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Chew S, Young H. Palliative home oxygen: practical framework for clinicians. BMJ Support Palliat Care 2024:spcare-2024-004902. [PMID: 38658049 DOI: 10.1136/spcare-2024-004902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 04/04/2024] [Indexed: 04/26/2024]
Abstract
The British Thoracic Society 2015 guidelines on home oxygen use in adults have been pivotal in guiding clinicians on the use of long-term oxygen therapy in improving survival outcomes for patients. However, guidance for use of home oxygen in the palliative care setting has not been as robust owing to the lack of evidence-based studies. Therefore, this narrative review aims to provide a clinical framework on the use of palliative home oxygen therapy by considering its prognostic and symptomatic benefits as well as offering pragmatic advice for palliative home oxygen in end-of-life care.
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Affiliation(s)
- Shaun Chew
- Croydon Health Services NHS Trust, Croydon, UK
| | - Holly Young
- Croydon Health Services NHS Trust, Croydon, UK
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2
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Yamamoto Y, Tanaka S, Matsuura K, Yamamoto S, Urano K, Okita J, Kato E, Odagiri T, Deguchi Y. Effectiveness of opioid switching for dyspnea and its predictors in cancer patients: a single-center retrospective observational study. Jpn J Clin Oncol 2024; 54:549-555. [PMID: 38323655 DOI: 10.1093/jjco/hyae008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 01/16/2024] [Indexed: 02/08/2024] Open
Abstract
BACKGROUND Morphine is the most used opioid for dyspnea, but other opioids such as oxycodone and fentanyl are increasingly used, and opioid switching to these is sometimes undertaken. No studies have verified the effectiveness of opioid switching for relief of dyspnea. We retrospectively investigated the effectiveness of opioid switching for dyspnea and its predictors. METHODS All patients with opioid switching for dyspnea during hospitalization at Komaki City Hospital from January 2019 to August 2022 were included. Opioid switching was defined as a change to another opioid, and the assessment period for evaluating the effectiveness and adverse events of opioid switching was set as 1 week. Patients with Numeric Rating Scale or Japanese version of the Support Team Assessment Schedule reduction for dyspnea of at least 1, or with clear improvement based on medical records, were considered valid. Mitigating factors for dyspnea were identified using logistic regression analysis. RESULTS Of the 976 patients with opioid switching, 57 patients had opioid switching for relief of dyspnea. Of these, opioid switching was effective in 21 patients (36.8%). In a multivariate analysis, older patients (odds ratio: 5.52, 95% CI: 1.50-20.20, P < 0.01), short prognosis for post-opioid switching (odds ratio: 0.20, 95% CI: 0.04-0.87, P = 0.03) and cachexia (odds ratio: 0.12, 95% CI: 0.02-0.64, P < 0.01) were significantly associated with opioid switching effects for dyspnea. There were no serious adverse events after opioid switching. CONCLUSION This study indicates that opioid switching for dyspnea may have some effect. Furthermore, opioid switching for dyspnea may be more effective in older patients and less effective in terminally ill patients or in those with cachexia.
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Affiliation(s)
| | - Shion Tanaka
- Department of Clinical Pharmacy, School of Pharmacy, Aichi Gakuin University, Nagoya, Aichi, Japan
| | - Katsuhiko Matsuura
- Department of Clinical Pharmacy, School of Pharmacy, Aichi Gakuin University, Nagoya, Aichi, Japan
| | - Seiji Yamamoto
- Department of Clinical Pharmacy, School of Pharmacy, Aichi Gakuin University, Nagoya, Aichi, Japan
| | - Kimihiko Urano
- Department of Clinical Pharmacy, School of Pharmacy, Aichi Gakuin University, Nagoya, Aichi, Japan
| | - Junya Okita
- Department of Palliative Care, Komaki City Hospital, Komaki, Aichi, Japan
| | - Eisuke Kato
- Department of Palliative Care, Komaki City Hospital, Komaki, Aichi, Japan
| | - Takuya Odagiri
- Department of Palliative Care, Komaki City Hospital, Komaki, Aichi, Japan
- Department of Palliative Care, Seino Kosei Hospital, Gifu Seino Medical Center, Gifu, Japan
| | - Yuko Deguchi
- Departments of Pharmacy, Komaki City Hospital, Komaki, Aichi, Japan
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3
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Zheng J, Huang Y, He J, Zhou H, Liu T, Huang J, Shi M, Zhao Y, Fang W, Yang Y, Zhang L. Trends in pain undertreatment among lung cancer patients at the EOL: Analysis of urban city medical insurance data in China. Thorac Cancer 2024; 15:693-701. [PMID: 38316629 PMCID: PMC10961226 DOI: 10.1111/1759-7714.15240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 01/20/2024] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Cancer-related pain is one of the common priority symptoms in advanced lung cancer patients at the end-of-life (EOL). Alleviating pain is undoubtedly a critical component of palliative care in lung cancer. Our study was initiated to examined trends in opioid prescription-level outcomes as potential indicators of undertreated pain in China. METHODS This study used data on 1330 patients diagnosed with lung cancer of urban city medical insurance in China who died between 2014 and 2017. Opioid prescription-level outcomes were determined by annual trends of the proportion of patients filling an opioid prescription, the total dose of opioids filled by decedents, and morphine milligram equivalents per day (MMED) at the EOL (defined as the 60 days before death). We further analyzed monthly changes in the number of opioid prescriptions filled, MMED, and mean daily dose of opioids per prescription (MDDP) of the last 60 days of life by year at death and age, respectively. RESULTS A total of 959 patients with exact dates of death were included, with 432 cases (45.06%; 95% CI: 44.36%-45.77%) receiving at least one opioid prescription at the EOL. The declining trends were shown in the proportion of patients filling any opioid prescription, the total dose of opioids filled by decedents and MMED, with an annual decrease of 0.341% (p = 0.01), 104.23 mg (p = 0.011) and 2.84 mg (p = 0.014), respectively. Within the 31-60 days to the 0-30 days of life, the MMED declined 6.08 mg (95% CI: -7.14 to -5.03; p = 0.000351), while the number of opioid prescriptions rose 0.66 (95% CI: 0.160-1.16; p = 0.025). Like the MMED, the MDDP fell 4.11 mg (95% CI: -5.86 to -2.37; p = 0.005) within the last month before death compared to the previous month. CONCLUSION Terminal lung cancer populations in urban China have experienced reduced access to opioids at the EOL. The clinicians did not prescribe a satisfactory dose of opioids per prescription, while the patients suffered increasing pain in the last 30 days of life. Sufficient opioid analgesic administration should be advocated for lung cancer patients during the EOL period.
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Affiliation(s)
- Jiani Zheng
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
| | - Yihua Huang
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
| | - Junyi He
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
| | - Huaqiang Zhou
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
| | - Tingting Liu
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
| | - Jie Huang
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
| | - Mengting Shi
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
| | - Yuanyuan Zhao
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
| | - Wenfeng Fang
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
| | - Yunpeng Yang
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
| | - Li Zhang
- Department of Medical OncologySun Yat‐sen University Cancer CenterGuangzhouPeople's Republic of China
- State Key Laboratory of Oncology in South ChinaGuangdong Provincial Clinical Research Center for CancerGuangzhouPeople's Republic of China
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4
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Rodrigues-Ribeiro JL, Castro L, Pinto-Ribeiro F, Nunes R. Impact of palliative care at end-of-life Covid-19 patients - a small-scale pioneering experience. BMC Palliat Care 2024; 23:37. [PMID: 38336652 PMCID: PMC10858566 DOI: 10.1186/s12904-024-01368-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 01/25/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND In March 2020, the outbreak caused by the SARS-CoV-2 virus was declared a pandemic, resulting in numerous fatalities worldwide. To effectively combat the virus, it would be beneficial to involve professionals who specialize in symptom control for advanced illnesses, working closely with other specialties throughout the illness process. This approach can help manage a range of symptoms, from mild to severe and potentially life-threatening. No studies have been conducted in Portugal to analyse the intervention of Palliative Medicine at the end of life of Covid-19 patients and how it differs from other specialties. This knowledge could help determine the importance of including it in the care of people with advanced Covid-19. OBJECTIVES The objective of this study is to examine potential differences in the care provided to patients with Covid-19 during their Last Hours and Days of Life (LHDOL) between those who received care from Palliative Medicine doctors and those who did not. METHODS This is a retrospective cohort study spanning three months (Dec 2020 to Feb 2021), the duration of the Support Unit especially created to deal with Covid-19 patients. The database included clinical files from 181 patients admitted to the Support Unit, 27 of which died from Covid-19. RESULTS Statistically significant differences were identified in the care provided. Specifically, fewer drugs were administered at the time of death, including drugs for dyspnoea, pain and agitation, suspension of futile devices and use of palliative sedation to control refractory symptoms. CONCLUSIONS End-of-life care and symptomatic control differ when there's regular follow-up by Palliative Medicine, which may translate less symptomatic suffering and promote a dignified and humane end of life.
