59%, with positive and negative predictive values of 37% and 82% respectively. The verbal mood item alone had an optimal cut-off point of 3, with a sensitivity of 80% and specificity of 43%. Patients diagnosed as being depressed according to psychiatric interview rated each symptom higher than nondepressed patients. The verbal mood item and total verbal rating score correlated with a high significance (rs = 0.607, P < 0.01), implying a relationship between a patient's subjective mood state and other symptoms. Both using the verbal scale and asking patients to verbally rate their mood alone had poor efficacy as a screening tool. However, there is a close association between physical symptoms and the presence of depression in palliative care patients.

Assessing fatigue and self-care strategies in patients receiving radiotherapy for non-small cell lung cancer

Lung cancer represents a major public health problem worldwide (ISD 2000) with approximately 80% of patients presenting with locally advanced or metastatic disease. Treatment is essentially palliative; therefore, symptom management is important. This paper describes the findings from a prospective study of fatigue in newly diagnosed patients with non-small cell lung cancer. Fifty-three patients undergoing radical or high-dose palliative radiotherapy for Stage I, II and III disease were recruited to the study. Patients completed a structured health diary throughout radiotherapy and for up to 1 month post-treatment. Tape-recorded interviews were conducted with a sub-sample (n=11) to explore the nature of fatigue. Complete data sets were available on 46 patients. Consistent with current literature, the study findings demonstrated the progressive nature of this symptom throughout treatment; however, the levels of distress reported and interference with daily living were not found to be as overwhelming in this group of patients as the literature thus far suggests.

Breathlessness in cancer and chronic obstructive pulmonary disease: Using a qualitative approach to describe the experience of patients and carers

Objective: To investigate and document the effects of breathlessness on the everyday lives of patients with cancer and COPD and their carers. This subject has been little researched, although dyspnoea is recognized as a disabling, distressing symptom. The number of breathless people is increasing as patients with all types of cardio-respiratory disease live longer.

Methods: Patients with severe COPD and cancer and their carers were interviewed at home using a semistructured format to record their perceptions of the impact of breathlessness, the help they had received from medical and caring services, and their ideas on how these could be improved.

Results: 10 patients with COPD (6 male) and 10 with cancer (6 male) and their spouses were interviewed. All patients found breathlessness frightening, disabling, and restricting. Patients developed a stoical, philosophical approach in order to live with dyspnoea and the difficulties it imposed: this was also an important way of reducing the emotional impact of breathlessness. Patients' spouses suffered significantly, experiencing severe anxiety and helplessness as they witnessed their partners' suffering and felt powerless to reduce it. The restrictions imposed by breathlessness affected their lives profoundly. Support of all kinds, practical, medical, and psychosocial was highly valued but was provided inconsistently and sporadically. Where help was given it came most frequently from general practitioners (GPs, family physicians) and specialist respiratory nurses.

Significance of results: This study is the first to document the psychosocial needs of carers, which are not adequately recognized or addressed at present. Patients and carers may feel most isolated and need support outside the working hours of most services and future provision needs to reflect this. Patients with cancer experience a more rapid onset of breathlessness. More clinicians need to be educated in the management of chronic breathlessness so known helpful strategies are more widely employed.

Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea

OBJECTIVE

To determine the efficacy of oral morphine in relieving the sensation of breathlessness in patients in whom the underlying aetiology is maximally treated.

DESIGN

Randomised, double blind, placebo controlled crossover study.

SETTING

Four outpatient clinics at a hospital in South Australia.

PARTICIPANTS

48 participants who had not previously been treated with opioids (mean age 76, SD 5) with predominantly chronic obstructive pulmonary disease (42, 88%) were randomised to four days of 20 mg oral morphine with sustained release followed by four days of identically formulated placebo, or vice versa. Laxatives were provided as needed.

MAIN OUTCOME MEASURES

Dyspnoea in the morning and evening as shown on a 100 mm visual analogue scale, quality of sleep, wellbeing, performance on physical exertion, and side effects as measured at the end of the four day treatment period.

RESULTS

38 participants completed the study; three withdrew because of definite and two because of possible side effects of morphine (nausea, vomiting, and sedation). Participants reported significantly different dyspnoea scores when treated with morphine: an improvement of 6.6 mm (95% confidence interval 1.6 mm to 11.6 mm) in the morning and of 9.5 mm (3.0 mm to 16.1 mm) in the evening (P = 0.011 and P = 0.006, respectively). During the period in which they were taking morphine participants also reported better sleep (P = 0.039). More participants reported distressing constipation while taking morphine (9 v 1, P = 0.021) in spite of using laxatives. All other side effects were not significantly worse with morphine, although the study was not powered to address side effects.

CONCLUSIONS

Sustained release, oral morphine at low dosage provides significant symptomatic improvement in refractory dyspnoea in the community setting.