A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer

Treatment Recommendation for Dyspnea in Patients with Advanced Disease: Revised Clinical Guidelines from the Japanese Society for Palliative Medicine

Dyspnea is one of the most common and distressing symptoms in patients with cancer and noncancer advanced diseases. The Japanese Society for Palliative Medicine revised previous guidelines for the management of respiratory symptoms in patients with cancer and newly developed clinical guidelines for managing dyspnea in patients with advanced disease, based on the result of systematic reviews for each clinical question and consensus among experts. We describe the recommendations of the guidelines as well as provide insights into the reasoning behind the recommendations and their development process. There has been a paucity of evidence regarding the interventions for dyspnea in patients with advanced disease. Thus, more clinical research that includes not only randomized controlled trials but also real-world observational studies is warranted.

Thoracic Society of Australia and New Zealand clinical practice guideline on adult home oxygen therapy

This Thoracic Society of Australia and New Zealand Guideline on the provision of home oxygen therapy in adults updates a previous Guideline from 2015. The Guideline is based upon a systematic review and meta-analysis of literature to September 2022 and the strength of recommendations is based on GRADE methodology. Long-term oxygen therapy (LTOT) is recommended for its mortality benefit for patients with COPD and other chronic respiratory diseases who have consistent evidence of significant hypoxaemia at rest (PaO2 ≤ 55 mm Hg or PaO2 ≤59 mm Hg in the presence of hypoxaemic sequalae) while in a stable state. Evidence does not support the use of LTOT for patients with COPD who have moderate hypoxaemia or isolated nocturnal hypoxaemia. In the absence of hypoxaemia, there is no evidence that oxygen provides greater palliation of breathlessness than air. Evidence does not support the use of supplemental oxygen therapy during pulmonary rehabilitation in those with COPD and exertional desaturation but normal resting arterial blood gases. Both positive and negative effects of LTOT have been described, including on quality of life. Education about how and when to use oxygen therapy in order to maximize its benefits, including the use of different delivery devices, expectations and limitations of therapy and information about hazards and risks associated with its use are key when embarking upon this treatment.

Efficacy of supplemental oxygen for dyspnea relief in patients with advanced progressive illness: A systematic review and meta-analysis

BACKGROUND

Supplemental oxygen is widely used for dyspnea relief; however, its efficacy is yet to be verified. This study aimed to determine the efficacy of supplemental oxygen for dyspnea relief in patients with advanced progressive illness.

METHODS

In this systematic review, several databases, including MEDLINE and EMBASE, were searched to identify eligible randomized controlled trials (RCTs) on the topic published up to September 23, 2019. The search criteria included RCTs investigating patients with advanced progressive illness (advanced cancer, chronic obstructive pulmonary disease, and chronic heart failure). The study protocol was registered with PROSPERO (No. CRD42020161838). Separate analyses were pre-planned regarding the presence or absence of resting hypoxemia.

RESULTS

RCTs investigating supplemental oxygen for dyspnea relief in participants with and without resting hypoxemia (39 and five, respectively) were included in the study. Heterogeneity of supplemental oxygen for dyspnea in RCTs, including participants without resting hypoxemia was evident; hence, post-hoc analyses in four subgroups (supplemental oxygen during exercise or daily activities, short-burst oxygen, continuous supplemental oxygen, and supplemental oxygen during rehabilitation intervention) were conducted. In the meta-analysis, supplemental oxygen during exercise was found to improve dyspnea in patients without resting hypoxemia compared with that in the control (standardized mean difference = -0.57, 95% confidence interval = -0.77 to -0.38). However, supplemental oxygen for the other subgroups failed to improve patients' dyspnea.

CONCLUSION

The results of this systematic review do not support supplemental oxygen therapy for dyspnea relief in patients with advanced progressive illness, except during exercise.

Treatment of Dyspnea in Advanced Disease and at the End of Life

Dyspnea is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations, varies in intensity, and can only be known through the patient's report. Dyspnea is akin to suffocation and is one of the most distressing symptoms experienced by patients with advanced illness and at the end of life. Common approaches to dyspnea management, such as pulmonary rehabilitation, breathing strategies, or supplemental oxygen, have become accepted through pragmatic use or because studies do not include dyspnea as a measured outcome. Patients and clinicians urgently need evidence-based treatments to alleviate this frightening symptom. To fill this gap, a group of dyspnea researchers with expertise to conduct a literature review of evidence-based interventions for dyspnea in patients with serious illness produced these guidelines. We present the evidence from the strongest recommendations for practice to the weakest recommendations and include practical considerations for clinical nurses.