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Affiliation(s)
- João Luís Rodrigues-Ribeiro
- Palliative Care Unit, WeCare Saúde, Rua Corregedor Gaspar Cardoso, 480, Póvoa de Varzim, Porto, 4490-492, Portugal.
- Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal.
- Intra-Hospital Team for Palliative Care Support, Hospital de Braga, ULS Braga, Braga, Portugal.
| | - Luísa Castro
- Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
- Center for Health Technology and Services Research (CINTESIS), Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
- Department of Community Medicine, Information and Health Decision Sciences (MEDCIDS), Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
| | - Filipa Pinto-Ribeiro
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, 4710-057, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Guimarães, 4806-909, Portugal
| | - Rui Nunes
- Faculty of Medicine, University of Porto, Porto, 4200-319, Portugal
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Gosselin C, Côté M, Tremblay L, Lacasse Y. Use of Palliative Oxygen in Cancer Patients. Am J Hosp Palliat Care 2023; 40:1087-1092. [PMID: 36452992 PMCID: PMC10507986 DOI: 10.1177/10499091221144005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/19/2023] Open
Abstract
Background: Despite the lack of evidence to support the use of palliative oxygen to relieve dyspnea at the end of life, its prescription is widespread and often supported by local and national practice guidelines. Objectives: The objectives of this study were (1) to determine to what extent oxygen prescriptions meet the proposed prescription criteria in our institution, (2) to examine the indication of individual prescriptions in relation to the severity of dyspnea and (3) to review the utilization of opioids in patients receiving palliative oxygen. Methods: Retrospective chart review of cancer patients who were prescribed palliative oxygen between April 2015 and January 2020 through a respiratory home care program in Quebec City, Canada. According to provincial prescription guidelines, palliative oxygen was provided and reimbursed in case of severe hypoxemia (pulse oximetry saturation at rest < 88%) in cancer patients with an estimated prognosis of less than 3 months. Results: 134 patients receiving palliative oxygen were included; 25 (19%) did not fulfill reimbursement criteria. Median survival was 44 days. At initiation of palliative oxygen, 48 patients (36%) had only mild or moderate dyspnea (Medical Research Council dyspnea score 1-3), 26 (19%) did not receive opioids, and 9 (7%) were prescribed palliative oxygen without being dyspneic or receiving opioids. Conclusion: Most prescriptions of palliative oxygen met the proposed prescription criteria in our institution. Half of those who received palliative oxygen were only mildly dyspneic and/or were not receiving opioids at the time of the prescription.
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Affiliation(s)
- Caroline Gosselin
- Centre de Recherche, Université Laval, Institut universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada
| | - Mélanie Côté
- Centre de Recherche, Université Laval, Institut universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada
| | - Lise Tremblay
- Centre de Recherche, Université Laval, Institut universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada
| | - Yves Lacasse
- Centre de Recherche, Université Laval, Institut universitaire de Cardiologie et de Pneumologie de Québec, QC, Canada
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Lojo-Cruz C, Mora-Delgado J, Rivas Jiménez V, Carmona Espinazo F, López-Sáez JB. Survival Outcomes in Palliative Sedation Based on Referring Versus On-Call Physician Prescription. J Clin Med 2023; 12:5187. [PMID: 37629229 PMCID: PMC10455353 DOI: 10.3390/jcm12165187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/04/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
This study sought to determine the survival duration of patients who underwent palliative sedation, comparing those who received prescriptions from referring physicians versus on-call physicians. It included all patients over 18 years old who died in the Palliative Care, Internal Medicine, and Oncology units at the Hospital Universitario of Jerez de la Frontera between 1 January 2019, and 31 December 2019. Various factors were analyzed, including age, gender, oncological or non-oncological disease, type of primary tumor and refractory symptoms. Statistical analysis was employed to compare survival times between patients who received palliative sedation from referring physicians and those prescribed by on-call physicians, while accounting for other potential confounding variables. This study revealed that the median survival time after the initiation of palliative sedation was 25 h, with an interquartile range of 8 to 48 h. Notably, if the sedation was prescribed by referring physicians, the median survival time was 30 h, while it decreased to 17 h when prescribed by on-call physicians (RR 0.357; 95% CI 0.146-0.873; p = 0.024). Furthermore, dyspnea as a refractory symptom was associated with a shorter survival time (RR 0.307; 95% CI 0.095-0.985; p = 0.047). The findings suggest that the on-call physician often administered palliative sedation to rapidly deteriorating patients, particularly those experiencing dyspnea, which likely contributed to the shorter survival time following sedation initiation. This study underscores the importance of careful patient selection and prompt initiation of palliative sedation to alleviate suffering.
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Affiliation(s)
- Cristina Lojo-Cruz
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Juan Mora-Delgado
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Víctor Rivas Jiménez
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Jerez de la Frontera, Ronda de Circunvalación S/N, 11407 Jerez de la Frontera, Spain; (C.L.-C.); (V.R.J.)
| | - Fernando Carmona Espinazo
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Puerta del Mar, Avenida Ana de Viya 21, 11009 Cádiz, Spain;
| | - Juan-Bosco López-Sáez
- Internal Medicine and Palliative Care Clinical Management Unit, Hospital Universitario de Puerto Real, Calle Romería 7, 11510 Puerto Real, Spain;
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7
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Sandau C, Hansen EF, Ringbæk TJ, Kallemose T, Bove DG, Poulsen I, Nørholm V, Pedersen L, Jensen JUS, Ulrik CS. Automated Oxygen Administration Alleviates Dyspnea in Patients Admitted with Acute Exacerbation of COPD: A Randomized Controlled Trial. Int J Chron Obstruct Pulmon Dis 2023; 18:599-614. [PMID: 37096159 PMCID: PMC10122478 DOI: 10.2147/copd.s397782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 03/27/2023] [Indexed: 04/26/2023] Open
Abstract
Objective Devices for Automated Oxygen Administration (AOA) have been developed to optimize the therapeutic benefit of oxygen supplementation. We aimed to investigate the effect of AOA on multidimensional aspects of dyspnea and as-needed consumption of opioids and benzodiazepines, as opposed to conventional oxygen therapy, in hospitalized patients with Acute Exacerbation of COPD (AECOPD). Method and Patients A multicenter randomized controlled trial across five respiratory wards in the Capital Region of Denmark. Patients admitted with AECOPD (n=157) were allocated 1:1 to either AOA (O2matic Ltd), a closed loop device automatically delivering oxygen according to the patient's peripheral oxygen saturation (SpO2), or conventional nurse-administered oxygen therapy. Oxygen flows and SpO2 levels were measured by the O2matic device in both groups, while dyspnea, anxiety, depression, and COPD symptoms were accessed by Patient Reported Outcomes. Results Of the 157 randomized patients, 127 had complete data for the intervention. The AOA reduced patients' perception of overall unpleasantness significantly on the Multidimensional Dyspnea Profile (MDP) with a difference in medians of -3 (p=0.003) between the intervention group (n=64) and the control group (n=63). The AOA also provided a significant between group difference in all single items within the sensory domain of the MDP (all p-values≤0.05) as well as in the Visual Analogue Scale - Dyspnea (VAS-D) within the past three days (p=0.013). All between group differences exceeded the Minimal Clinical Important Difference of the MDP and VAS-D, respectively. AOA did not seem to have an impact on the emotional response domain of the MDP, the COPD Assessment Test, the Hospital Anxiety and Depression Scale, or use of as-needed opioids and/or benzodiazepines (all p-values>0.05). Conclusion AOA reduces both breathing discomfort and physical perception of dyspnea in patients admitted with AECOPD but did not seem to impact the emotional status or other COPD symptoms.
