Dyspnea experience in patients with lung cancer in palliative care

Randomized Controlled Trial of a Nurse-Led Brief Behavioral Intervention for Dyspnea in Patients With Advanced Lung Cancer

PURPOSE

In patients with lung cancer, dyspnea is one of the most prevalent and disabling symptoms, for which effective treatments are lacking. We examined the efficacy of a nurse-led brief behavioral intervention to improve dyspnea in patients with advanced lung cancer.

METHODS

Patients with advanced lung cancer reporting at least moderate breathlessness (n = 247) were enrolled in a randomized trial of a nurse-led two-session intervention (focused on breathing techniques, postural positions, and fan therapy) versus usual care. At baseline and weeks 8 (primary end point), 16, and 24, participants completed measures of dyspnea (Modified Medical Research Council Dyspnea Scale [mMRCDS]; Cancer Dyspnoea Scale [CDS]), quality of life (Functional Assessment of Cancer Therapy-Lung [FACT-L]), psychological symptoms (Hospital Anxiety and Depression Scale), and activity level (Godin-Shephard Leisure Time Physical Activity Questionnaire). To examine intervention effects, we conducted analysis of covariance and longitudinal mixed effects models.

RESULTS

The sample (Agemean = 66.15 years; 55.9% female) primarily included patients with advanced non-small cell lung cancer (85.4%). Compared with usual care, the intervention improved the primary outcome of patient-reported dyspnea on the mMRCDS (difference = -0.33 [95% CI, -0.61 to -0.05]) but not the CDS total score at 8 weeks. Intervention patients also reported less dyspnea on the CDS sense of discomfort subscale (difference = -0.59 [95% CI, -1.16 to -0.01]) and better functional well-being per the FACT-L (difference = 1.39 [95% CI, 0.18 to 2.59]) versus the control group. Study groups did not differ in overall quality of life, psychological symptoms, or activity level at 8 weeks or longitudinally over 24 weeks.

CONCLUSION

For patients with advanced lung cancer, a scalable behavioral intervention alleviated the intractable symptom of dyspnea. Further research is needed on ways to enhance intervention effects over the long-term and across additional outcomes.

Dyspnea-Related Dimensions And Self-Efficacy: Associations With Well-Being in Advanced Lung Cancer

CONTEXT

Dyspnea is a complex, multidimensional symptom comprising sensory-perceptual, affective, and functional domains that commonly persists in patients with lung cancer and impairs mental health and quality of life (QOL). However, data are lacking on how dyspnea's dimensions or self-efficacy to manage dyspnea are associated with patient outcomes.

OBJECTIVES

To assess the associations of dyspnea dimensions (dyspnea-related sensory-perceptual experience, affective distress, and functional impact) and dyspnea self-efficacy with depression, anxiety, and QOL in patients with advanced lung cancer reporting dyspnea.

METHODS

We conducted a secondary analysis of baseline clinical trial data testing a supportive care intervention for dyspnea. Patients with advanced lung cancer reporting at least moderate dyspnea (≥2 on the Modified Medical Research Council Dyspnea Scale) self-reported dyspnea and patient outcome measures. Hierarchical regressions tested the associations of the dyspnea dimensions with depressive and anxiety symptoms (Hospital Anxiety and Depression Scale) and QOL (Functional Assessment of Cancer Therapy-Lung) while adjusting for variables known to affect these outcomes.

RESULTS

The sensory-perceptual experience of dyspnea (effort) was associated with worse depressive symptoms (b = 0.21, P < 0.01) and QOL (b = -0.53, P = 0.01). Dyspnea self-efficacy was associated with improved depressive (b = -1.26, P < 0.01) and anxiety symptoms (b = -1.72, P < 0.01) and QOL (b = 3.66, P < 0.01). The affective and functional dimensions of dyspnea were not associated with the patient outcomes in the final models.