Critically ill cancer patient's resuscitation: a Belgian/French societies' consensus conference

To respond to the legitimate questions raised by the application of invasive methods of monitoring and life-support techniques in cancer patients admitted in the ICU, the European Lung Cancer Working Party and the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique, set up a consensus conference. The methodology involved a systematic literature review, experts' opinion and a final consensus conference about nine predefined questions1. Which triage criteria, in terms of complications and considering the underlying neoplastic disease and possible therapeutic limitations, should be used to guide admission of cancer patient to intensive care units?2. Which ventilatory support [High Flow Oxygenation, Non-invasive Ventilation (NIV), Invasive Mechanical Ventilation (IMV), Extra-Corporeal Membrane Oxygenation (ECMO)] should be used, for which complications and in which environment?3. Which support should be used for extra-renal purification, in which conditions and environment?4. Which haemodynamic support should be used, for which complications, and in which environment?5. Which benefit of cardiopulmonary resuscitation in cancer patients and for which complications?6. Which intensive monitoring in the context of oncologic treatment (surgery, anti-cancer treatment …)?7. What specific considerations should be taken into account in the intensive care unit?8. Based on which criteria, in terms of benefit and complications and taking into account the neoplastic disease, patients hospitalized in an intensive care unit (or equivalent) should receive cellular elements derived from the blood (red blood cells, white blood cells and platelets)?9. Which training is required for critical care doctors in charge of cancer patients?

Management of Dyspnea in Advanced Cancer: ASCO Guideline

PURPOSE

To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer.

METHODS

ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020.

RESULTS

The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea.

RECOMMENDATIONS

A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed. Additional information is available at www.asco.org/supportive-care-guidelines .

Nonpharmacological Interventions for Managing Breathlessness in Patients With Advanced Cancer: A Systematic Review

Importance

Breathlessness is a frequent and debilitating symptom in patients with advanced cancer. Often, in the context of breathlessness, aggressive cancer treatment is not beneficial, feasible, or aligned with goals of care. Targeted symptom-focused interventions may be helpful in this scenario.

Objective

To evaluate the advantages and harms of nonpharmacological interventions for managing breathlessness in adults with advanced cancer.

Evidence Review

PubMed, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials were searched from inception through May 2020 for published randomized clinical trials (RCTs), nonrandomized controlled trials, and observational studies of the advantages and/or harms of nonpharmacological interventions on alleviating breathlessness in adults with advanced cancer. Only English-language studies were screened for eligibility, titles, abstracts, and full text. Risk of bias and strength of evidence (SOE) were independently assessed. The key outcomes reported in studies were breathlessness, anxiety, exercise capacity, health-related quality of life, and harms. Data were analyzed from October 1, 2019, to June 30, 2020.

Findings

A total of 29 RCTs (2423 participants) were included. These RCTs evaluated various types of interventions, such as respiratory (9 RCTs), activity and rehabilitation (7 RCTs), behavioral and psychoeducational (3 RCTs), integrative medicine (4 RCTs), and multicomponent (6 RCTs). Several nonpharmacological interventions were associated with improved breathlessness, including fan therapy (standardized mean difference [SMD], -2.09; 95% CI, -3.81 to -0.37; I2 = 94.3%; P for heterogeneity = .02; moderate SOE) and bilevel ventilation (estimated slope difference, -0.58; 95% CI, -0.92 to -0.23; low SOE), lasting for a few minutes to hours, in the inpatient setting. In the outpatient setting, nonpharmacological interventions associated with improved breathlessness were acupressure and reflexology (integrative medicine) (low SOE) and multicomponent interventions (combined activity and rehabilitation, behavioral and psychoeducational, and integrative medicine) (low SOE) lasting for a few weeks to months. Five of the 29 RCTs (17%) reported adverse events, although adverse events and study dropouts were uncommon.

Conclusions and Relevance

Findings of this review include the safety and association with improved breathlessness of several nonpharmacological interventions for adults with advanced cancer. Guidelines and clinical practice should evolve to incorporate nonpharmacological interventions as first-line treatment for adults with advanced cancer and breathlessness.

[Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]

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.

Oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care: a preliminary retrospective cohort study

Background

The role of oxygen therapy in end-of-life care for patients with advanced cancer is incompletely understood. We aimed to evaluate the association between oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care.

Methods

We conducted a retrospective cohort study at a primary care practice in suburban Tokyo. Adult patients in home care with advanced cancer demonstrating first low oxygen saturation (less than 90%) detected in home visits were consecutively included in the study. Cox proportional hazards regression was used to investigate the effect of oxygen use on overall survival and survival at home, adjusted for systolic blood pressure, decreased level of consciousness, dyspnea, oral intake, performance status, and cardiopulmonary comorbidity.

Results

Of 433 identified patients with advanced cancer, we enrolled 137 patients (oxygen use, n = 35; no oxygen use, n = 102) who developed low oxygen saturation. In multivariable analysis, the adjusted hazard ratio (HR) of oxygen use was 0.68 (95% confidence interval 0.39–1.17) for death and 0.70 (0.38–1.27) for death at home. In patients with dyspnea, the HR was 0.35 (0.13–0.89) for death and 0.33 (0.11–0.96) for death at home; without dyspnea, it was 1.03 (0.49–2.17) for death and 0.84 (0.36–1.96) for death at home.

Conclusions

Oxygen use was not significantly associated with survival in patients with advanced cancer and low oxygen saturation, after adjusting for potential confounders. It may not be necessary to use oxygen for prolongation of survival in such patients, particularly in those without dyspnea.

Oncologic Emergencies: Palliative Care in the Emergency Department Setting

BACKGROUND

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

OBJECTIVE

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

DISCUSSION

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

CONCLUSIONS

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

High-Flow Nasal Cannula Versus Conventional Oxygen Therapy in Relieving Dyspnea in Emergency Palliative Patients With Do-Not-Intubate Status: A Randomized Crossover Study

STUDY OBJECTIVE

Palliative patients often visit the emergency department (ED) with respiratory distress during their end-of-life period. The goal of management is alleviating dyspnea and providing comfort. High-flow nasal cannula may be an alternative oxygen-delivering method for palliative patients with do-not-intubate status. We therefore aim to compare the efficacy of high-flow nasal cannula with conventional oxygen therapy in improving dyspnea of palliative patients with do-not-intubate status who have hypoxemic respiratory failure in the ED.

METHODS

This randomized, nonblinded, crossover study was conducted with 48 palliative patients aged 18 years or older with do-not-intubate status who presented with hypoxemic respiratory failure to the ED of Siriraj Hospital, Bangkok, Thailand. The participants were randomly allocated to conventional oxygen therapy for 60 minutes, followed by high-flow nasal cannula for 60 minutes (n=24) or vice versa (n=24). The primary outcome was modified Borg scale score. The secondary outcomes were numeric rating scale score of dyspnea and vital signs.

RESULTS

Intention-to-treat analysis included 44 patients, 22 in each group. Baseline mean modified Borg scale score was 7.6 (SD 2.2) (conventional oxygen therapy first) and 8.2 (SD 1.8) (high-flow nasal cannula first). At 60 minutes, mean modified Borg scale score in patients receiving conventional oxygen therapy and high-flow nasal cannula was 4.9 (standard of mean 0.3) and 2.9 (standard of mean 0.3), respectively (mean difference 2.0; 95% confidence interval 1.4 to 2.6). Results for the numeric rating scale score of dyspnea were similar to those for the modified Borg scale score. Respiratory rates were lower with high-flow nasal cannula (mean difference 5.9; 95% confidence interval 3.5 to 8.3), and high-flow nasal cannula was associated with a significantly lower first-hour morphine dose.

CONCLUSION

High-flow nasal cannula was superior to conventional oxygen therapy in reducing the severity of dyspnea in the first hour of treatment in patients with do-not-intubate status and hypoxemic respiratory failure.

Airflow relieves chronic breathlessness in people with advanced disease: An exploratory systematic review and meta-analyses

BACKGROUND

Chronic breathlessness is a neglected symptom of advanced diseases.

AIM

To examine the effect of airflow for chronic breathlessness relief.

DESIGN

Exploratory systematic review and meta-analysis.

DATA SOURCES

Medline, CINAHL, AMED and Cochrane databases were searched (1985-2018) for observational studies or randomised controlled trials of airflow as intervention or comparator. Selection against predefined inclusion criteria, quality appraisal and data extraction was conducted by two independent reviewers with access to a third for unresolved differences. 'Before and after' breathlessness measures from airflow arms were analysed. Meta-analysis was carried out where possible.

