Effect of hydromorphone on ventilation in palliative care patients with dyspnea

Cancer-related breathlessness: opioids other than morphine - comprehensive literature review

INTRODUCTION

Although there is low-quality evidence, there has been an increase in publications on the experience of evaluating and managing cancer-related breathlessness using opioids other than morphine.

METHODS

The author conducted a non-systematic literature review in the PubMed/Medline and Embase until 4 October 2022. Eligible studies have evaluated the efficacy of opioids other than morphine for cancer-related breathlessness. Studies focused on sedation, anaesthesia, paediatric patients, opioid toxicity or basic research were excluded. Reviews/meta-analyses and non-English language publications were also excluded.

RESULTS

A total of 1556 records were identified, of which 23 studies including 469 patients who were treated with fentanyl (n=223), oxycodone (n=171) and hydromorphone (n=75) were considered eligible. Six phase II randomised clinical trials (RCTs), four observational studies and four case reports of fentanyl were found. For breathlessness on exertion, fentanyl yielded promising results, but no RCT showed significant superiority of fentanyl to placebo or morphine. For terminal breathlessness, three RCTs, five non-randomised or observational studies and one case report on oxycodone or hydromorphone were found. Although the results of the observational studies suggested that oxycodone and hydromorphone might be effective alternatives to morphine, the superiority over placebo or non-inferiority to morphine had not been demonstrated in the RCTs.

CONCLUSION

As an alternative to morphine, the author recommends fentanyl for breathless crisis or breathlessness on exertion, and oxycodone or hydromorphone for terminal breathlessness in advanced cancer. Larger and well-designed studies based on firm research policies are needed to confirm this current knowledge.

Hydromorphone for dyspnoea in terminally ill patients with cancer: case series

OBJECTIVE

Opioids can mitigate dyspnoea, but the efficacy of hydromorphone use for dyspnoea in patients with cancer is not well known.

METHODS

Patients with cancers with more than mild dyspnoea treated with subcutaneous injection of hydromorphone between March 2020 and February 2022 at Kitano Hospital (Osaka, Japan) were reviewed retrospectively. Only patients who could self-report their symptoms ≥3 days after the start of hydromorphone therapy were included. Dyspnoea severity was rated on a five-point scale (0: 'not bothersome'; 1: 'mild'; 2: 'moderate'; 3: 'severe'; 4: 'overwhelming').

RESULTS

Fifteen patients (2 with moderate, 12 with severe and 1 with overwhelming dyspnoea) were deemed eligible. The median interval from the start of hydromorphone initiation to death was 19 (IQR, 11-37) days. Thoracic drainage and palliative sedation after the start of hydromorphone therapy was undertaken in three and two patients, respectively. At 3 days, the median score of the Dyspnoea Rating Scale was improved significantly from 3 to 2 compared with that at baseline (p=0.0023). The intensity of dyspnoea was improved in 11 patients (73%). Opioid-related adverse events were not observed within 3 days.

CONCLUSIONS

Using hydromorphone for dyspnoea in patients with cancer seems to be appropriate if morphine use is contraindicated.

Opioid Management of Dyspnea at End of Life: A Systematic Review

Objective: The objective of this systematic review is to consolidate the existing evidence on opioid use, including administration, dosing, and efficacy, for the relief of dyspnea at end of life. The overarching goal is to optimize clinical management of dyspnea by identifying patterns in opioid use, improving opioid management of dyspnea, and to prioritize future research. Background: Opioids are commonly used in the management of dyspnea at end of life, yet specific administration guidelines are limited. A greater understanding of the effectiveness of opioids in relieving end-of-life dyspnea with consideration of study design, patients, and opioids, including dyspnea evaluation tools and outcomes, will leverage development of standardized administration and dosing. Methods: A PRISMA-guided systematic review using six databases identified quality studies of opioid management for patients with dyspnea at end of life. Results: Twenty-three references met review inclusion criteria, which included terminally ill cancer and noncancer patients with various diagnoses. Studies included two randomized controlled trials, and three nonrandomized experimental, three prospective observational, one cross-sectional, and one case series. Thirteen retrospective chart reviews were also included due to the limited rigorous studies rendered by the search. Thirteen studies evaluated morphine, followed by fentanyl (6), oxycodone (5), general opioid use (4), and hydromorphone (2). Routes of administration were parenteral, oral, combination, and nebulization. Dyspnea was evaluated using self-reporting and non-self-reporting evaluation tools. Sedation was the most reported opioid-related adverse effect. Discussion: Challenges persist in conducting end-of-life research, preventing consensus on standardization of opioid treatment for dyspnea within this specific palliative time frame. Future robust prospective trials using specific, accurate assessment with reassessment of dyspnea/respiratory distress, and consideration of opioid tolerance, polypharmacy, and comorbidities are required.