CONCLUSIONS

Dyspnea-related sensory-perceptual experience and self-efficacy were associated with mental health and QOL outcomes in patients with lung cancer. Examining the individual contributions of dyspnea's multiple dimensions provides a nuanced understanding of its patient impact.

A cognitive-behavioral model of dyspnea: Qualitative interviews with individuals with advanced lung cancer

OBJECTIVES

Shortness of breath, or dyspnea, is the subjective experience of breathing discomfort and is a common, distressing, and debilitating symptom of lung cancer. There are no efficacious pharmacological treatments, but there is suggestive evidence that cognitive-behavioral treatments could relieve dyspnea. For this, understanding the psychological, behavioral, and social factors that may affect dyspnea severity is critical. To this end, patients with dyspnea were interviewed with questions framed by the cognitive-behavioral model-emphasizing thoughts, emotions, and behaviors as contributors and outcomes of dyspnea.

METHODS

Two trained individuals conducted semi-structured interviews with lung cancer patients (N = 15) reporting current dyspnea. Interviews assessed patients' cognitive-behavioral experiences with dyspnea. Study personnel used a grounded theory approach for qualitative analysis to code the interviews. Inter-rater reliability of codes was high (κ = 0.90).

RESULTS

Thoughts: Most common were patients' catastrophic thoughts about their health and receiving enough oxygen when breathless. Emotions: Anxiety about dyspnea was the most common, followed by anger, sadness, and shame related to dyspnea. Behaviors: Patients rested and took deep breaths to relieve acute episodes of dyspnea. To reduce the likelihood of dyspnea, patients planned their daily activity or reduced their physical activity at the expense of engagement in hobbies and functional activities.

SIGNIFICANCE OF RESULTS

Patients identified cognitive-behavioral factors (thoughts, emotions, and behaviors) that coalesce with dyspnea. The data provide meaningful insights into potential cognitive-behavioral interventions that could target contributors to dyspnea.

Multi-Dimensional Dyspnea-Related Scales Validated in Individuals With Cardio-Respiratory and Cancer Diseases. A Systematic Review of Psychometric Properties

CONTEXT

In order to examine the multi-dimensional nature of dyspnea and its impact on the activities of daily living (ADLs) in patients with cardio-respiratory and cancer diseases, validated measures are needed.

OBJECTIVES

Our aim was to identify all the multi-dimensional clinical scales assessing dyspnea and its impact on ADLs in patients with cardio-respiratory and cancer diseases, and to critically appraise their psychometric properties.

METHODS

Five databases were systematically searched up to July 2020. Eligible criteria were: the examination of at least one psychometric property, and the recruitment of adults with a cardio-respiratory or cancer disease in non-emergency settings. The characteristics and psychometric properties of the studies included were presented through a narrative synthesis. The methodological quality of the studies and evidence synthesis were rated using the "COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN)" criteria.

RESULTS

Forty-three studies, for which eight assessment scales had been identified, were included in the review. At the time of the review, three multi-dimensional assessment scales were available for assessing dyspnea symptoms, and five multi-dimensional scales were available to examine the impact of dyspnea on ADLs. Although the use of these scales has rapidly grown, evidence of psychometric properties has been reported as limited in most of the scales.

CONCLUSION

Despite the potential of the identified scales, further studies are needed to strength evidence on the validity and reliability of the multi-dimensional dyspnea scales. Furthermore, more studies appraising the content validity and responsiveness of the scales are specifically recommended.

[Dyspnoea and Comorbidity in Lung Cancer-Patients: The Therapy Starts with Taking the Patients History]

AIM

 Dyspnoea is a frequent and compromising symptom in patients with advanced and metastatic lung cancer. Exogenous as well as endogenous factors contribute to development of shortness of breath. Knowledge of these influences is essential for effective treatment of this important symptom. In our study, we evaluated the influence of cofactors and comorbidity on development of dyspnoea in lung cancer patients for the purpose of effective therapy of shortness of breath in this target group.