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Affiliation(s)
- Charlotte Sandau
- Department of Respiratory Medicine and Endocrinology, Pulmonary Section, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Correspondence: Charlotte Sandau, Email
| | - Ejvind Frausing Hansen
- Department of Respiratory Medicine and Endocrinology, Pulmonary Section, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | | | - Thomas Kallemose
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Dorthe Gaby Bove
- University College Absalon, Centre for Nursing, Roskilde, Denmark
| | - Ingrid Poulsen
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Research Unit Nursing and Health Care, Aarhus University, Aarhus, Denmark
| | - Vibeke Nørholm
- Department of Clinical Research, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Lars Pedersen
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Bispebjerg Hospital, Copenhagen, Denmark
| | - Jens Ulrik Stæhr Jensen
- Respiratory Medicine Section, Department of Medicine, Herlev-Gentofte Hospital, Hellerup, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, København, Denmark
| | - Charlotte Suppli Ulrik
- Department of Respiratory Medicine and Endocrinology, Pulmonary Section, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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8
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Jones KF, Abdulhay LB, Orris SR, Merlin JS, Schenker Y, Bulls HW. The Relevance of State Laws Regulating Opioid Prescribing for People Living With Serious Illness. J Pain Symptom Manage 2022; 64:89-99. [PMID: 35561937 DOI: 10.1016/j.jpainsymman.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/29/2022] [Accepted: 05/02/2022] [Indexed: 10/18/2022]
Abstract
CONTEXT Opioids are commonly used to relieve symptoms such as pain and dyspnea in people living with serious illness. In recent years, 36 states enacted limitations for opioid prescriptions to mitigate the impact of the opioid overdose crisis. Palliative care clinicians have been vocal about the unintended consequences of opioid policies, yet little is known about how state policies apply to opioid prescribing in non-cancer-related serious illness. OBJECTIVE To summarize current state-level limitations to opioid prescribing and exemptions relevant to people living with non-cancer-related serious illness. METHODS Investigators searched publicly available laws ("[state] + opioid legislation") to extract information on opioid prescribing and exemptions. Laws were examined for application to palliative care, hospice, non-cancer-related serious illness, and language about specific symptoms was documented when applicable (e.g., pain, dyspnea). RESULTS Most state laws focused on acute pain and/or initial opioid prescriptions. Thirty-three of the thirty-six states with opioid-limiting legislation exempt situations applicable to people living with non-cancer-related serious illness. Three states did not have any exemptions relevant to people living with non-cancer-related serious illness. DISCUSSION The results indicate that while most states recognize the importance of timely opioid access for palliation of pain, clinically relevant exemptions for people living with non-cancer-related serious illness may be lacking. When present, language describing palliative care, hospice, and terminal illness exemptions is often broad and may generate confusion between primary and specialty palliative care.
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Affiliation(s)
- Katie Fitzgerald Jones
- William F. Connell School of Nursing (K.F.J.), Boston College, Chestnut Hill, Massachusetts, USA.
| | - Lindsay Bell Abdulhay
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Steve R Orris
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jessica S Merlin
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yael Schenker
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hailey W Bulls
- Section of Palliative Care and Medical Ethics and Palliative Research Center, Division of General Internal Medicine (L.B.A., S.R.O., J.S.M., Y.S., H.W.B.), University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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9
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Zemel RA. Pharmacologic and Non-Pharmacologic Dyspnea Management in Advanced Cancer Patients. Am J Hosp Palliat Care 2021; 39:847-855. [PMID: 34510917 DOI: 10.1177/10499091211040436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
As there is a high propensity for patients with advanced malignancy to experience refractory dyspnea, it is necessary for physicians to be well-versed in the management of these patients' dyspneic symptoms. For symptomatic treatment of cancer patients with dyspnea, both pharmacologic and non-pharmacologic methods should be considered. The main source of pharmacologic symptom management for dyspnea is oral and parenteral opioids; benzodiazepines and corticosteroids may serve as helpful adjuncts alongside opioid treatments. However, oxygen administration and nebulized loop diuretics have not been shown to clinically benefit dyspneic cancer patients. Applying non-pharmacologic dyspnea management methods may be valuable palliative therapies for advanced cancer patients, as they provide benefit with negligible harm to the patient. Advantageous and minimally harmful non-pharmacologic dyspnea therapies include facial airflow, acupuncture and/or acupressure, breathing exercises, cognitive behavioral therapy, music therapy, and spiritual interventions. Thus, it is vital that physicians are prepared to provide symptomatic care for dyspnea in advanced cancer patients as to minimize suffering in this patient population during definitive cancer treatments or hospice care.
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Affiliation(s)
- Rachel A Zemel
- MedStar Georgetown University Hospital, Brookeville, MD, USA
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10
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Liberman T, Lopez S, Roofeh R, Izard S, Parikh S, Burns E. Respiratory Distress in Hospitalized Non-Mechanically Ventilated COVID-19 Adults: A Retrospective Multicenter Cohort Study. Am J Hosp Palliat Care 2021; 39:584-590. [PMID: 34344174 PMCID: PMC8984589 DOI: 10.1177/10499091211036702] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Background: COVID-19 typically presents with respiratory symptoms which may progress with
severe disease. There are standard guidelines for managing respiratory
distress (e.g. opioids, anxiolytics) and palliative care teams are well
versed in managing these symptoms. Aim: Determine the extent to which hospitalized COVID-19 patients with moderate
respiratory distress received medications or palliative consultation for
symptom management and if these interventions had any association with
outcomes. Design: Retrospective chart review for hospitalized COVID-19+ patients from March
2-April 30, 2020. Setting: Large integrated health system in the New York Metropolitan area. Patients: 312 adult patients hospitalized with COVID-19 with an order for a
non-rebreather mask and meeting criteria for moderate respiratory distress
on the Respiratory Distress Observation Scale: concurrent respiratory rate
≥30 and heart rate ≥110 at any point during hospitalization. Patients
receiving mechanical ventilation or intensive care were excluded. Results: Most COVID-19 patients experiencing moderate respiratory distress did not
receive medications or palliative consultation for symptom management.
Patients who received medications were predominantly white, older, and had a
Do-Not-Resuscitate order. Patients who received a palliative consultation
were more likely to be older, female, and white, with a Do-Not-Resuscitate
order. Mortality was similar between those receiving medication and those
who did not. Conclusion: Medications and palliative expertise for symptom management were underused
for patients with moderate respiratory distress due to COVID-19. Education
and triggers may help providers to identify moderate respiratory distress
and consider symptomatic treatment and palliative consultation when
appropriate.
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Affiliation(s)
- Tara Liberman
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Northwell Health, Manhasset, NY, USA
| | - Santiago Lopez
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Northwell Health, Manhasset, NY, USA
| | - Regina Roofeh
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Northwell Health, Manhasset, NY, USA
| | - Stephanie Izard
- Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Sima Parikh
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Northwell Health, Manhasset, NY, USA
| | - Edith Burns
- Division of Geriatrics and Palliative Medicine, Department of Medicine, Northwell Health, Manhasset, NY, USA.,Center for Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
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11
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Berezin L, Zhabokritsky A, Andany N, Chan AK, Estrada-Codecido J, Gershon A, Lam PW, Leis JA, MacPhee S, Mubareka S, Simor AE, Daneman N. Diagnostic accuracy of subjective dyspnoea in detecting hypoxaemia among outpatients with COVID-19: a retrospective cohort study. BMJ Open 2021; 11:e046282. [PMID: 34006036 PMCID: PMC7941675 DOI: 10.1136/bmjopen-2020-046282] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The majority of patients with mild-to-moderate COVID-19 can be managed using virtual care. Dyspnoea is challenging to assess remotely, and the accuracy of subjective dyspnoea measures in capturing hypoxaemia have not been formally evaluated for COVID-19. We explored the accuracy of subjective dyspnoea in diagnosing hypoxaemia in COVID-19 patients. METHODS This is a retrospective cohort study of consecutive outpatients with COVID-19 who met criteria for home oxygen saturation monitoring at a university-affiliated acute care hospital in Toronto, Canada from 3 April 2020 to 13 September 2020. Dyspnoea measures were treated as diagnostic tests, and we determined their sensitivity (SN), specificity (SP), negative/positive predictive value (NPV/PPV) and positive/negative likelihood ratios (+LR/-LR) for detecting hypoxaemia. In the primary analysis, hypoxaemia was defined by oxygen saturation <95%; the diagnostic accuracy of subjective dyspnoea was also assessed across a range of oxygen saturation cutoffs from 92% to 97%. RESULTS During the study period, 89/501 (17.8%) of patients met criteria for home oxygen saturation monitoring, and of these 17/89 (19.1%) were diagnosed with hypoxaemia. The presence/absence of dyspnoea had limited accuracy for diagnosing hypoxaemia, with SN 47% (95% CI 24% to 72%), SP 80% (95% CI 68% to 88%), NPV 86% (95% CI 75% to 93%), PPV 36% (95% CI 18% to 59%), +LR 2.4 (95% CI 1.2 to 4.7) and -LR 0.7 (95% CI 0.4 to 1.1). The SN of dyspnoea was 50% (95% CI 19% to 81%) when a cut-off of <92% was used to define hypoxaemia. A modified Medical Research Council dyspnoea score >1 (SP 98%, 95% CI 88% to 100%), Roth maximal count <12 (SP 100%, 95% CI 75% to 100%) and Roth counting time <8 s (SP 93%, 95% CI 66% to 100%) had high SP that could be used to rule in hypoxaemia, but displayed low SN (≤50%). CONCLUSIONS Subjective dyspnoea measures have inadequate accuracy for ruling out hypoxaemia in high-risk patients with COVID-19. Safe home management of patients with COVID-19 should incorporate home oxygenation saturation monitoring.