Efficacy and Safety of Opioids in Treating Cancer-Related Dyspnea: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials

BACKGROUND

Dyspnea is one of the most distressing symptoms encountered by advanced cancer patients. In this study, we aimed to evaluate the role of opioids in the management of cancer-related dyspnea.

METHODS

A systematic review and meta-analysis based on Randomized Controlled Trials was conducted in the databases PUBMED, EMBASE, and Cochrane Central Register of Controlled Trials testing the effect of opioids in relieving cancer-related dyspnea. Subgroup and sensitivity analyses were performed to evaluate various types of opioids in dyspnea management and stabilization of the study respectively.

RESULTS

Eleven RCTs fulfilled the eligibility criteria and had a total of 290 participants. Nine of these studies were included in meta-analyses. Compared with control, opioid therapy showed a small positive effect in dyspnea, SMD-0.82 (95%CI = -1.54 to -0.10) and Borg score, WMD-0.95 (95%CI = -1.83 to -0.06); Opioid therapy did not increase the risk of somnolence, OR0.93 (95%CI = 0.34 to 2.58), whereas a negative effect on respiratory rate was observed,WMD-1.89 (95%CI = -3.36 to -0.43); Also, there was no evidence to suggest improved performance of the 6MWT test, WMD6.49 (95%CI = -34.23 to 47.21), or the level of peripheral oxygen saturation, WMD0.33 (95%CI = -0.59 to 1.24) after opioid therapy. Subgroup analysis yielded a small positive effect for morphine on dyspnea, SMD-0.78 (95%CI = -1.45 to -0.10), whereas fentanyl showed no improvement in dyspnea, SMD-0.44 (95%CI = -0.89 to 0.02). Sensitivity analysis showed no changes in the direction of effect when any one study was excluded from the meta-analyses.

CONCLUSIONS

Our systematic review and meta-analysis indicated low quality evidence for a small positive effect of opioids in cancer-related dyspnea. Evidence for safety is insufficient as comprehensive adverse events were not adequately reported in studies.

Multiple potential targets of opioids in the treatment of acute respiratory distress syndrome from COVID-19

COVID-19 can present with a variety of clinical features, ranging from asymptomatic or mild respiratory symptoms to fulminant acute respiratory distress syndrome (ARDS) depending on the host's immune responses and the extent of the associated pathologies. This implies that several measures need to be taken to limit severely impairing symptoms caused by viral-induced pathology in vital organs. Opioids are most exploited for their analgesic effects but their usage in the palliation of dyspnoea, immunomodulation and lysosomotropism may represent potential usages of opioids in COVID-19. Here, we describe the mechanisms involved in each of these potential usages, highlighting the benefits of using opioids in the treatment of ARDS from SARS-CoV-2 infection.

Oncologic Emergencies: Palliative Care in the Emergency Department Setting

BACKGROUND

Palliative care is an essential component of emergency medicine, as many patients with terminal illness will present to the emergency department (ED) for symptomatic management at the end of life (EOL).

OBJECTIVE

This narrative review evaluates palliative care in the ED, with a focus on the literature behind management of EOL symptoms, especially dyspnea and cancer-related pain.

DISCUSSION

As the population ages, increasing numbers of patients present to the ED with severe EOL symptoms. An understanding of the role of palliative care in the ED is crucial to effectively communicating with these patients to determine their goals and provide medical care in line with their wishes. Beneficence, nonmaleficence, and patient autonomy are essential components of palliative care. Patients without medical decision-making capacity may have an advance directive, do not resuscitate or do not intubate order, or Portable Medical Orders for Life-Sustaining Treatment available to assist clinicians. Effective and empathetic communication with patients and families is vital to EOL care discussions. Two of the most common and distressing symptoms at the EOL are dyspnea and pain. The most effective treatment of EOL dyspnea is opioids, with literature showing little efficacy for other therapies. The most effective treatment for cancer-related pain is opioids, with expeditious pain control achievable with a rapid fentanyl titration. It is also important to address nausea, vomiting, and secretions, as these are common at the EOL.

CONCLUSIONS

Emergency clinicians play a vital role in EOL patient care. Clear, empathetic communication and treatment of EOL symptoms are essential.

Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer

Breathlessness is among the most common and deteriorating symptoms in patients with advanced cancer, which may worsen towards the end of life. Breathlessness in patients with estimated life expectancy of weeks to days has unique clinical features: it tends to worsen rapidly over days to hours as death approaches often despite current symptom control measures. Breathlessness in patients during the last weeks to days of life can be called ‘terminal breathlessness’. While evidence has accumulated for the management of breathlessness in patients with cancer who are not dying, such evidence may not be fully applied to terminal breathlessness. Only a few studies have investigated the best practice of terminal breathlessness in patients with cancer. In this paper, we summarise the current evidence for the management of terminal breathlessness, and propose future directions of clinical research.

Management of Respiratory Symptoms in Those with Serious Illness

Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.

The Current Practice of Opioid for Cancer Dyspnea: The Result From the Nationwide Survey of Japanese Palliative Care Physicians

CONTEXT

Morphine is recommended as the first-line pharmacological therapy for cancer dyspnea. However, the detailed practice of morphine has not been evaluated and consensus about other opioids for cancer dyspnea has not been established.

OBJECTIVES

To explore the physician-reported practice of opioid for cancer dyspnea.

METHODS

A nationwide mail-questionnaire survey was conducted among 536 Japanese certified palliative care physicians. We randomly selected 268 and asked the following: 1) how the physicians themselves initiate and use morphine for cancer dyspnea, 2) opioid choice for dyspnea in patients who have already used opioid other than morphine regularly, and 3) opioid choice for dyspnea in patients with various degrees of renal impairment in their daily practice.

RESULTS

Overall, 192 physicians responded (response rate, 71.6%). The major (58.3%) practice of initiating morphine was "immediate-release morphine as needed" in opioid-naïve patients, and the mean % increase when they titrate morphine for cancer dyspnea was 29.4 ± 11.3% of the baseline dose. Although "titrate baseline oxycodone" was the most frequent (42.3%) for low-to-moderate-dose regular oxycodone cases, "stepwise switch to morphine" (30.0%) and "add morphine on baseline oxycodone" (27.1%) were the more frequent practices for high-dose regular oxycodone. Regardless of the baseline dose, "add morphine on baseline fentanyl" was the most frequent practice for regular transdermal fentanyl cases. Oxycodone was the most frequent choice in renal insufficiency cases, regardless of its degree.

CONCLUSIONS

Among Japanese palliative care physicians, using oxycodone for cancer dyspnea was relatively popular practice, whereas fentanyl was not. Oxycodone was the most preferred opioid for cancer dyspnea in the setting of renal insufficiency among Japanese palliative care physicians. We should conduct studies to confirm the safety and effectiveness of these opioid practices for cancer dyspnea.

Respiratory adverse effects of opioids for breathlessness: a systematic review and meta-analysis

Previous studies have shown that opioids can reduce chronic breathlessness in advanced disease. However, physicians remain reluctant to prescribe opioids for these patients, commonly due to fear of respiratory adverse effects. The aim of this study was to systematically review reported respiratory adverse effects of opioids in patients with advanced disease and chronic breathlessness.PubMed, Embase, the Cochrane Central Register of Controlled Trials, CINAHL, ClinicalTrials.gov and the reference lists of relevant systematic reviews were searched. Two independent researchers screened against predefined inclusion criteria and extracted data. Meta-analysis was conducted where possible.We included 63 out of 1990 articles, describing 67 studies. Meta-analysis showed an increase in carbon dioxide tension (0.27 kPa, 95% CI 0.08-0.45 kPa,) and no significant change in oxygen tension and oxygen saturation (both p>0.05). Nonserious respiratory depression (definition variable/not stated) was described in four out of 1064 patients. One cancer patient pretreated with morphine for pain needed temporary respiratory support following nebulised morphine for breathlessness (single case study).We found no evidence of significant or clinically relevant respiratory adverse effects of opioids for chronic breathlessness. Heterogeneity of design and study population, and low study quality are limitations. Larger studies designed to detect respiratory adverse effects are needed.

[Ermergency diagnostics and therapeutic management of acute dyspnea]

This article presents the relevant diagnostic examinations and principles for the initial management of acute dyspnea in detail. The emergency physician must work through broad differential diagnostic considerations while providing appropriate initial treatment for a potentially life-threatening disease. The airway, breathing and circulation are the primary focus for the emergency physician when beginning emergency management. As soon as these are stabilized, further clinical investigations and treatment can be continued. The appropriate place for further treatment is determined by risk stratification.