METHODS

 In this prospective monocentric study, we registered severity of dyspnoea in advanced lung cancer patients using the modified Medical Research Council-Scale (mMRC-scale). Patients' history of COPD and cardiopulmonary comorbidity was recorded using a standardized questionnaire. Moreover, cofactors such as pain or cancer-induced mental stress were documented by visual rating scale.

RESULTS

 25 (48,1 %) of 52 recruited lung cancer-patients reported moderate or severe dyspnoea. In logistic regression analysis history of COPD or cardiopulmonary comorbidity, severe pain, airway obstruction or pleural effusion were associated with severe dyspnoea (mMRC-scale ≥ 3). Furthermore, in our study cohort lower cancer level III UICC and absence of metastasis correlated with severe dyspnoea.

CONCLUSIONS

 Our findings confirm the relevance of dyspnoea in patients with advanced lung cancer. Probability of occurrence is influenced by comorbidity and cofactors. The knowledge of these factors contributes to better understanding of occurrence and treatment of dyspnoea.

Association Between Heart Rate and Reversibility of the Symptom, Refractoriness to Palliative Treatment, and Survival in Dyspneic Cancer Patients

CONTEXT

Dyspnea is one of the most distressing symptoms for terminally ill cancer patients and a predictor of poor prognosis. Identification of simple clinical signs, such as heart rate, indicating clinical course of each patient is of value.

OBJECTIVES

To explore the potential association between heart rate and reversibility of the symptom, treatment response to palliative intervention, and survival in terminally ill cancer patients with dyspnea at rest.

METHODS

This is a secondary analysis of a multicenter prospective cohort study of patients with advanced cancer to validate multiple prognostic tools. In the patients with dyspnea at rest at the baseline, we examined a potential association between heart rate and the reversibility of dyspnea and refractoriness to palliative treatment using logistic regression analysis. Survivals were compared using the Cox proportional hazards model among four groups with different levels of the heart rate (≤74, 75-84, 85-97, and ≥98).

RESULTS

A total of 2298 patients were enrolled, and 418 patients (18%) had dyspnea at rest. Reversibility of dyspnea was significantly higher in the patients with lower heart rate (P for trend = 0.008), and the refractoriness to palliative treatment tended to be higher in the patients with higher heart rate (P for trend = 0.101). The median survival for each heart rate quartile groups was significantly higher in the lower heart rate group (24 vs. 21 vs. 14 vs. 9 days; heart rate ≤74, 75-84, 85-97, and ≥98, respectively; log-rank P < 0.001).

CONCLUSION

Heart rate may help clinicians to make the prediction of the patient's clinical course more accurate.

Terminological Usage Related to Dyspnea by Nursing Staff: A Cross-Sectional Questionnaire Survey

In recent years, additional expressions such as 'sensation of breathing discomfort' and 'discomfort of dyspnea' are being used in daily nursing care in Japan. To better understand the current status of the use of these terms by nurses, and to ascertain what the term 'dyspnea' may not express, we designed an original questionnaire and conducted a study with all nurses at our hospital. The questionnaire included questions to determine if nurses used these terms, and in what context. Of the 279 nurses in our hospital, 225 (80.6%) responded. Three-quarters of nurses indicated that they use these terms in clinical nursing practice. There was no difference in the usage of these terms between nurses who had or had not worked in a respiratory outpatients/ward. However, the percentage of nurses using these terms was higher amongst those with 10 years or less nursing experience compared with those with more than 10 years' experience. Open-ended questions revealed that these terms were used to communicate information between nurses and between nurses and patients' families. Our observations need to be verified in large-scale studies to determine if these terms are meaningful for nursing practice in that they describe something not expressed with 'dyspnea'. There is the possibility of confusion due to the use of inappropriate terms and a lack of education on the subject. Many nurses used these terms, and there may be things that the term 'dyspnea' could not express. The results of this study can be used to identify something that is lacking in communication about dyspnea between nurses, nurses and patients, and nurses and patients' families.