RESULTS

In all, 16 of 78 studies (n = 929) were included: 11 randomised controlled trials of oxygen versus medical air, 4 randomised controlled trials and 1 fan cohort study. Three meta-analyses were possible: (1) Fan at rest in three studies (n = 111) offered significant benefit for breathlessness intensity (0-100 mm visual analogue scale and 0-10 numerical rating scale), mean difference -11.17 (95% confidence intervals (CI) -16.60 to -5.74), p = 0.06 I² 64%. (2) Medical air via nasal cannulae at rest in two studies (n = 89) improved breathlessness intensity (visual analogue scale), mean difference -12.0 mm, 95% CI -7.4 to -16.6, p < 0.0001 I² = 0%. (3) Medical airflow during a constant load exercise test before and after rehabilitation (n = 29) in two studies improved breathlessness intensity (modified Borg scale, 0-10), mean difference -2.9, 95% CI -3.2 to -2.7, p < 0.0001 I² = 0%.

CONCLUSION

Airflow appears to offer meaningful relief of chronic breathlessness and should be considered as an adjunct treatment in the management of breathlessness.

Literature review of clinical benefits and reasons to prescribe palliative oxygen therapy in non-hypoxaemic patients

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.

Using the 'Social Marketing Mix Framework' to explore recruitment barriers and facilitators in palliative care randomised controlled trials? A narrative synthesis review

BACKGROUND

Effective recruitment to randomised controlled trials is critically important for a robust, trustworthy evidence base in palliative care. Many trials fail to achieve recruitment targets, but the reasons for this are poorly understood. Understanding barriers and facilitators is a critical step in designing optimal recruitment strategies.

AIM

To identify, explore and synthesise knowledge about recruitment barriers and facilitators in palliative care trials using the '6 Ps' of the 'Social Marketing Mix Framework'.

DESIGN

A systematic review with narrative synthesis.

DATA SOURCES

Medline, CINAHL, PsycINFO and Embase databases (from January 1990 to early October 2016) were searched. Papers included the following: interventional and qualitative studies addressing recruitment, palliative care randomised controlled trial papers or reports containing narrative observations about the barriers, facilitators or strategies to increase recruitment.

RESULTS

A total of 48 papers met the inclusion criteria. Uninterested participants (Product), burden of illness (Price) and 'identifying eligible participants' were barriers. Careful messaging and the use of scripts/role play (Promotion) were recommended. The need for intensive resources and gatekeeping by professionals were barriers while having research staff on-site and lead clinician support (Working with Partners) was advocated. Most evidence is based on researchers' own reports of experiences of recruiting to trials rather than independent evaluation.

CONCLUSION

The 'Social Marketing Mix Framework' can help guide researchers when planning and implementing their recruitment strategy but suggested strategies need to be tested within embedded clinical trials. The findings of this review are applicable to all palliative care research and not just randomised controlled trials.

ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement

Despite significant advances in the field of resuscitation science, important knowledge gaps persist. Current guidelines for resuscitation are based on the International Liaison Committee on Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, which includes treatment recommendations supported by the available evidence. The writing group developed this consensus statement with the goal of focusing future research by addressing the knowledge gaps identified during and after the 2015 International Liaison Committee on Resuscitation evidence evaluation process. Key publications since the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations are referenced, along with known ongoing clinical trials that are likely to affect future guidelines.

Symptomatic treatment of dyspnea in advanced cancer patients : A narrative review of the current literature

BACKGROUND

Dyspnea is a common, very distressing symptom in advanced cancer patients that challenges them, their relatives, and healthcare professionals. This narrative review summarizes important literature dealing with the evidence for opioids, benzodiazepines, oxygen, and steroids for treating dyspnea in advanced cancer patients.

METHODS

A selective literature search was undertaken in PubMed, Embase, and the Cochrane Library and extended with literature from the reference lists of included studies up to April 2016. Inclusion criteria were that patients were suffering from advanced cancer and were receiving either opioids, benzodiazepines, corticosteroids, or oxygen. The outcome of interest was the reduction of dyspnea measured via a visual analogue scale (VAS), a numerical rating scale (NRS), or a Borg scale. This narrative review describes in detail the findings of 13 studies.

