1
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Julià-Torras J, Moreno-Alonso D, Porta-Sales J, Monforte-Royo C. Episodic breathlessness in patients with cancer: definition, terminology, clinical features - integrative systematic review. BMJ Support Palliat Care 2024; 13:e585-e596. [PMID: 36600405 DOI: 10.1136/spcare-2022-003653] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 11/25/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE Breatlessness flares directly impair quality of life of patients with cancer. The aim of this review was to analyse and synthesise the available information related to its terminology, definition and clinical features in patients with cancer. METHODS Integrative systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Literature search was conducted in MEDLINE PubMed, CINAHLPlus, Web of Science, Cochrane Central Register Controlled Trials CENTRAL, Scopus and OpenAire. RESULTS Data from 1065 patients with cancer included in 12 studies were analysed. The preferred term for breathlessness flares was episodic dyspnoea (ED). The reported frequency of ED was 20.4% (70.9% in patients reporting background dyspnoea (BD)). ED intensity was moderate to severe with short duration (<10 min) in >80% of patients. The most common trigger was exertion (>90%) followed by emotional or environmental factors. ED management consisted mainly of pharmacological and non-pharmacological measures. CONCLUSIONS This systematic review shows that ED is common in patients with cancer, especially in those with BD. Further studies are urgently needed to better understand this condition and to develop specific therapeutic management. PROSPERO REGISTRATION NUMBER CRD42019126708.
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Affiliation(s)
- Joaquim Julià-Torras
- Palliative Care Department, Institut Català d'Oncologia, Badalona, Spain
- School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Deborah Moreno-Alonso
- School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
- Palliative Care Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Spain
| | - Josep Porta-Sales
- School of Medicine and Health Sciences, Universitat Internacional de Catalunya, Barcelona, Spain
- Palliative Care Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Spain
| | - Cristina Monforte-Royo
- Department of Nursing, Universitat Internacional de Catalunya-Campus Sant Cugat, Sant Cugat del Valles, Spain
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2
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Mooren K, Wester D, Kerstjens H, Bergkamp E, Spathis A, Engels Y. Filling the Gap: A Feasibility Study of a COPD-Specific Breathlessness Service. COPD 2022; 19:324-329. [PMID: 36004678 DOI: 10.1080/15412555.2022.2099821] [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: 10/15/2022]
Abstract
Refractory breathlessness is a devastating symptom in chronic obstructive pulmonary disease (COPD). Symptom-focused breathlessness services, involving palliative care teams, offer individualized support but are not yet widely available for people with nonmalignant disease among which COPD. Our primary aim was to demonstrate the feasibility of setting up a breathlessness service specifically for COPD patients within a respiratory outpatient clinic. Our secondary aims were to assess how many sessions patients need to complete the intervention; to obtain an indication of effect size (on the Chronic Respiratory Questionnaire (CRQ), subset mastery domain); and to evaluate patient and professional satisfaction. We conducted a non-randomized single-center feasibility study. Participants had COPD and refractory breathlessness. During at least one session with a respiratory nurse and a pulmonologist, and one session with a physiotherapist, patients learned non-pharmacological interventions to manage breathlessness. Of 34 screened patients, 19 were included. All completed the intervention. A median of two clinical visits and two telephone calls were needed to complete the intervention. The mean improvement of 1.55 in CRQ, mastery domain, significantly exceeded the clinically important difference of 0.5. The service was rated as excellent by the eight patients who completed the survey. The health professional team gave positive feedback on the experience of delivering the intervention. Delivery of a breathlessness service for COPD outpatients with refractory breathlessness appears feasible, easy to implement in a respiratory outpatient clinic, and has the potential to be effective. A randomized controlled clinical trial is needed to test effectiveness and cost-effectiveness in this context.