Assessment of Breathlessness in Lung Cancer: Psychometric Properties of the Dyspnea-12 Questionnaire

CONTEXT

The Dyspnea-12 (D-12) Questionnaire is a well-validated instrument in respiratory illnesses for breathlessness assessment, but its psychometric properties have not been tested in lung cancer.

OBJECTIVE

To demonstrate the psychometric properties of the D-12 in lung cancer patients.

METHODS

Baseline data from a lung cancer feasibility trial were adopted for this analysis. D-12 and a series of patient-reported tools, including five Numeric Rating Scales (NRS), the Hospital Anxiety and Depression Scale (HADS), and the Lung Cancer Symptom Scale (LCSS), were used for the psychometric assessment. Spearman's correlation coefficients (rs) were used to estimate the convergent validity of the D-12 with the NRS, HADS, and LCSS. Exploratory factor analysis was performed to examine construct validity. Reliability was tested by Cronbach's alpha and item-to-total correlations. D-12 score difference between patients with or without anxiety, depression, and chronic obstructive pulmonary disease (COPD) was explored to identify its discriminate performance.

RESULTS

One hundred and one lung cancer patients were included. There were significantly positive correlations between the D-12 and the HADS, LCSS, and NRS measuring breathlessness severity and its associated affective distress. Factor analysis clearly identified two components (physical and emotional) of the D-12. Cronbach's alpha for D-12 total, physical, and emotional subscales was 0.95, 0.92, and 0.94, respectively. Patients with anxiety or depression demonstrated significantly higher D-12 scores than those without it, and patients with COPD reported significantly more severe breathlessness than those without COPD.

CONCLUSION

The D-12 is a valid and reliable self-reported questionnaire for use in breathlessness assessment in lung cancer patients.

Integrated Palliative Care and Oncologic Care in Non-Small-Cell Lung Cancer

OPINION STATEMENT

Palliative care integrated into standard medical oncologic care will transform the way we approach and practice oncologic care. Integration of appropriate components of palliative care into oncologic treatment using a pathway-based approach will be described in this review. Care pathways build on disease status (early, locally advanced, advanced) as well as patient and family needs. This allows for an individualized approach to care and is the best means for proactive screening, assessment, and intervention, to ensure that all palliative care needs are met throughout the continuum of care. Components of palliative care that will be discussed include assessment of physical symptoms, psychosocial distress, and spiritual distress. Specific components of these should be integrated based on disease trajectory, as well as clinical assessment. Palliative care should also include family and caregiver education, training, and support, from diagnosis through survivorship and end of life. Effective integration of palliative care interventions have the potential to impact quality of life and longevity for patients, as well as improve caregiver outcomes.

Breathlessness During the Last Week of Life in Palliative Care: An Australian Prospective, Longitudinal Study

CONTEXT

Breathlessness is a major cause of suffering and distress, and little is known about the trajectory of breathlessness near death.

OBJECTIVES

To determine the trajectory and clinical-demographic factors associated with breathlessness in the last week of life in patients receiving specialist palliative care.

METHODS

This was a prospective, longitudinal cohort study using national data on specialist palliative care from the Australian Palliative Care Outcomes Collaboration. We included patients in the Australian Palliative Care Outcomes Collaboration who died between July 1, 2013 and June 30, 2014 with at least one measurement of breathlessness on a 0-10 numerical rating scale in the week before death. The trajectory and factors associated with breathlessness were analyzed using multivariate random-effects linear regression.

RESULTS

A total 12,778 patients from 87 services (33,404 data points) were analyzed. The average observed breathlessness was 2.1 points and remained constant over time. Thirty-five percent reported moderate to severe distress (numerical rating scale ≥4) at some time in their last week. Factors associated with higher breathlessness were younger age, male gender, cardiopulmonary involvement, concurrent fatigue, nausea, pain, sleeping problems, higher Australia-modified Karnofsky Performance Status, and clinical instability in the multivariate analysis. Respiratory failure showed the largest association (mean adjusted difference 3.1 points; 95% confidence interval, 2.8-3.4).