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Affiliation(s)
- Linor Berezin
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | | | - Nisha Andany
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Adrienne K Chan
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jose Estrada-Codecido
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Gershon
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Respirology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Philip W Lam
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Jerome A Leis
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Scott MacPhee
- Department of Nursing, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Samira Mubareka
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
- Department of Laboratory Medicine and Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Andrew E Simor
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Nick Daneman
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Infectious Diseases, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
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12
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Luo N, Tan S, Li X, Singh S, Liu S, Chen C, Huang Z, Feng S, Lin Y, Lin Y, Cen H, Liang M, Chen M. Efficacy and Safety of Opioids in Treating Cancer-Related Dyspnea: A Systematic Review and Meta-Analysis Based on Randomized Controlled Trials. J Pain Symptom Manage 2021; 61:198-210.e1. [PMID: 32730950 DOI: 10.1016/j.jpainsymman.2020.07.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/14/2020] [Accepted: 07/18/2020] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Ning Luo
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Shifan Tan
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Xiaocai Li
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | | | - Si Liu
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Chunjie Chen
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Zhuangzhi Huang
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Shuangshuang Feng
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Yacong Lin
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Yuemei Lin
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China
| | - Hongdan Cen
- Department of Otolaryngology, Maoming People's Hospital, Maoming, China
| | - Min Liang
- Department of Respiratory and Critical Care Medicine, Maoming People's Hospital, Maoming, China.
| | - Mafeng Chen
- Department of Otolaryngology, Maoming People's Hospital, Maoming, China.
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13
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Haidl P, Jany B, Geiseler J, Andreas S, Arzt M, Dreher M, Frey M, Hauck RW, Herth F, Hämäläinen N, Jehser T, Kenn K, Lamprecht B, Magnet F, Oldenburg O, Schenk P, Schucher B, Studnicka M, Voshaar T, Windisch W, Woehrle H, Worth H. [Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]. Pneumologie 2020; 74:813-841. [PMID: 33291162 DOI: 10.1055/a-1252-1492] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Long-term oxygen therapy is of great importance both for reducing mortality and for improving performance in patients with chronic lung diseases. The prerequisites for Long-term oxygen therapy are adequate diagnostics and clearly defined indication. A causal distinction into chronic hypoxaemic and hypercapnic respiratory failure is reasonable, from which the differential indication for non-invasive ventilation results.The revised guideline covers the diagnostics and indication of chronic lung and heart diseases, the role of oxygen in terminal illness and gives a detailed description of available oxygen devices. The guideline is intended to help avoid undersupply, oversupply and false prescriptions. Furthermore, the chapter "Postacute Oxygen Therapy" discusses the procedure, relevant in everyday life, but not yet clearly defined, for prescribing oxygen therapy for the home at the end of an inpatient stay. Another important point, the correct prescription of mobile oxygen systems, is also presented in the guideline. This document is a revised version of the guideline for longterm oxygen therapy and replaces the version of 2008.
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Affiliation(s)
- P Haidl
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg
| | - B Jany
- Klinikum Würzburg Mitte (KWM), Klinik für Innere Medizin, Pneumologie und Beatmungsmedizin, Standort MissioKlinik, Würzburg
| | - J Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl
| | - S Andreas
- Lungenfachklinik Immenhausen, Universitätsmedizin Göttingen, Immenhausen
| | - M Arzt
- Universitätsklinikum Regensburg, Klinik und Poliklinik für Innere Medizin II, Regensburg
| | - M Dreher
- Universitätsklinikum Aachen, Klinik für Pneumologie und Internistische Intensivmedizin, Aachen
| | - M Frey
- Klinik Barmelweid, Rombach, Schweiz
| | - R W Hauck
- Klinikum Altötting, Klinik für Pneumologie, Beatmungs- und Schlafmedizin, Altötting
| | - F Herth
- Thoraxklinik, Abteilung für Pneumologie und Beatmungsmedizin, Universität Heidelberg, Heidelberg
| | | | - T Jehser
- Gemeinschaftskrankenhaus Havelhöhe, Palliativstation, Berlin
| | - K Kenn
- Philips Universität Marburg, Lehrstuhl für pneumologische Rehabilitation, Marburg
| | - B Lamprecht
- Kepler Universitätsklinikum, Med Campus III, Linz, Österreich
| | - F Magnet
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten-Herdecke, Fakultät für Gesundheit - Department für Humanmedizin, Köln
| | - O Oldenburg
- Clemenshospital, Klinik für Kardiologie, Münster
| | - P Schenk
- Landesklinikum Hochegg, Abteilung für Pulmologie, Grimmenstein, Österreich
| | - B Schucher
- LungenClinic Grosshansdorf, Großhansdorf
| | - M Studnicka
- Landeskrankenhaus Salzburg, Universitätsklinikum der PMU, Universitätsklinik für Pneumologie, Salzburg, Österreich
| | - T Voshaar
- Krankenhaus Bethanien Lungenzentrum, Medizinische Klinik III, Moers
| | - W Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten-Herdecke, Fakultät für Gesundheit - Department für Humanmedizin, Köln
| | | | - H Worth
- Facharztzentrum Fürth, Fürth
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14
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Fusi-Schmidhauser T, Preston NJ, Keller N, Gamondi C. Conservative Management of COVID-19 Patients-Emergency Palliative Care in Action. J Pain Symptom Manage 2020; 60:e27-e30. [PMID: 32276101 PMCID: PMC7144848 DOI: 10.1016/j.jpainsymman.2020.03.030] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 03/26/2020] [Accepted: 03/27/2020] [Indexed: 11/23/2022]
Abstract
CONTEXT The COVID-19 pandemic is spreading across the world. Many patients will not be suitable for mechanical ventilation owing to the underlying health conditions, and they will require a conservative approach including palliative care management for their important symptom burden. OBJECTIVES To develop a management plan for patients who are not suitable for mechanical ventilation that is tailored to the stage their COVID-19 disease. METHODS Patients were identified as being stable, unstable, or at the end of life using the early warning parameters for COVID-19. Furthermore, a COVID-19-specific assessment tool was developed locally, focusing on key symptoms observed in this population which assess dyspnoea, distress, and discomfort. This tool helped to guide the palliative care management as per patients' disease stage. RESULTS A management plan for all patients' (stable, unstable, end of life) was created and implemented in acute hospitals. Medication guidelines were based on the limitations in resources and availability of drugs. Staff members who were unfamiliar with palliative care required simple, clear instructions to follow including medications for key symptoms such as dyspnoea, distress, fever, and discomfort. Nursing interventions and family involvement were adapted as per patients' disease stage and infection control requirements. CONCLUSION Palliative care during the COVID-19 pandemic needs to adapt to an emergency style of palliative care as patients can deteriorate rapidly and require quick decisions and clear treatment plans. These need to be easily followed up by generalist staff members caring for these patients. Furthermore, palliative care should be at the forefront to help make the best decisions, give care to families, and offer spiritual support.
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Affiliation(s)
- Tanja Fusi-Schmidhauser
- Palliative and Supportive Care Clinic, Institute of Oncology of Southern Switzerland and Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Nancy J Preston
- International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom.
| | - Nikola Keller
- Palliative and Supportive Care Clinic, Institute of Oncology of Southern Switzerland and Ente Ospedaliero Cantonale, Bellinzona, Switzerland
| | - Claudia Gamondi
- Palliative and Supportive Care Clinic, Institute of Oncology of Southern Switzerland and Ente Ospedaliero Cantonale, Bellinzona, Switzerland
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15
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Collis SP. Literature review of clinical benefits and reasons to prescribe palliative oxygen therapy in non-hypoxaemic patients. BRITISH JOURNAL OF NURSING (MARK ALLEN PUBLISHING) 2018; 27:1255-1260. [PMID: 30457378 DOI: 10.12968/bjon.2018.27.21.1255] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
AIMS: to review current guidelines and studies available to health professionals in the UK and explore the literature to identify reasons for the prescription of palliative oxygen therapy in non-hypoxaemic patients. BACKGROUND: oxygen therapy is often associated with the palliative treatment for breathlessness. Although prescription guidelines are available and the risks of oxygen therapy are known, the therapy is still prescribed for non-hypoxaemic patients. DESIGN: a literature search was conducted using relevant databases. Cited evidence from published guidelines was also consulted. RESULTS: the findings suggest that oxygen is no more effective than room air for treating dyspnoea for non-hypoxaemic patients, although two small studies of self-reported benefits from patients and carers indicate different perceptions of need. CONCLUSION: the findings suggest that there is a knowledge gap with regards understanding the reasons for the prescription of oxygen therapy for non-hypoxaemic patients.