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Affiliation(s)
- Kris Mooren
- Department of Lung Disease, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands.,Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Danielle Wester
- Department of Lung Disease, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - Huib Kerstjens
- Department of Pulmonary Diseases and Tuberculosis, University of Groningen, and University Medical Centre Groningen, and Groningen Research Center for Asthma and COPD, Groningen, The Netherlands
| | - Erik Bergkamp
- Department of Lung Disease, Spaarne Gasthuis, Haarlem, Noord-Holland, The Netherlands
| | - Anna Spathis
- Department of Public Health and Primary Care, Cambridge University, Cambridge, UK
| | - Yvonne Engels
- Department of Anaesthesiology, Pain and Palliative Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
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3
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Julià-Torras J, Almeida Felipe JM, Gándara Del Castillo Á, González-Barboteo J, Forero D, Alegre S, Cuervo-Pinna MÁ, Serna J, Muñoz-Unceta N, Alonso-Babarro A, Miró Catalina Q, Moreno-Alonso D, Porta-Sales J. Prevalence, Clinical Characteristics, and Management of Episodic Dyspnea in Advanced Lung Cancer Outpatients: A Multicenter Nationwide Study-The INSPIRA-DOS Study. J Palliat Med 2022; 25:1197-1207. [PMID: 35196465 DOI: 10.1089/jpm.2021.0562] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Background: Episodic dyspnea (ED) is a common problem in patients with advanced lung cancer (LC). However, the prevalence of ED and other related aspects in this patient population is not known. Objectives: To assess and describe the prevalence, clinical features, treatment, and risk factors for ED in outpatients with advanced LC. Design: Multicenter cross-sectional study. Subjects: Consecutive sample of adult outpatients with advanced LC. Measurements: We assessed background dyspnea (BD), the characteristics, triggers, and management of ED. Potential ED risk factors were assessed through multivariate logistic regression. Results: A total of 366 patients were surveyed. Overall, the prevalence of ED was 31.9% (90% in patients reporting BD). Patients reported a median of one episode per day (interquartile range [IQR]: 1-2), with a median intensity of 7/10 (IQR: 5-8.25). ED triggers were identified in 89.9% of patients. ED was significantly associated with chronic obstructive pulmonary disease (p = 0.011), pulmonary vascular disease (p = 0.003), cachexia (p = 0.002), and palliative care (p < 0.001). Continuous oxygen use was associated with higher risk of ED (odds ratio: 9.89; p < 0.001). Opioids were used by 44% patients with ED. Conclusions: ED is highly prevalent and severe in outpatients with advanced LC experiencing BD. The association between intrathoracic comorbidities and oxygen therapy points to alveolar oxygen exchange failure having a potential etiopathogenic role in ED in this population. Further studies are needed to better characterize ED in LC to better inform treatments and trial protocols.
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Affiliation(s)
- Joaquim Julià-Torras
- Palliative Care Department, Institut Català d'Oncologia, Badalona, Spain.,School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain
| | - J M Almeida Felipe
- Palliative Care Unit, Complejo Hospitalario Insular Materno Infantil, Las Palmas de Gran Canaria, Spain
| | | | - Jesús González-Barboteo
- Palliative Care Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Spain.,Palliative Care Research Group, EPIBELL Programme, Bellvitge Biomedical Research Institute (IDIBELL), L'Hospitalet de Llobregat (Barcelona), Spain
| | - Diana Forero
- Palliative Care Department, Hospital Universitari Arnau de Vilanova, Lleida, Spain
| | - Salvador Alegre
- Internal Medicine Department, Hospital de San Lázaro, Sevilla, Spain
| | | | - Judit Serna
- Support and Palliative Care Unit, Hospital Universitari Campus Vall d'Hebron, Barcelona, Spain
| | - Nerea Muñoz-Unceta
- Medical Oncology Department, Hospital Universitario 12 de Octubre, Madrid, Spain.,Medical Oncology Department, Hospital Universitario Marqués de Valdecilla and Instituto de Investigación Marqués de Valdecilla (IDIVALL), Santander, Spain
| | | | - Queralt Miró Catalina
- Unitat de Suport a la Recerca de la Catalunya Central, Fundació Institut Universitari per a la Recerca a l'Atenció Primària de Salut Jordi Gol i Gurina, Sant Fruitós de Bages, Spain.,Servei d'Atenció Primària Bages-Berguedà-Moianès, Gerència Territorial de Barcelona, Institut Català de la Salut, Manresa, Spain
| | - Deborah Moreno-Alonso
- School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain.,Palliative Care Department, Institut Català d'Oncologia, L'Hospitalet de Llobregat, Spain
| | - Josep Porta-Sales
- School of Medicine and Health Science, Universitat Internacional de Catalunya, Barcelona, Spain.,Universitat Internacional de Catalunya, Sant Cugat del Vallès-Barcelona, Spain
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4