CONCLUSION

Although breathlessness has been reported to worsen in the last months, the mean severity remained stable in the final week of life. In specialized palliative care, one in three people experienced significant breathlessness especially in respiratory disease.

Acupuncture for Dyspnea in Lung Cancer: Results of a Feasibility Trial

Purpose. Dyspnea is a common and distressing symptom for patients with lung cancer (LC) because of disease burden, therapy toxicity, and comorbid illnesses. Acupuncture is a centuries-old therapy with biological plausibility for relief of dyspnea in this setting. This pilot study aimed to evaluate the feasibility and preliminary effectiveness of acupuncture for dyspnea among patients with LC. Methods. Eligible patients had a diagnosis of LC and clinically significant dyspnea without a clear organic cause. The treatment consisted of 10 weekly acupuncture sessions, with a follow-up visit 4 weeks after therapy. The primary outcome was dyspnea severity as measured using a validated Numerical Rating Scale (NRS) of 0 to 10 (10 being “most severe shortness of breath imaginable”). Results. We enrolled 12 patients in the study. The median age was 64.5 years; 66.7% of the patients were female, and 66.7% were Caucasians. Among those enrolled, 10 (83.3%) were able to complete all 10 acupuncture sessions. Acupuncture was well tolerated; adverse events were mild and self-limited. Mean (SD) dyspnea scores on the NRS improved from 6.3 (1.7) at baseline to 3.6 (1.9; P = .003) at the end of treatment and 3.2 (2.3; P = .008) at follow-up. Fatigue and quality of life also improved significantly with acupuncture (P < .05). Conclusion. Among patients with LC, acupuncture was well tolerated and exhibited promising preliminary beneficial effects in the treatment of dyspnea, fatigue, and quality of life. Performing a trial in this population appears feasible.

Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial

BACKGROUND

Breathlessness is common in advanced cancer. The Breathlessness Intervention Service (BIS) is a multi-disciplinary complex intervention theoretically underpinned by a palliative care approach, utilising evidence-based non-pharmacological and pharmacological interventions to support patients with advanced disease. We sought to establish whether BIS was more effective, and cost-effective, for patients with advanced cancer and their carers than standard care.

METHODS

A single-centre Phase III fast-track single-blind mixed-method randomised controlled trial (RCT) of BIS versus standard care was conducted. Participants were randomised to one of two groups (randomly permuted blocks). A total of 67 patients referred to BIS were randomised (intervention arm n = 35; control arm n = 32 received BIS after a two-week wait); 54 completed to the key outcome measurement. The primary outcome measure was a 0 to 10 numerical rating scale for patient distress due to breathlessness at two-weeks. Secondary outcomes were evaluated using the Chronic Respiratory Questionnaire, Hospital Anxiety and Depression Scale, Client Services Receipt Inventory, EQ-5D and topic-guided interviews.

RESULTS

BIS reduced patient distress due to breathlessness (primary outcome: -1.29; 95% CI -2.57 to -0.005; P = 0.049) significantly more than the control group; 94% of respondents reported a positive impact (51/53). BIS reduced fear and worry, and increased confidence in managing breathlessness. Patients and carers consistently identified specific and repeatable aspects of the BIS model and interventions that helped. How interventions were delivered was important. BIS legitimised breathlessness and increased knowledge whilst making patients and carers feel 'not alone'. BIS had a 66% likelihood of better outcomes in terms of reduced distress due to breathlessness at lower health/social care costs than standard care (81% with informal care costs included).

CONCLUSIONS

BIS appears to be more effective and cost-effective in advanced cancer than standard care.