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Affiliation(s)
- Steven P Collis
- Senior Lecturer, College of Health and Social Care, University of Derby, UK
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16
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17
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Ecenarro PS, Iguiñiz MI, Tejada SP, Malanda NM, Imizcoz MA, Marlasca LA, Navarrete BA. Management of COPD in End-of-Life Care by Spanish Pulmonologists. COPD 2018; 15:171-176. [PMID: 29558226 DOI: 10.1080/15412555.2018.1441274] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Chronic obstructive pulmonary disease is progressive and in its advanced stage is associated with major disability. Previous studies suggest that patients with this disease receive little palliative care, even in very advanced stages. Given this, our objectives were to describe the clinical practice of Spanish pulmonologists in the care of patients with end-stage chronic obstructive pulmonary disease, to identify potential barriers to implementing palliative care in these patients and to correlate these responses with doctor's years of experience. A link to an online survey was sent to pulmonologists on (a) symptom management, (b) structure of their department and collaboration with other services, (c) specialized medical training in palliative care, (d) communication with patients and their families, and (e) limiting barriers identified in the management of these patients. A total of 387 responses were received. The majority used opioids to treat dyspnea (52.9%) or pain (54.2%) and many treated anxiety/depression (41%). Around half of the respondents had no established routines in their departments to offer palliative care to patients with chronic obstructive pulmonary disease. There was little communication with end-of-life patients and their families on disease course, mainly associated with a lack of medical training (83% of cases) and changes in patient wishes regarding care through the disease course (81%). In our setting, communication with end-of-life patients with chronic obstructive pulmonary disease is poor. The key challenges identified are insufficient medical training and changing desires of patients. No substantial differences in attitude were found as a function of experience.
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Affiliation(s)
| | - Marta Inchausti Iguiñiz
- b Respiratory Department , Hospital Universitario Donostia , San Sebastián, Donostia , Gipuzkoa , Spain
| | - Sandra Pedrero Tejada
- a Respiratory Department , Hospital Universitario Cruces , Barakaldo , Vizcaya , Spain
| | - Nuria Marina Malanda
- a Respiratory Department , Hospital Universitario Cruces , Barakaldo , Vizcaya , Spain
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18
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Verberkt CA, van den Beuken-van Everdingen MHJ, Schols JMGA, Datla S, Dirksen CD, Johnson MJ, van Kuijk SMJ, Wouters EFM, Janssen DJA. Respiratory adverse effects of opioids for breathlessness: a systematic review and meta-analysis. Eur Respir J 2017; 50:50/5/1701153. [PMID: 29167300 DOI: 10.1183/13993003.01153-2017] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/18/2017] [Indexed: 01/19/2023]
Abstract
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.
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Affiliation(s)
- Cindy A Verberkt
- Dept of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | | | - Jos M G A Schols
- Dept of Health Services Research, Maastricht University, Maastricht, The Netherlands.,Dept of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Sushma Datla
- Hull York Medical School, University of Hull, Hull, UK
| | - Carmen D Dirksen
- Dept of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | | | - Sander M J van Kuijk
- Dept of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Emiel F M Wouters
- CIRO, Centre of expertise for chronic organ failure, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Daisy J A Janssen
- Centre of Expertise for Palliative Care, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,CIRO, Centre of expertise for chronic organ failure, Horn, The Netherlands
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Ezekowitz JA, O'Meara E, McDonald MA, Abrams H, Chan M, Ducharme A, Giannetti N, Grzeslo A, Hamilton PG, Heckman GA, Howlett JG, Koshman SL, Lepage S, McKelvie RS, Moe GW, Rajda M, Swiggum E, Virani SA, Zieroth S, Al-Hesayen A, Cohen-Solal A, D'Astous M, De S, Estrella-Holder E, Fremes S, Green L, Haddad H, Harkness K, Hernandez AF, Kouz S, LeBlanc MH, Masoudi FA, Ross HJ, Roussin A, Sussex B. 2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure. Can J Cardiol 2017; 33:1342-1433. [PMID: 29111106 DOI: 10.1016/j.cjca.2017.08.022] [Citation(s) in RCA: 435] [Impact Index Per Article: 62.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 08/28/2017] [Accepted: 08/28/2017] [Indexed: 02/06/2023] Open
Abstract
Since the inception of the Canadian Cardiovascular Society heart failure (HF) guidelines in 2006, much has changed in the care for patients with HF. Over the past decade, the HF Guidelines Committee has published regular updates. However, because of the major changes that have occurred, the Guidelines Committee believes that a comprehensive reassessment of the HF management recommendations is presently needed, with a view to producing a full and complete set of updated guidelines. The primary and secondary Canadian Cardiovascular Society HF panel members as well as external experts have reviewed clinically relevant literature to provide guidance for the practicing clinician. The 2017 HF guidelines provide updated guidance on the diagnosis and management (self-care, pharmacologic, nonpharmacologic, device, and referral) that should aid in day-to-day decisions for caring for patients with HF. Among specific issues covered are risk scores, the differences in management for HF with preserved vs reduced ejection fraction, exercise and rehabilitation, implantable devices, revascularization, right ventricular dysfunction, anemia, and iron deficiency, cardiorenal syndrome, sleep apnea, cardiomyopathies, HF in pregnancy, cardio-oncology, and myocarditis. We devoted attention to strategies and treatments to prevent HF, to the organization of HF care, comorbidity management, as well as practical issues around the timing of referral and follow-up care. Recognition and treatment of advanced HF is another important aspect of this update, including how to select advanced therapies as well as end of life considerations. Finally, we acknowledge the remaining gaps in evidence that need to be filled by future research.
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Affiliation(s)
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | | | - Michael Chan
- Edmonton Cardiology Consultants, Edmonton, Alberta, Canada
| | - Anique Ducharme
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Adam Grzeslo
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | | | | | | | - Serge Lepage
- Université de Sherbrooke, Sherbrooke, Québec, Canada
| | | | | | - Miroslaw Rajda
- QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | | | - Sean A Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | | | | | - Sabe De
- London Health Sciences, Western University, London, Ontario, Canada
| | | | - Stephen Fremes
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Lee Green
- University of Alberta, Edmonton, Alberta, Canada
| | - Haissam Haddad
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Karen Harkness
- Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | | | - Simon Kouz
- Centre Hospitalier Régional de Lanaudière, Joliette, Québec, Canada
| | | | | | | | - Andre Roussin
- Centre hospitalier de l'Université de Montréal, Montréal, Québec, Canada
| | - Bruce Sussex
- Memorial University, St John's, Newfoundland, Canada
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20
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O'Driscoll BR, Howard LS, Earis J, Mak V. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72:ii1-ii90. [DOI: 10.1136/thoraxjnl-2016-209729] [Citation(s) in RCA: 316] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/03/2017] [Accepted: 02/12/2017] [Indexed: 12/15/2022]
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21
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Abstract
INTRODUCTION LTOT is a well-established treatment option for hypoxemic patients. Scientific evidence for its benefits of LTOT dates back to the 1980s, when two randomized controlled trials showed prolonged survival in COPD-patients undergoing LTOT for at least 15 hours/day. In contrast, the potential benefits of LTOT in non-COPD-patients has not been well researched and the recommendations for its application are primarily extrapolated from trials on COPD-patients. Recently, a large trial confirmed that COPD-patients who don't meet classic indication criteria, and have moderate desaturation at rest or during exercise, do not benefit from oxygen therapy. Also the significant technical evolution of LTOT devices has improved its application. Areas covered: A literature research was performed in pubmed regarding home oxygen therapy (terms: LTOT, ambulatory oxygen therapy, short burst oxygen therapy, nocturnal oxygen therapy). Expert commentary: LTOT proved a survival benefit for COPD patients about 30 years ago. Whether the results of these trials are still valid for patients under modern treatment guidelines remains unknown. Nevertheless, the classic indication criteria for LTOT still persist in guidelines, since there is a lack of updated evidence for the effects of LTOT in more severe hypoxemic patients.