Opioids for the Management of Dyspnea in Cancer Patients: Evidence of the Last 15 Years--A Systematic Review

The objective of this study was to review the evidence on the use of opioids for treatment of the dyspnea in adult cancer patients. A systematic literature review was conducted in the databases MEDLINE, CINAHL (EBSCO), ScienceDirect, and Cochrane Library of trials testing the effect of opioids in relieving dyspnea in cancer patients. Fourteen trials met the criteria for inclusion in the review. Eight randomized trials and six nonrandomized trials. All randomized clinical trials analyzed present risks of bias. Morphine has been the most studied strong opioid showing efficacy in alleviating dyspnea when administered, either orally or subcutaneously, in cancer patients. The potential benefit of the strong opioids in the alleviation of dyspnea in cancer patients is modest and limited to some opioids. More studies are needed to sufficiently support the role of opioids in dyspnea at rest, at exertion, and for breakthrough dyspnea and to clarify the safety issues.

Outcomes of lung transplant candidates referred for co-management by palliative care: A retrospective case series

BACKGROUND

Lung transplant candidates experience important symptoms, but they are rarely referred for palliative care consultation until they are deemed ineligible for transplant. Our lung transplant service has a high rate of palliative care referral for patients awaiting transplant.

AIM

We reviewed the characteristics, interventions, and outcomes of lung transplant candidates referred for co-management by palliative care, to determine whether they safely received opioids and went on to transplantation.

DESIGN AND PARTICIPANTS

Retrospective review of lung transplant candidates referred to our palliative care consultation service between January 2010 and May 2012.

RESULTS

Of 308 lung transplant candidates, 64 (20.7%) were referred to palliative care. Most had interstitial lung disease and were referred for dyspnea and a rapidly deteriorating course. A total of 59 (92%) were prescribed opioids for dyspnea, 55/59 used the opioids more than once, and 38/59 were maintained on standing opioids. There were no episodes of clinically important opioid toxicity or respiratory depression, and there was a trend toward increased exertion during exercise sessions post-opioid versus pre-opioid (19.3 vs 17.0 kcal, respectively, p = 0.06). At last follow-up, 30 (47%) had been transplanted, 23 (36%) had died while on the wait-list, 9 (14%) had died after delisting, and 2 (3%) were still awaiting transplantation. Of the 30 patients who underwent lung transplantation, only 7 (23%) still required an opioid prescription 1 month post-discharge.

CONCLUSION

In lung transplant candidates, palliative care and opioids in particular can be safely provided without compromising eligibility for transplantation. Palliative care should not be delayed until a patient is deemed ineligible for transplant.

Attitudes toward opioids for refractory dyspnea in COPD among Dutch chest physicians

Dyspnea is the most frequently reported symptom of outpatients with advanced chronic obstructive pulmonary disease (COPD). Opioids are an effective treatment for dyspnea. Nevertheless, the prescription of opioids to patients with advanced COPD seems limited. The aims of this study are to explore the attitudes of Dutch chest physicians toward prescription of opioids for refractory dyspnea to outpatients with advanced COPD and to investigate the barriers experienced by chest physicians toward opioid prescription in these patients. All chest physicians (n = 492) and residents in respiratory medicine (n = 158) in the Netherlands were invited by e-mail to complete an online survey. A total of 146 physicians (response rate 22.5%) completed the online survey. Fifty percent of the physicians reported to prescribe opioids for refractory dyspnea in 20% or less of their outpatients with advanced COPD and 18.5% reported never to prescribe opioids in these patients. The most frequently reported barriers toward prescription of opioids were resistance of the patient, fear of possible adverse effects, and fear of respiratory depression. To conclude, Dutch chest physicians and residents in respiratory medicine rarely prescribe opioids for refractory dyspnea to outpatients with advanced COPD. This reluctance is caused by perceived resistance of the patient and fear of adverse effects, including respiratory adverse effects.

End of life/palliative care/ethics

Palliative and end-of-life care, once the purview of oncologists and intensivists, has also become the responsibility of the emergency physician. As our population ages and medical technology enables increased longevity, it is essential that all medical professionals know how to help patients negotiate the balance between quantity and quality of life. Emergency physicians have the opportunity to educate patients and their loved ones on how to best accomplish their goals of care while also enhancing quality of life through treatment of symptoms. The emergency physician must be aware of the ethical and medico-legal parameters that govern decision making.