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Schloesser K, Eisenmann Y, Bergmann A, Simon ST. Development of a Brief Cognitive and Behavioral Intervention for the Management of Episodic Breathlessness-A Delphi Survey With International Experts. J Pain Symptom Manage 2021; 61:963-973.e1. [PMID: 33002596 DOI: 10.1016/j.jpainsymman.2020.09.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 09/21/2020] [Accepted: 09/22/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Episodic breathlessness is characterized by a severe worsening of breathlessness intensity that goes beyond usual fluctuations. Episodes are usually short; therefore, nonpharmacological strategies (cognitive and behavioral) seem most promising to be beneficial. Which strategies-delivered separately or in combination-might be most effective and feasible remains unclear. OBJECTIVES The Delphi survey selects and determines different nonpharmacological strategies for coping with episodic breathlessness to develop a brief cognitive and behavioral intervention for the management of episodic breathlessness. METHODS Using an online Delphi survey comprising three rounds, international, multidisciplinary experts in breathlessness summarized and determined cognitive and behavioral strategies. The a priori target agreement for close-ended questions was 70%. RESULTS Experts (n = 41/87; n = 45/85; n = 36/85) agreed on 15 of the 31 cognitive and behavioral strategies. Based on the panellists' opinion, the final version of the cognitive and behavioral intervention comprised the following characteristics: individually tailored intervention, a high proportion of communication, short duration, the involvement of carers, and use of the Breathing, Thinking, Functioning Model of Spathis et al. Consensus upon the delivery of the subsequent strategies within the intervention was reached: handheld fan, forward lean, diaphragmatic breathing, distraction, pursed lips breathing, long breaths out, and relaxation training. CONCLUSION Using the consented nonpharmacological strategies, a brief cognitive and behavioral intervention was developed that balances between individualization and standardization of the intervention.
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Affiliation(s)
- Karlotta Schloesser
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany.
| | - Yvonne Eisenmann
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany
| | - Anja Bergmann
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany
| | - Steffen T Simon
- Faculty of Medicine and University Hospital, Department of Palliative Medicine, University of Cologne, Cologne, Germany; Faculty of Medicine and University Hospital, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf (CIO ABCD), University of Cologne, Cologne, Germany; Faculty of Medicine and University Hospital, Clinical Trials Center (ZKS), University of Cologne, Cologne, Germany
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5
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Sobanski PZ, Krajnik M, Goodlin SJ. Palliative Care for People Living With Heart Disease-Does Sex Make a Difference? Front Cardiovasc Med 2021; 8:629752. [PMID: 33634172 PMCID: PMC7901984 DOI: 10.3389/fcvm.2021.629752] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 01/14/2021] [Indexed: 12/26/2022] Open
Abstract
The distribution of individual heart disease differs among women and men and, parallel to this, among particular age groups. Women are usually affected by cardiovascular disease at an older age than men, and as the prevalence of comorbidities (like diabetes or chronic pain syndromes) grows with age, women suffer from a higher number of symptoms (such as pain and breathlessness) than men. Women live longer, and after a husband or partner's death, they suffer from a stronger sense of loneliness, are more dependent on institutionalized care and have more unaddressed needs than men. Heart failure (HF) is a common end-stage pathway of many cardiovascular diseases and causes substantial symptom burden and suffering despite optimal cardiologic treatment. Modern, personalized medicine makes every effort, including close cooperation between disciplines, to alleviate them as efficiently as possible. Palliative Care (PC) interventions include symptom management, psychosocial and spiritual support. In complex situations they are provided by a specialized multiprofessional team, but usually the application of PC principles by the healthcare team responsible for the person is sufficient. PC should be involved in usual care to improve the quality of life of patients and their relatives as soon as appropriate needs emerge. Even at less advanced stages of disease, PC is an additional layer of support added to disease modifying management, not only at the end-of-life. The relatively scarce data suggest sex-specific differences in symptom pathophysiology, distribution and the requisite management needed for their successful alleviation. This paper summarizes the sex-related differences in PC needs and in the wide range of interventions (from medical treatment to spiritual support) that can be considered to optimally address them.