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Affiliation(s)
- F S Magnet
- a Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital , Kliniken der Stadt Köln gGmbH, Witten/Herdecke University , Köln , Germany
| | - J H Storre
- a Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital , Kliniken der Stadt Köln gGmbH, Witten/Herdecke University , Köln , Germany.,b Department of Pneumology , University Medical Hospital , Freiburg , Germany
| | - W Windisch
- a Department of Pneumology, Faculty of Health/School of Medicine, Cologne Merheim Hospital , Kliniken der Stadt Köln gGmbH, Witten/Herdecke University , Köln , Germany
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Abstract
Heart failure presents unique challenges to the clinician who desires to provide excellent and humane care near the end of life. Accurate prediction of mortality in the individual patient is complicated by a chronic disease that is punctuated by recurrent acute episodes and sudden death. Health care providers continue to have difficulty communicating effectively with terminally ill patients and their caregivers regarding end-of-life care preferences, all of which needs to occur earlier rather than later. This article also discusses various means of providing palliative care, and specific issues regarding device therapy, cardiopulmonary resuscitation, and palliative sedation with concurrent discussion of the ethical ramifications and pitfalls of each.
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Affiliation(s)
- John Arthur McClung
- Division of Cardiology, Westchester Medical Center, New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA.
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[Ermergency diagnostics and therapeutic management of acute dyspnea]. Med Klin Intensivmed Notfmed 2017; 110:555-66; quiz 567-8. [PMID: 26407960 DOI: 10.1007/s00063-015-0084-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Abstract
High-flow nasal cannula (HFNC) oxygen therapy has several physiological advantages over traditional oxygen therapy devices, including decreased nasopharyngeal resistance, washing out of the nasopharyngeal dead space, generation of positive pressure in the pharynx, increasing alveolar recruitment in the lungs, humidification of the airways, increased fraction of inspired oxygen and improved mucociliary clearance. Recently, the use of HFNC in treating adult critical illness patients has significantly increased, and it is now being used in many patients with a range of different disease conditions. However, there are no established guidelines to direct the safe and effective use of HFNC for these patients. This review article summarizes the available published literature on the positive physiological effects, mechanisms of action, and the clinical applications of HFNC, compared with traditional oxygen therapy devices. The available literature suggests that HFNC oxygen therapy is an effective modality for the early treatment of critically adult patients.
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Affiliation(s)
- Jian Zhang
- 1 Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Ling Lin
- 1 Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Konghan Pan
- 1 Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Jiancang Zhou
- 1 Department of Critical Care Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
| | - Xiaoyin Huang
- 2 Department of Emergency Medicine, Sir Run Run Shaw Hospital, Medical School of Zhejiang University, Hangzhou, Zhejiang Province, China
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Afrane M, Sera L, Holmes HM, McPherson ML. Commonly Prescribed Medications Among Patients in Hospice Care for Chronic Obstructive Pulmonary Disease. Am J Hosp Palliat Care 2016; 33:638-43. [PMID: 26261375 PMCID: PMC4747865 DOI: 10.1177/1049909115598928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
PURPOSE End-stage chronic obstructive pulmonary disease (COPD) presents health care providers with challenges of providing optimal palliative care for patients who follow a less predictable trajectory. The objectives of this study were to evaluate medications being prescribed to patients with end-stage COPD, compared to recommendations made by the Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, and to determine which medications were provided by the hospice organization. METHODS We retrospectively reviewed our database for medications pertaining to COPD management as stated in the GOLD criteria or those used for symptoms associated with end of life. RESULTS A total of 745 patients met inclusion criteria, and approximately 63% were prescribed opioids. Prescribing rates for oxygen, short-acting β2-agonists, and short-acting anticholinergics were 37%, 33%, and 31%, respectively. Systemic and inhaled corticosteroids were prescribed at higher rates of 20% and 18% compared to long-acting bronchodilators. DISCUSSION Medications used for COPD exacerbation management were prescribed at higher rate than those used for maintenance treatment.
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Affiliation(s)
- Mary Afrane
- Department of Pharmacy Services, MedStar Union Memorial Hospital, Baltimore, MD, USA
| | - Leah Sera
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
| | - Holly M Holmes
- Department of General Internal Medicine/Healthy Aging Clinic, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mary L McPherson
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, MD, USA
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26
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Suntharalingam J, Hippolyte S, Knowles V, Freeman D, Patel I, Hardinge M. When should I be considering home oxygen for my patients? NPJ Prim Care Respir Med 2016; 26:15074. [PMID: 26742088 PMCID: PMC4704531 DOI: 10.1038/npjpcrm.2015.74] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2015] [Accepted: 09/08/2015] [Indexed: 12/05/2022] Open
Abstract
The ability to provide oxygen in a patient’s home can offer enormous benefits, including improvements in life expectancy when given in the appropriate setting. Confusingly, however, home oxygen is available in many forms, including long-term oxygen therapy (LTOT), ambulatory oxygen therapy (AOT), palliative oxygen therapy (POT) and short-burst oxygen therapy (SBOT)—each with varying degrees of supporting evidence. The British Thoracic Society (BTS) has recently published new guidance on home oxygen therapy, after collating the available evidence. This article aims to summarise those guidelines, focusing on who should and should not be considered for oxygen therapy. Although the BTS guidelines target a UK audience, many of the principles covered below are applicable internationally, even if the availability of certain oxygen modalities and supporting service arrangements may vary between different healthcare systems.
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Affiliation(s)
- Jay Suntharalingam
- Respiratory Department, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Sabrine Hippolyte
- Respiratory Department, Respiratory SpR, Royal Brompton Hospital, London, UK
| | - Vikki Knowles
- Guildford and Waverley Clinical Commissioning Group, Guildford, UK
| | - Daryl Freeman
- Mundesley Medical Centre, NHS England, Midlands and East, Norfolk, UK
| | - Irem Patel
- Respiratory Department, Integrated Care, Kings Health Partners, King College London School of Medicine, London, UK
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27
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Vargas-Bermúdez A, Cardenal F, Porta-Sales J. Opioids for the Management of Dyspnea in Cancer Patients: Evidence of the Last 15 Years--A Systematic Review. J Pain Palliat Care Pharmacother 2015; 29:341-52. [PMID: 26523974 DOI: 10.3109/15360288.2015.1082005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
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.
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28
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Hardinge M, Annandale J, Bourne S, Cooper B, Evans A, Freeman D, Green A, Hippolyte S, Knowles V, MacNee W, McDonnell L, Pye K, Suntharalingam J, Vora V, Wilkinson T. British Thoracic Society guidelines for home oxygen use in adults: accredited by NICE. Thorax 2015; 70 Suppl 1:i1-43. [DOI: 10.1136/thoraxjnl-2015-206865] [Citation(s) in RCA: 170] [Impact Index Per Article: 18.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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29
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Janssen DJA, de Hosson SM, bij de Vaate E, Mooren KJM, Baas AAF. Attitudes toward opioids for refractory dyspnea in COPD among Dutch chest physicians. Chron Respir Dis 2015; 12:85-92. [PMID: 25676931 DOI: 10.1177/1479972315571926] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Daisy J A Janssen
- Department of Research and Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands Centre of Expertise for Palliative Care, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
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30
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Venot M, Kouatchet A, Jaber S, Demoule A, Azoulay É. Stratégies ventilatoires en situations palliatives. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1023-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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31
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Abstract
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.
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32
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Gotera C, Díaz Lobato S, Pinto T, Winck J. Clinical evidence on high flow oxygen therapy and active humidification in adults. REVISTA PORTUGUESA DE PNEUMOLOGIA 2013; 19:217-27. [DOI: 10.1016/j.rppneu.2013.03.005] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 03/12/2013] [Indexed: 11/29/2022] Open
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33
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Abstract
Long-term oxygen therapy (LTOT) has been shown to reduce pulmonary hypertension and improve survival in patients with chronic obstructive pulmonary disease and resting hypoxemia (reduced arterial partial pressure of oxygen ≤55 mmHg). However, the benefit of its use for chronic pulmonary diseases other than chronic obstructive pulmonary disease as well as for nonpulmonary conditions is debatable. Its role in patients with mild hypoxemia (reduced arterial partial pressure of oxygen >55 mmHg at rest) is presently being investigated in the LOTT. A meta-analysis of four controlled trials reporting the role of LTOT in patients with either nocturnal desaturation or daytime moderate hypoxemia found no difference in survival between patients on LTOT than those without. Advances in oxygen delivery and conservation devices have made domiciliary oxygen therapy more practical and popular for patients. There still remain concerns with the actual compliance of therapy among the needy patients.