Continuous Subcutaneous Infusion of Compound Oxycodone for the Relief of Dyspnea in Patients With Terminally Ill Cancer

Pain and dyspnea are the most prevalent and distressing symptoms in patients with terminally ill cancer. Evidences have accumulated for the effects of morphine on dyspnea, whereas little is known about the effects of oxycodone on dyspnea. We investigated the effectiveness of oxycodone for dyspnea in patients with terminally ill cancer. The injectable form of compound oxycodone (iOC) containing hydrocotarnine was administered continuously via subcutaneous route. We administered iOC to 136 patients. The effect on dyspnea was less conspicuous than pain, yet iOC was effective for dyspnea with varying degrees. None of the adverse effects observed were serious. These results suggest that continuous subcutaneous administration of oxycodone could be one of the reasonable alternatives in the management of dyspnea in patients with terminally ill cancer.

Dyspnea review for the palliative care professional: treatment goals and therapeutic options

Although dyspnea is frequently encountered in the palliative care setting, its optimal management remains uncertain. Clinical approaches begin with accurate assessment, as delineated in part one of this two-part series. Comprehensive dyspnea assessment, which encompasses the physical, emotional, social, and spiritual aspects of this complex symptom, guide the clinician in choosing therapeutic approaches herein presented as part two. Global management of dyspnea is appropriate both as complementary to disease-targeted treatments that target the underlying etiology, and as the sole focus when the symptom has become intractable, disease is maximally treated, and goals of care shift to comfort and quality of life. In this setting, current evidence supports the use of oral or parenteral opioids as the mainstay of dyspnea management, and of inhaled furosemide and anxiolytics as adjuncts. Nonpharmacologic interventions such as acupuncture and pulmonary rehabilitation have potential effectiveness, although further research is needed, and use of a simple fan warrants consideration given its potential benefit and minimal burden and cost.

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.

A comparison of the effects of hydromorphone HCl and a novel extended release hydromorphone on arterial blood gas values in conscious healthy dogs

The purpose of this study was to evaluate arterial blood gases in dogs that were given hydromorphone or extended release liposome-encapsulated hydromorphone (LEH). Dogs were randomly administered LEH, n=6, (2.0 mg kg(-1)), hydromorphone, n=6, (0.2 mg kg(-1)) or a placebo of blank liposomes, n=3, subcutaneously on separate occasions. Arterial blood samples were drawn at serial time points over a 6-h time period for blood gas analysis. There was no change from baseline values in P(a)CO(2), P(a)O(2), (HCO(3)-), pH, and SBEc in the dogs that received the placebo. Administration of hydromorphone resulted in significant increases in P(a)CO(2) (maximum (mean+SD] 44.4+1.1mm of Hg) and significant decreases in P(a)O(2) (minimum (mean+SD) 82.4+4.7 mm of Hg) and pH (minimum (mean+SD) 7.31+0.01) compared with baseline. Administration of LEH resulted in significant increases in P(a)CO(2) (maximum (mean+SD) 44.6+0.9 mm of Hg) and significant decreases in P(a)O(2) (minimum (mean+SD) 84.8+2.6mm of Hg) and pH (minimum (mean+SD) 7.34+0.02) compared with baseline. There was no significant difference between these two groups at any time point. The changes observed in P(a)CO(2), P(a)O(2), and pH, however, were within clinically acceptable limits for healthy dogs. LEH was determined to cause moderate changes in arterial blood gas values similar to those caused by hydromorphone.

Patient and/or family controlled palliative sedation with midazolam for intractable symptom control: a case series

Introduction

Our case series prospectively evaluate the concept of Patient/Family-Controlled Sedation with midazolam, as an alternative to sedation by continuous infusion in terminal cancer patients.

Cases presentation

Our method was applied in 8 pts. Midazolam was administered in a Patient Control Analgesia mode. The infusion pump was activated "as-needed" by the pt or a caretaker. Sedation was rated as: 1) awake 2) arousable to voice 3) arousable to light pain or 4) unarousable. Family satisfaction was rated as: 1) good, 2) fair, 3) poor, or 4) unacceptable. Mean midazolam consumption was 12 – 40 mg/24 hours. We did not observe respiratory depression. Death occurred 1–6 days after sedation started. Family satisfaction was mainly good and median sedation was in the range 2 – 3.

Conclusion

Patient/Family-Controlled Sedation with midazolam was effective in providing comfort, by allowing titration of sedation to each patient's needs.