RESULTS

Nine studies deal with the effectiveness of opioids for reducing dyspnea in advanced cancer patients. Five of these found a significant benefit to the use of opioids compared to a placebo. Three found no significant improvements, and two favored combinations of opioids and benzodiazepines. Few high-quality studies were available that used benzodiazepines (n = 3, no difference, significant improvement with midazolam + morphine, significant difference for midazolam) or oxygen (n = 2, both without significant difference). Only one study examined treating dyspnea with steroids in patients with advanced cancer, and that study indicated a benefit of steroids compared to a placebo.

CONCLUSIONS

Opioids are the drug of choice for treating refractory dyspnea in advanced cancer patients. Neither benzodiazepines nor oxygen showed significant benefit. In addition, there is insufficient literature available to draw a conclusion about the effectiveness of steroids for treating persistent dyspnea in advanced cancer patients.

Home oxygen therapy: evidence versus reality

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.

Hand-held Fan Airflow Stimulation Relieves Dyspnea in Lung Cancer Patients

Objective:

The main symptom of lung cancer is dyspnea which can lead to depression, anxiety, limited independent activities, and decreased quality of life. The purpose of this study was to identify the effect of airflow stimulation from a hand-held fan as nonpharmacological palliative intervention on dyspnea in patients with lung cancer.

Methods:

This study used open, randomized, controlled, crossover trial design involved 21 participants. Diaphragmatic breathing technique was used in control arm.

Results:

Wilcoxon test result showed that airflow stimulation significantly influenced dyspnea scale (P = 0.003) and respiratory rate (RR) (P = 0.008). Combination of airflow stimulation and diaphragmatic breathing can lower both dyspnea scale and RR significantly (P < 0.0001).

Conclusions:

This combination can be applied on nonhypoxemic dyspneic lung cancer patients.

Treatment Recommendations for Respiratory Symptoms in Cancer Patients: Clinical Guidelines from the Japanese Society for Palliative Medicine

BACKGROUND

Respiratory symptoms, dyspnea, cough, and death rattle, are common and distressing in advanced cancer patients. Palliation of respiratory symptoms is important to improve quality of life in cancer patients and their families/caregivers. Currently published clinical guidelines for the management of these respiratory symptoms in cancer patients did not cover the topics comprehensively or were not based on formal process for the development of clinical guidelines.

METHODS

The Japanese Society for Palliative Medicine (JSPM) decided to develop comprehensive clinical guidelines for the management of respiratory symptoms in cancer patients following the formal guideline developing process.

RESULTS

This article provides a summary of the recommendations with the rationales, as well as a short summary of the developing process, of the JSPM respiratory symptom management guidelines. We established 26 recommendations and all recommendations are based on the best available evidences and expert consensus.

DISCUSSION

More future clinical researches and continuous guideline updates are required to improve the quality of respiratory symptom management in cancer patients.

Patient considerations and drug selection in the treatment of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease of unknown cause. Approximately 5,000 people are diagnosed with IPF in the UK every year. People with IPF suffer significant morbidity and, without any curative treatment at present, survival rates remain poor with a median survival of 3 years. While treatment remains largely supportive, many drug therapies have been trialed in IPF over the years. Pirfenidone and nintedanib are newly licensed treatments for IPF and the first drugs to have shown convincing evidence of slowing disease progression. In addition to evaluating clinical evidence, we also discuss elements affecting drug choice from the viewpoint of patients and health care professionals. We discuss pharmacological and nonpharmacological aspects of providing best supportive care for patients with IPF. However, few good quality studies exist focusing on controlling symptoms specifically in patients with IPF, and recommendations are often extrapolated from evidence in other chronic diseases. In covering these topics, we hope to provide readers with a comprehensive review of the available evidence pertaining to all aspects of care for patients suffering with IPF.

When should I be considering home oxygen for my patients?

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.

How are palliative care cancer populations characterized in randomized controlled trials? A literature review

CONTEXT

The difficulties in defining a palliative care patient accentuate the need to provide stringent descriptions of the patient population in palliative care research.

OBJECTIVES

To conduct a systematic literature review with the aim of identifying which key variables have been used to describe adult palliative care cancer populations in randomized controlled trials (RCTs).

METHODS

The data sources used were MEDLINE (1950 to January 25, 2010) and Embase (1980 to January 25, 2010), limited to RCTs in adult cancer patients with incurable disease. Forty-three variables were systematically extracted from the eligible articles.