TRIAL REGISTRATION

RCT registration at ClinicalTrials.gov NCT00678405 (May 2008) and Current Controlled Trials ISRCTN04119516 (December 2008).

Dyspnea and panic among patients with newly diagnosed non-small cell lung cancer

CONTEXT

Among patients with lung cancer, dyspnea is associated with psychological distress, fatigue, and poor coping. Respiratory symptoms are also a common trigger for panic attacks in the general population. Minimal research has addressed the prevalence of panic disorder or the association of dyspnea with the risk of panic disorder in lung cancer.

OBJECTIVES

We explored the frequency of panic disorder symptoms and the association of dyspnea with the risk of panic disorder symptoms among patients with newly diagnosed non-small cell lung cancer.

METHODS

During 2006-2010, consecutive patients presenting for initial consultation at a thoracic oncology clinic completed a survey of current symptoms, including dyspnea and panic disorder symptoms. We evaluated the frequency of panic disorder symptoms. Logistic regression was used to test the association of dyspnea with the risk of panic disorder symptoms, adjusting for age, gender, disease stage, performance status, and major depression symptoms.

RESULTS

Among 624 patients (mean age=63.7; standard deviation=12.1; 52.6% female), 48.1% reported that breathing was at least somewhat difficult and 11.2% endorsed panic disorder symptoms. Dyspnea was independently associated with higher risk of panic disorder symptoms (odds ratio=2.19, 95% confidence interval=1.11-4.31, P=0.02). Younger age and major depression symptoms also were associated with higher risk (P<0.01).

CONCLUSION

Almost half of the patients with newly diagnosed non-small cell lung cancer reported dyspnea, and patients with dyspnea were more than twice as likely to endorse panic disorder symptoms relative to patients without dyspnea. Results highlight the need to differentiate panic disorder symptoms among patients who report dyspnea, particularly those who are younger or experiencing major depression symptoms.

Integrating palliative care: when and how?

PURPOSE OF REVIEW

Lung cancer is the leading cause of cancer mortality in men and women. Most patients present with advanced disease and face significant morbidity, with many reporting distressing symptoms throughout the course of their illness. The purpose of this review is to highlight the recent studies that support the integration of early palliative care into the standard oncology care of patients with advanced lung cancer.

RECENT FINDINGS

Historically, palliative care was provided predominantly as a hospital-based consultation service; however, recent data support an outpatient delivery model of early palliative care alongside standard oncology care. In two randomized controlled trials, patients with advanced cancer who were assigned to early palliative care reported improved quality of life and mood. Numerous organizations have published guidelines to support the integration of palliative care into the routine care of patients with lung cancer.

SUMMARY

Palliative care is appropriate for patients at any point in a serious illness. Unlike hospice, palliative care is not limited by prognosis and may be provided at the same time as disease-directed therapies. There is strong evidence underscoring the importance of integrating palliative care across the trajectory of lung cancer. The primary oncology team should routinely assess for pain and other symptoms, and regularly inquire about a patient's understanding of his disease and his goals of care. Specialty palliative care can provide an extra layer of support for patients with lung cancer and their families by helping with more challenging symptom management, psychosocial support, complex decision-making, advance care planning, and transitions in care.

Psycho-emotional manifestations of valvular heart diseases: prospective assessment in mitral regurgitation

OBJECTIVE

To define the prevalence and consequences of post-traumatic stress disorder (PTSD) as an emotional response to cardiac diseases in patients with mitral regurgitation.

METHODS

We prospectively enrolled 186 patients with moderate or severe organic mitral regurgitation, presenting class I (absent) or II (minimal) dyspnea, who were compared with 80 controls of similar age (38 with completely normal cardiac function; 42 with mild mitral-valve prolapse; all with no, or at most mild, mitral regurgitation). Mitral-regurgitation severity and consequences were comprehensively measured, simultaneously with PTSD, anxiety, and depression.