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Affiliation(s)
- Surinder K Jindal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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34
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Johnson MJ, Abernethy AP, Currow DC. The evidence base for oxygen for chronic refractory breathlessness: issues, gaps, and a future work plan. J Pain Symptom Manage 2013; 45:763-75. [PMID: 23017616 DOI: 10.1016/j.jpainsymman.2012.03.017] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2011] [Revised: 03/03/2012] [Accepted: 03/09/2012] [Indexed: 10/27/2022]
Abstract
Breathlessness or "shortness of breath," medically termed dyspnea, is a common and distressing symptom featuring strongly in advanced lung, cardiac, and neuromuscular diseases; its prevalence and intensity increase as death approaches. However, despite the increasing understanding in the genesis of breathlessness, as well as an increasing portfolio of treatment options, breathlessness is still difficult to manage and engenders helplessness in caregivers and health care professionals and fear for patients. Although hypoxemia does not appear to be the dominant driver for breathlessness in advanced disease, the belief that oxygen is important for the relief of acute, chronic, and acute-on-chronic shortness of breath is firmly embedded in the minds of patients, caregivers, and health care professionals. This article presents current understanding of the use of oxygen for treating refractory breathlessness in advanced disease. The objective is to highlight what is still unknown, set a research agenda to resolve these questions, and highlight methodological issues for consideration in planned studies.
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Affiliation(s)
- Miriam J Johnson
- Palliative Medicine, Hull York Medical School, University of Hull, Hull, United Kingdom.
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35
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Mackay AJ, Hurst JR. COPD exacerbations: causes, prevention, and treatment. Immunol Allergy Clin North Am 2012; 33:95-115. [PMID: 23337067 DOI: 10.1016/j.iac.2012.10.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The mechanisms of chronic obstructive pulmonary disease exacerbation are complex. Respiratory viruses (in particular rhinovirus) and bacteria play a major role in the cause of these events. A distinct group of patients seems susceptible to frequent exacerbations, irrespective of disease severity, and this phenotype is stable over time. Many current therapeutic strategies help reduce exacerbation frequency. Further work is required to develop novel anti-inflammatory therapies for exacerbation prevention and treatment. This article focuses on the cause of chronic obstructive pulmonary disease exacerbations, and the current preventative and acute interventions available.
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Affiliation(s)
- Alex J Mackay
- Academic Unit of Respiratory Medicine, Royal Free Campus, UCL Medical School, Rowland Hill Street, London NW3 2PF, UK.
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36
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Lowey SE, Powers BA, Xue Y. Short of breath and dying: state of the science on opioid agents for the palliation of refractory dyspnea in older adults. J Gerontol Nurs 2012; 39:43-52. [PMID: 23244062 DOI: 10.3928/00989134-20121204-06] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 07/18/2012] [Indexed: 11/20/2022]
Abstract
The purpose of this narrative literature review was to describe the state of the science on the effectiveness of opioid medications to palliate dyspnea in older adults with advanced disease. A three-stage critical appraisal process was used to evaluate articles published between 2000-2011 that were retrieved from the CINAHL, Ovid MEDLINE, and PsycINFO databases. Low-dose opioid medication use was associated with statistically significant reductions in dyspnea intensity scores in the majority of studies included in the analysis. Many recent articles on this topic shed light on the importance but underuse of opioid agents to palliate dyspnea, particularly in older adults with advanced chronic illnesses, such as heart failure and chronic obstructive pulmonary disease. ADRA (Assess, Document, Re-assess, Advocate) is a proposed framework that gerontological nurses can use to ensure patients receive adequate symptom management for refractory dyspnea.
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Affiliation(s)
- Susan E Lowey
- University of Rochester School of Nursing, Rochester, NY 14642, USA.
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37
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Ben-Aharon I, Gafter-Gvili A, Leibovici L, Stemmer SM. Interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. Acta Oncol 2012; 51:996-1008. [PMID: 22934558 DOI: 10.3109/0284186x.2012.709638] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Dyspnea is commonly encountered by many cancer patients in the terminal stage of their disease and it severely hampers their quality of life. We aimed to evaluate the role of interventions to alleviate dyspnea. METHODS Systematic review and meta-analysis of randomized controlled trials assessing all interventions for dyspnea palliation in cancer patients, and searched the Cochrane Library, MEDLINE, conference proceedings, and references. RESULTS Our search yielded 18 trials. Eight studies evaluated opioids in any route of administration, seven studies evaluated the use of oxygen, two studies assessed the role of benzodiazepines and two studies evaluated the role of furosemide in alleviating cancer-related dyspnea. Weighted mean difference (WMD) was calculated for continuous variables that were reported on the same scale. For continuous data reported in different scales, standardized mean difference (SMD) was calculated. Meta-analysis of three trials yielded a positive effect for opioid administration, WMD -1.31[95% CI (-2.49)-(- 0.13)]. Meta-analysis of the six studies showed lack of benefit to oxygen to improve dyspnea, SMD -0.3[95% CI -1.06-0.47]. The role of benzodiazepines remains unclear, furosemide was not beneficial. CONCLUSIONS Our systematic review and meta-analysis demonstrate a beneficial effect to opioids in alleviating cancer-related dyspnea, and no advantage for the use of oxygen.
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Affiliation(s)
- Irit Ben-Aharon
- Institute of Oncology, Davidoff Center, Rabin Medical Center, Petah-Tiqva, Israel.
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38
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Abstract
PURPOSE OF REVIEW Breathlessness is a symptom which is felt as shortness of breath or tightness in the chest. The symptom of breathlessness is essentially an awareness of difficult respiration; in other words, respiration becomes an effort. The increase due to pathological change supplements the effect of exercise. In this article, the combined modalities of palliative management of breathlessness are discussed on the basis of current literature (published and indexed in PubMed from January 2009 to week 1 in January 2012). The findings were used to derive a treatment algorithm for the management of dyspnoea. RECENT FINDINGS The findings in the recently published literature with treatment recommendations for the management of breathlessness were scarce. Although there are multiple clinical trials regarding treatment of breathlessness, there is a paucity of well designed, prospective, randomized controlled trials with large enough numbers of patients suffering from breathlessness and treated with combined pharmacological and nonpharmacological methods. SUMMARY As yet, there is no clinical trial that can accurately reflect the far-reaching effects of combined treatment modalities of breathlessness. Therefore, at present, we would recommend combining a treatment with opioids, anxiolytics and corticosteroids accompanied by oxygen and physiotherapeutic treatment options.
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Hallenbeck J. Pathophysiologies of Dyspnea Explained: Why Might Opioids Relieve Dyspnea and Not Hasten Death? J Palliat Med 2012; 15:848-53. [DOI: 10.1089/jpm.2011.0167] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- James Hallenbeck
- School of Medicine, Department of Medicine, Division of General Medical Disciplines, Stanford University, Stanford, California
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40
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Beyea A, Winzelberg G, Stafford RE. To drain or not to drain: an evidence-based approach to palliative procedures for the management of malignant pleural effusions. J Pain Symptom Manage 2012; 44:301-6. [PMID: 22871511 DOI: 10.1016/j.jpainsymman.2012.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 05/07/2012] [Accepted: 05/09/2012] [Indexed: 10/28/2022]
Abstract
Malignant pleural effusions are often symptomatic and diagnosed late in the course of cancer. The optimal management strategy is controversial and includes both invasive and non-invasive strategies. Practitioners have the option of invasive procedures such as intermittent drainage or more permanent catheter drainage to confirm malignancy and to palliate symptoms. Because these effusions are often detected late in the course of disease in patients who may have limited life expectancy, procedural management may be associated with harms that outweigh benefits. We performed a literature review to examine the available evidence for catheter drainage of malignant pleural effusions in advanced cancer and reviewed alternative management strategies for the management of dyspnea. We provide a clinical case within the context of the research evidence for invasive and non-invasive management strategies. Our intent is to help inform decision making of patients and families in collaboration with their health care practitioners and interventionists by weighing the risks and benefits of catheter drainage versus alternative medical management strategies for malignant pleural effusions.
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Affiliation(s)
- Annette Beyea
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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41
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Abstract
The mechanisms of COPD exacerbation are complex. Respiratory viruses (in particular rhinovirus) and bacteria play a major role in the causative etiology of COPD exacerbations. In some patients, noninfective environmental factors may also be important. Data recently published from a large observational study identified a phenotype of patients more susceptible to frequent exacerbations. Many current therapeutic strategies can reduce exacerbation frequency. Future studies may target the frequent exacerbator phenotype, or those patients colonized with potential bacterial pathogens, for such therapies as long-term antibiotics, thus preventing exacerbations by decreasing bacterial load or preventing new strain acquisition in the stable state. Respiratory viral infections are also an important therapeutic target for COPD. Further work is required to develop new anti-inflammatory agents for exacerbation prevention, and novel acute treatments to improve outcomes at exacerbation.
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Affiliation(s)
- Alex J Mackay
- Academic Unit of Respiratory Medicine, Royal Free Campus, UCL Medical School, London, UK.