RESULTS

The review includes 336 articles reporting RCTs in palliative care cancer patients. Age (98%), gender (90%), cancer diagnosis (89%), performance status (45%), and survival (45%) were the most frequently reported variables. A large number of other variables were much less frequently reported.

CONCLUSION

A substantial variation exists in how palliative care cancer populations are described in RCTs. Few variables are consistently registered and reported. There is a clear need to standardize the reporting. The results from this work will serve as the basis for an international Delphi process with the aim of reaching consensus on a minimum set of descriptors to characterize a palliative care cancer population.

Defining the palliative care patient: a systematic review

BACKGROUND

The lack of a clear definition of the palliative care patient hampers the comparison of results across different studies and impedes implementation of research findings in everyday practice.

AIM

The aim of this article is to propose minimum characteristics that define a palliative care patient.

DESIGN

The design involved a systematic review of medical literature searching randomised controlled trials (RCTs) in palliative care for clear descriptions of their palliative care patients. We systematically describe relevant characteristics of the study populations of 60 eligible RCTs.

DATA SOURCES

The data sources used were MEDLINE, EMBASE, CINAHL, and PSYCHINFO, including all non-cancer RCTs (1 January 1995-4 March 2010) and an equivalent number of the most recent cancer RCTs (1 January 2003-4 March 2010).

RESULTS

Half of the non-cancer studies were excluded because they did not relate to palliative care. We conclude that published RCTs have no clear definitions of their palliative care patients and illustrate the diversity of this patient, the lack of consensus concerning the attributes of illnesses needing palliation and the ambiguous use of the adjective 'palliative'.

CONCLUSIONS

We propose elements of the patients' health status (e.g. a progressive, life-threatening disease with no possibility of obtaining remission or stabilisation, or modifying the course of the illness) and the care delivered to them (e.g. a holistic interdisciplinary approach that focuses on supporting the quality of the end of life) to be included in the definition of a palliative care patient. We also suggest considering the patients' readiness to accept palliative care and a vision of palliative care shared by the patient and all caregivers involved as potentially important elements in this definition.

Interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis

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.

Update on combined modalities for the management of breathlessness

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.

Humidified high-flow nasal oxygen utilization in patients with cancer at Memorial Sloan-Kettering Cancer Center

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.

Patients' experience of oxygen therapy and dyspnea: a qualitative study in home palliative care

BACKGROUND

Dyspnea is a common and distressing symptom in advanced cancer patients. Our preliminary work shows that in the home palliative care population sampled for this study, the prevalence of dyspnea is 29.5% and of those, 26.2% used oxygen therapy. Previous studies suggested that oxygen therapy can be a burden to patients.

PURPOSE

This study seeks to report the prevalence and describe the experience of dyspnea, pattern of oxygen use, and patients' perceived benefits and/or burdens of oxygen therapy in home palliative care patients receiving oxygen therapy.

METHODS

Qualitative in-depth interviews, using an interview guide, were conducted with eight participants in their homes. Thematic analysis was performed using a framework approach.

RESULTS

All patients in this project used oxygen most of the time. The descriptions of shortness of breath varied and were nonspecific. The patients identified more advantages than disadvantages. The advantages of oxygen use included increased functional capacity, patients' perceiving oxygen as a life-saving intervention, as well as a symptom-management tool. The identified disadvantages were decreased mobility, discomfort related to the nasal prongs, barriers to accessing oxygen therapy and noise related to the equipment.

CONCLUSION

The advantages of oxygen usage outweighed the disadvantages for this sample of patients in the home palliative setting.

Improved oxygen prescribing using a nurse-facilitated reminder

Poor oxygen prescribing and administration is well documented despite junior doctor education and oxygen prescription charts. This prescribing behaviour can be harmful to patients. This study examines whether oxygen prescribing and the appropriateness of oxygen therapy would be increased by medical admissions unit (MAU) nurse education and a nurse-mediated reminder strategy to junior medical staff. A quality improvement study was carried out involving a prospective single centre audit, educational intervention to MAU nurses, and implementation of a nurse-facilitated oxygen prescribing reminder strategy with prospective re-audit. The study took place in a 26-bed MAU in a 678-bed teaching hospital with a lung centre serving a population of 540,000. Fifty-one patients were involved in the initial and re-audits and two nurses were involved in the audit team. A team of 10 acute medical nurses were involved in facilitating the appropriate administration and prescription of oxygen by liaison with junior medical staff. Oxygen prescription and appropriateness of oxygen therapy were measured. Results showed an improvement in oxygen prescribing from 0% to 49% (p < 0.0001). Non-significant improvements in appropriate oxygen prescription (pre- versus post-intervention) overall (70.6% versus 76.5%, p = 0.65); more marked reduction in type 1 respiratory failure errors (18.4% versus 3.8%, p = 0.13) and less marked reduction in type 2 respiratory failure errors (61.3% versus 44.0%, p = 0.49). In conclusion, significant and quick improvements in oxygen prescribing behaviour are achievable through a nurse-facilitated reminder strategy with reduction in inappropriate oxygen prescribing. These strategies are relevant to other ward settings and aspects of patient care.