RESULTS

PTSD prevalence was higher in mitral-regurgitation patients vs controls (23% vs 9%, P <.01). Although mitral-regurgitation objective severity (regurgitant volume 77.8 ± 28.9 vs 79.0 ± 27.5 mL, P = .8) and objective consequences (left-atrial volume 59.1 ± 20.9 vs 54.02 ± 15.6 mL, P = .1; right-ventricular systolic pressure 34.1 ± 11.4 vs 32.9 ± 7.2 mm Hg, P = .6) were similar with and without PTSD (all P ≥.1), patients with PTSD were more symptomatic (class II 74 vs 38%; fatigue 71% vs 38%, both P <.0001) and had higher anxiety and depressions scores (P <.0001).

CONCLUSIONS

PTSD is prevalent in organic moderate or severe mitral-regurgitation patients but is not determined by objective mitral-regurgitation severity or consequences. PTSD is linked to anxiety and depression and to symptoms usually considered cardiac, such as dyspnea. Thus, PTSD and psycho-emotional manifestations, linked to symptoms, represent important responses to chronic-valve disease that may affect clinical outcomes.

Episodic and continuous breathlessness: a new categorization of breathlessness

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Episodic breathlessness in patients with advanced disease: a systematic review

CONTEXT

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Do the trajectories of dyspnea differ in prevalence and intensity by diagnosis at the end of life? A consecutive cohort study

CONTEXT

Breathlessness reportedly worsens as death approaches for many people, but the differences in intensity and time course between underlying causes are not well described.

OBJECTIVES

To determine differences in the intensity of breathlessness by diagnosis over time as death approaches in a consecutive cohort seen by a specialist palliative care service.

METHODS

Patients referred to Silver Chain Hospice Care Service over a period of four years (January 2004 to December 2007) had dyspnea evaluated at every clinical encounter until death. A numeric rating scale (NRS) was used to measure the intensity. Patients were categorized into five clusters (lung cancer, secondary cancer to lung, heart failure, end-stage pulmonary disease, and no identifiable cardiorespiratory cause) at three time points (60-53 [T(3)], 30-23 [T(2)], and 7-0 [T(1)] days before death [T(0)]). Group differences were assessed using analysis of variance. Joinpoint regression models defined significant changes in mean breathlessness intensity.

RESULTS

For 5,862 patients, data were collected an average of 20 times (median: 13; 116,982 data points) for an average of 86 days (median: 48). Breathlessness was significantly higher at all three time points in people with noncancer diagnoses. Breathlessness increased significantly at days 10 and 3 before death for people with cancer (P<0.001 for both), but remained unchanged, albeit significantly higher for patients with noncancer diagnoses. In the three months leading to death, the prevalence of "no breathlessness" decreased from 50% to 35%, and the proportion of patients with severe breathlessness (>7 out of 10) increased from 10% to 26%.

CONCLUSION

Prevalence of breathlessness increases rapidly at life's end, especially for people with primary lung cancer; the levels of breathlessness became close to those experienced by people with noncancer diagnoses despite symptom control measures.

Physiologic changes and clinical correlates of advanced dyspnea

PURPOSE OF REVIEW

To discuss the pathophysiology of dyspnea as it relates to patients suffering with chronic respiratory illness or end-stage disease.

RECENT FINDINGS

There are several publications highlighting important new concepts in this field including a new multidimensional model of dyspnea, similar to that developed for pain, that sheds new insight into the pathophysiology. Research in pulmonary rehabilitation, exercise testing and distractive auditory stimulation has also contributed to our understanding. Finally, there are new data on the emotional response of laboratory-induced dyspnea.

SUMMARY

Dyspnea is a complex symptom widely prevalent in advanced disease that involves multiple causes and pathophysiologies. The sensation of dyspnea is subjective and often evokes discomfort, fear, and anxiety. We recommend that this symptom be evaluated whenever vital signs are taken.