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42
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Comprehensive Management of Respiratory Symptoms in Patients with Advanced Lung Cancer. ACTA ACUST UNITED AC 2012; 10:1-9. [DOI: 10.1016/j.suponc.2011.07.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 05/26/2011] [Accepted: 07/11/2011] [Indexed: 11/23/2022]
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Kamal AH, Maguire JM, Wheeler JL, Currow DC, Abernethy AP. Dyspnea review for the palliative care professional: treatment goals and therapeutic options. J Palliat Med 2012; 15:106-14. [PMID: 22268406 PMCID: PMC3304253 DOI: 10.1089/jpm.2011.0110] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2011] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- Arif H. Kamal
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - Jennifer M. Maguire
- Department of Medicine, Division of Pulmonary Diseases and Critical Care Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Jane L. Wheeler
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
| | - David C. Currow
- Department of Palliative and Supportive Services, Division of Medicine, Flinders University, Bedford Park, South Australia, Australia
| | - Amy P. Abernethy
- Department of Medicine, Division of Medical Oncology, Duke University Medical Center, Durham, North Carolina
- Department of Palliative and Supportive Services, Division of Medicine, Flinders University, Bedford Park, South Australia, Australia
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Leppert W, Turska A, Majkowicz M, Dziegielewska S, Pankiewicz P, Mess E. Quality of Life in Patients With Advanced Lung Cancer Treated at Home and at a Palliative Care Unit. Am J Hosp Palliat Care 2011; 29:379-87. [DOI: 10.1177/1049909111426135] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background: To assess quality of life (QOL) in patients with advanced lung cancer. Patients and Methods: A prospective study of 78 patients cared at home and at a palliative care unit (PCU) with 2 QOL assessments was conducted. Results: Fifty patients completed the study. In the EORTC QLQ-C30 role, cognitive, social functioning, global QOL, fatigue, pain, dyspnea, and appetite deteriorated; nausea/vomiting improved; dyspnea was more intense in the case of in-home patients. In the EORTC QLQ-LC13 hemoptysis improved; pain in other parts was more intense in the PCU patients. Pain (Visual Analogue scale) was more intense in the PCU patients; the level of activity (Karnofsky) decreased in the case of patients treated at home. Conclusions: QOL deteriorated with few differences between home and the PCU patients.
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Affiliation(s)
- Wojciech Leppert
- Chair and Department of Palliative Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Anna Turska
- Chair and Department of Palliative Medicine, Poznan University of Medical Sciences, Poznan, Poland
| | - Mikolaj Majkowicz
- Department of Quality of Life Research, Gdansk Medical University, Gdansk, Poland
| | | | - Piotr Pankiewicz
- Department of Psychiatry, Gdansk Medical University, Gdansk, Poland
| | - Eleonora Mess
- Palliative Care Nursing Department, Wroclaw University of Medical Sciences, Wroclaw, Poland
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Abstract
Advanced heart failure (HF) is a disease process that carries a high burden of symptoms, suffering, and death. Palliative care can complement traditional care to improve symptom amelioration, patient-caregiver communication, emotional support, and medical decision making. Despite a growing body of evidence supporting the integration of palliative care into the overall care of patients with HF and some recent evidence of increased use, palliative therapies remain underused in the treatment of advanced HF. Review of the literature reveals that although barriers to integrating palliative care are not fully understood, difficult prognostication combined with caregiver inexperience with end-of-life issues specific to advanced HF is likely to contribute. In this review, we have outlined the general need for palliative care in advanced HF, detailed how palliative measures can be integrated into the care of those having this disease, and explored end-of-life issues specific to these patients.
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Affiliation(s)
- Lisa Lemond
- Division of Cardiology, Department of Medicine, University of Colorado Denver, Anschutz Medical Center, Aurora, USA
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46
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Affiliation(s)
- Romayne Gallagher
- Division of Palliative Care, Department of Family and Community Medicine, Providence Health Care, Vancouver, BC.
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Irvin W, Muss HB, Mayer DK. Symptom management in metastatic breast cancer. Oncologist 2011; 16:1203-14. [PMID: 21880861 PMCID: PMC3228166 DOI: 10.1634/theoncologist.2011-0159] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 07/12/2011] [Indexed: 11/17/2022] Open
Abstract
Approximately 40,000 women die as a result of breast cancer each year and many more live with advanced disease. When breast cancer recurs, the goals of treatment often shift from one of cure to controlling the disease for as long as possible while palliating symptoms interfering with the patient's functional status and quality of life. This requires ongoing discussions with the patient and family about the goals of care. Many symptoms depend on the site of metastasis, with bone being the most frequent, and commonly occur with fatigue, depression, insomnia, and pain. The purpose of this paper is to identify and provide an overview of the management of the most common symptoms in patients with breast cancer metastases.
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Affiliation(s)
- William Irvin
- Lineberger Comprehensive Cancer Center; University of North Carolina–Chapel Hill, Chapel Hill, North Carolina, USA
| | - Hyman B. Muss
- Lineberger Comprehensive Cancer Center; University of North Carolina–Chapel Hill, Chapel Hill, North Carolina, USA
| | - Deborah K. Mayer
- Lineberger Comprehensive Cancer Center; University of North Carolina–Chapel Hill, Chapel Hill, North Carolina, USA
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Laufenberg-Feldmann R, Kappis B, Weber M, Werner C. [Save life--allow death. Collation of emergency missions for terminally ill patients]. Schmerz 2011; 25:69-76. [PMID: 21161549 DOI: 10.1007/s00482-010-1000-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Emergency missions can also be necessary for patients in the terminal phase of a progressive incurable disease. The emergency physician, accustomed to acting under strict procedures and whose training focuses on the restoration and stabilization of acutely threatened vital functions, can face severe difficulties when treating incurably ill patients in the terminal phase. This study investigates the number of such cases, patient symptoms and the events occurring during life-threatening emergencies of terminally ill patients. METHOD All cases of emergency events involving terminally ill patients were analyzed prospectively. In addition to the standardized protocol (following DIVI/Mind 2) an enquiry sheet was used, which contained an 8-item checklist specifically for terminally ill patients, to be filled out by the responding physician. RESULTS The total number of patients in the terminal phase identified by the emergency physician was 55 (0.72% of total cases) and of these patients 30 (55%) were tumor patients. The most frequent complaint observed was dyspnea (30 patients, 55%), followed by relatives of the patients experiencing the stress of caring for a terminally ill person (19 patients, 35%). The leading symptom of 6 patients (11%) was pain. Only 17 cases (30.9%) required transport of the patient to hospital for further treatment. CONCLUSION Every emergency physician can be confronted with an emergency involving a patient with a progressive incurable disease. The condition of each patient must be assessed for each medical decision. Not only medical, but also psychosocial, ethical and legal aspects have to be considered.
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Affiliation(s)
- R Laufenberg-Feldmann
- Klinik für Anästhesiologie, Universitätsmedizin der Johannes Gutenberg-Universität Mainz, Langenbeckstr. 1, 55131 Mainz, Deutschland.
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Epstein AS, Hartridge-Lambert SK, Ramaker JS, Voigt LP, Portlock CS. Humidified high-flow nasal oxygen utilization in patients with cancer at Memorial Sloan-Kettering Cancer Center. J Palliat Med 2011; 14:835-9. [PMID: 21599530 DOI: 10.1089/jpm.2011.0005] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Respiratory signs and symptoms are commonly encountered by physicians who care for cancer patients. Supplemental oxygen (SOx) has long been used for treatment of hypoxic respiratory insufficiency, but data reveal mixed efficacy results. The use and outcome patterns of technologically advanced oxygen delivery devices, such as humidified high-flow nasal oxygen (HHFNOx), are incompletely understood. METHODS Institutional database search of the number of patient cases in which the current HHFNOx device was used, and abstraction of 183 patient medical records for usage characteristics. RESULTS Patients have been treated with HHFNOx at Memorial Sloan Kettering Cancer Center (MSKCC) since 2008. Of the 183 patients randomly selected for our study, 72% received HHFNOx in the intensive care unit (ICU) because of hypoxia. Patients usually improved (41%) or remained stable (44%) while on the device, whereas 15% declined. At study completion, 45% of patients were living, and 55% had died. The median time on HHFNOx was 3 days (range: 1-27). A do not resuscitate (DNR) order was present in 101 (55%) patients, either before (12%) or after (43%) device utilization. The majority (78%) of these 101 patients died at MSKCC. CONCLUSION Dyspnea is a common and important symptom in cancer patients for which SOx traditionally has had no clear basis except in select cases of hypoxia and patient preference. Our institutional experience with HHFNOx contributes to the understanding of the applications and challenges surrounding the use of new medical devices in the cancer population. Physiologic and quality-of-life benefits of HHFNOx compared with traditional oxygen delivery methods should be studied prospectively.
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Affiliation(s)
- Andrew S Epstein
- Memorial Sloan-Kettering Cancer Center , New York, NY 10065, USA
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