The national agenda for quality palliative care: promoting the National Consensus Project's domain of physical care and the National Quality Forum's preferred practices for physical aspects of care

The National Consensus Project (NCP) 2004 Clinical Practice Guidelines for Quality Palliative Care defines eight domains of care essential for palliative care clinical practice. The National Quality Forum (NQF) 2006 document entitled A National Framework and Preferred Practices for Palliative and Hospice Care Quality: A Consensus Report is based on the NCP Guidelines. The NQF document identifies 38 evidence-based preferred practices for palliative care. This paper demonstrates how the Guidelines and Preferred Practices may be operationalized by pharmacotherapists to better treat symptoms of debilitating or chronic illnesses falling under Domain 2 of the Guidelines, "Physical Care." Specifically, dementia and dyspnea are used as illustrative examples.

Oxygen for relief of dyspnea: what is the evidence?

PURPOSE OF REVIEW

Refractory dyspnea is a common and distressing symptom complicating respiratory illness, including chronic obstructive pulmonary disease, and life-limiting illnesses in general, including cancer. Oxygen is often prescribed for relief of dyspnea and several consensus guidelines support this practice. The goal of this review is to outline the evidence for the use of oxygen for relief of dyspnea, with specific attention to situations in which oxygen is not already funded through long-term oxygen treatment guidelines (i.e., when PaO2 is >/=55 mmHg; also known as palliative oxygen).

RECENT FINDINGS

Several recent systematic reviews, two focusing on people with chronic obstructive pulmonary disease and the other focusing on people with cancer, strengthen the evidence base behind the use of palliative oxygen for relief of refractory dyspnea, and support the observation that there are subgroups of people who benefit from oxygen, such as individuals with chronic obstructive pulmonary disease.

SUMMARY

The data highlighted in this review support the belief that certain individuals benefit from the use of palliative oxygen but continue to suggest that definitive randomized trials are required to fully establish the benefit of palliative oxygen and to delineate characteristics predictive of benefit.

Interventions for alleviating cancer-related dyspnea: a systematic review

PURPOSE

Dyspnea is one of the most distressing symptoms experienced by terminally ill cancer patients. This study aimed to evaluate the role of interventions for the palliation of dyspnea.

METHODS

We conducted a systematic review of randomized controlled trials assessing all pharmacologic and nonpharmacologic interventions for dyspnea palliation in cancer patients, and searched the Cochrane Library, MEDLINE, conference proceedings, and references. Two reviewers independently appraised the quality of trials and extracted data.

RESULTS

Our search yielded 18 trials. Fourteen evaluated pharmacologic interventions: seven assessing opioids (a total of 256 patients), five assessing oxygen (137 patients), one assessing helium-enriched air, and one assessing furosemide. Four trials evaluated nonpharmacologic interventions (403 patients). The administration of subcutaneous morphine resulted in a significant reduction in dyspnea Visual Analog Scale (VAS) compared with placebo. No difference was observed in dyspnea VAS score when nebulized morphine was compared with subcutaneous morphine, although patients preferred the nebulized route. The addition of benzodiazepines to morphine was significantly more effective than morphine alone, without additional adverse effects. Oxygen was not superior to air for alleviating dyspnea, except for patients with hypoxemia. Nursing-led interventions improved breathlessness. Acupuncture was not beneficial.

CONCLUSION

Our review supports the use of opioids for dyspnea relief in cancer patients. The use of supplemental oxygen to alleviate dyspnea can be recommended only in patients with hypoxemia. Nursing-led nonpharmacologic interventions seem valuable. Only a few studies addressing this question were performed. Thus, further studies evaluating interventions for alleviating dyspnea are warranted.