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Affiliation(s)
- Piotr Z Sobanski
- Palliative Care Unit and Competence Center, Department of Internal Medicine, Spital Schwyz, Schwyz, Switzerland
| | - Malgorzata Krajnik
- Department of Palliative Care, Collegium Medicum in Bydgoszcz, Nicolaus Copernicus University in Torun, Bydgoszcz, Poland
| | - Sarah J Goodlin
- Geriatrics and Palliative Medicine, Veterans Affairs Portland Health Care System, Department of Medicine, Oregon Health and Sciences University, Patient-Centered Education and Research, Portland, OR, United States
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6
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Higginson IJ, Reilly CC, Maddocks M. Breathlessness. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Abstract
Purpose of Review Palliative care is increasingly acknowledged as beneficial in supporting patients and families affected by heart failure, but policy documents have generally focused on the chronic form of this disease. We examined palliative care provision for those with acute heart failure, based on the recently updated National Consensus Project Clinical Practice Guidelines for Quality Palliative Care. Recent Findings The commonest reason for hospitalization in those > 65 years, acute heart failure admissions delineate crisis points on the unpredictable disease trajectory. Palliative care is underutilized, often perceived as limited to end-of-life care rather than determined by regular systematic needs assessment. No dominant paradigm of palliative care provision has emerged from the nascent evidence base related to this clinical cohort, underscoring the need for further research. Summary Embedding palliative support as mainstream to heart failure care from the point of diagnosis may better ensure treatment strategies for those admitted with acute heart failure remain consistent with patients’ preferences and values.
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8
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Lehto JT, Leivo-Korpela S, Korhonen T, Rantala HA, Raunio H, Lyly-Yrjänäinen T, Lehtimäki L. Mouthpiece ventilation in the management of dyspnea: A single-arm pilot study. Palliat Med 2020; 34:1274-1278. [PMID: 32579086 PMCID: PMC7495670 DOI: 10.1177/0269216320935003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Noninvasive ventilation may relieve dyspnea in advanced diseases, but noninvasive ventilation through mouthpiece has not been tested in palliative care. AIM To assess the feasibility of mouthpiece ventilation in relieving dyspnea among patients with advanced disease. DESIGN In this prospective single-arm pilot study, the change in dyspnea by mouthpiece ventilation was measured with numeric rating scale (0-10) and 100-mm visual analogue scale. Overall, benefit and adverse events of the therapy were also assessed. SETTING/PARTICIPANTS Twenty-two patients with an advanced disease and dyspnea from the Tampere University Hospital or Pirkanmaa Hospice were treated with mouthpiece ventilation. The patients used mouthpiece ventilation as long as they preferred, but for a minimum of 5 min. RESULTS After the treatment period lasting a median of 13.5 min, mean decrease in dyspnea was -1.1 (95 % confidence interval = -2.2 to -0.1, p = 0.034) on numeric rating scale and -11.8 mm (95 % confidence interval = -19.9 to -3.7, p = 0.006) on visual analogue scale. Nonetheless, there was a high variability in this effect between individual patients. About half of the patients found mouthpiece ventilation beneficial. No serious adverse events occurred, but dry mouth was the most common adverse event. Anxiety did not increase with mouthpiece ventilation. CONCLUSION Mouthpiece ventilation is feasible and may relieve dyspnea in some patients with an advanced disease. Further studies are needed, and these might concentrate on stable patients in early palliative care. Before initiation, this study was registered at clinicaltrials.gov (study no. NCT03012737).
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Affiliation(s)
- Juho T Lehto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Palliative Care Centre and Tays Cancer Centre, Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Sirpa Leivo-Korpela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland
| | - Tarja Korhonen
- Pirkanmaa Hospice, Palliative Care Centre, Tampere University Hospital, Tampere, Finland
| | - Heidi A Rantala
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland
| | - Hanna Raunio
- Palliative Care Centre and Tays Cancer Centre, Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Tiina Lyly-Yrjänäinen
- Palliative Care Centre and Tays Cancer Centre, Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland
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9
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Why treatment efficacy on breathlessness in laboratory but not daily life trials? The importance of standardized exertion. Curr Opin Support Palliat Care 2020; 13:179-183. [PMID: 31246594 DOI: 10.1097/spc.0000000000000444] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW Treatments for chronic breathlessness, including opioids and oxygen, have shown efficacy in the controlled laboratory setting, whereas effects have been inconsistent or absent in trials in daily life. This review discusses the lack of standardized exertion as a potential cause of false negative findings for breathlessness in daily life. RECENT FINDINGS The level of breathlessness can be modified by patients by changing their level of physical activity. Effects of opioids and oxygen have been shown at standardized level of exertion (iso-time) but not at the end of symptom-limited (peak) exertion. Trials in daily life reporting no effects on breathlessness did not standardize the exertion or employed insensitive methods, such as the 6-min walk test that should not be used for measuring breathlessness. Novel tests - the 3-min walk and stepping tests have been validated in chronic obstructive pulmonary disease and are responsive for measuring change in breathlessness. SUMMARY Breathlessness should be measured at standardized exertion, otherwise treatment effects may be biased or overlooked. Tests for valid measurement of breathlessness in clinical practice and daily life are available and emerging.
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Episodic Breathlessness with and without Background Dyspnea in Advanced Cancer Patients Admitted to an Acute Supportive Care Unit. Cancers (Basel) 2020; 12:cancers12082102. [PMID: 32751099 PMCID: PMC7464712 DOI: 10.3390/cancers12082102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/21/2020] [Accepted: 07/23/2020] [Indexed: 12/18/2022] Open
Abstract
Aim: To characterize episodic breathlessness (EB) in patients with advanced cancer, and to determine factors influencing its clinical appearance. Methods: A consecutive sample of advanced cancer patients admitted to an acute palliative care unit was surveyed. Continuous dyspnea and EB were measured by a numerical scale. The use of drugs used for continuous dyspnea and EB was recorded. Patients were asked about the characteristics of EB (frequency, intensity, duration and triggers). The Multidimensional dyspnea profile (MDP), the Brief dyspnea inventory (BDI), the Athens sleep scale (AIS) and the Hospital Anxiety and Depression Scale (HADS) were also administered. Results: From 439 advanced cancer patients surveyed, 34 and 27 patients had EB, without and with background dyspnea, respectively. The mean intensity and the number of episodes were higher in patients with background dyspnea (p < 0.0005 and p = 0.05, respectively). No differences in duration were observed. Most episodes lasted <10 min. A recognizable cause triggering EB was often found. The presence of both background dyspnea and EB was associated with higher values of MDP and BDI. EB was independently associated with frequency and intensity of background dyspnea (OR = 20.9, 95% CI (Confidence interval) 9.1–48.0; p < 0.0005 and OR = 1.97, 95% CI 1.09–3.58; p = 0.025, respectively) and a lower Karnofsky level (OR = 0.96, 95%CI 0.92–0.98, p = 0.05). Discussion: EB may occur in patients with and without continuous dyspnea, and is often induced by physical and psychological factors. EB intensity is higher in patients with continuous dyspnea. The duration was often so short that the use of drugs, as needed, may be too late, unless administered pre-emptively when the trigger was predictable.
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Maddocks M, Brighton LJ, Farquhar M, Booth S, Miller S, Klass L, Tunnard I, Yi D, Gao W, Bajwah S, Man WDC, Higginson IJ. Holistic services for people with advanced disease and chronic or refractory breathlessness: a mixed-methods evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background
Breathlessness is a common and distressing symptom of many advanced diseases, affecting around 2 million people in the UK. Breathlessness increases with disease progression and often becomes chronic or refractory. Breathlessness-triggered services that integrate holistic assessment and specialist palliative care input as part of a multiprofessional approach have been developed for this group, offering tailored interventions to support self-management and reduce distress.
Objectives
The aim was to synthesise evidence on holistic breathlessness services for people with advanced disease and chronic or refractory breathlessness. The objectives were to describe the structure, organisation and delivery of services, determine clinical effectiveness, cost-effectiveness and acceptability, identify predictors of treatment response, and elicit stakeholders’ evidence-based priorities for clinical practice, policy and research.
Design
The mixed-methods evidence synthesis comprised three components: (1) a systematic review to determine the clinical effectiveness, cost-effectiveness and acceptability of holistic breathlessness services; (2) a secondary analysis of pooled individual data from three trials to determine predictors of clinical response; and (3) a transparent expert consultation (TEC), comprising a stakeholder workshop and an online consensus survey, to identify stakeholders’ priorities.
Results
Thirty-seven papers reporting on 18 holistic breathlessness services were included in the systematic review. Most studies enrolled people with thoracic cancer, were delivered over 4–6 weeks, and included breathing training, relaxation techniques and psychological support. Meta-analysis demonstrated significant reductions in the Numeric Rating Scale (NRS) distress due to breathlessness, significant reductions in the Hospital Anxiety and Depressions Scale (HADS) depression scores, and non-significant reductions in the Chronic Respiratory Disease Questionnaire (CRQ) mastery and HADS anxiety, favouring the intervention. Recipients valued education, self-management interventions, and expertise of the staff in breathlessness and person-centred care. Evidence for cost-effectiveness was limited and inconclusive. The responder analysis (n = 259) revealed baseline CRQ mastery and NRS distress to be strong predictors of the response to breathlessness services assessed by these same measures, and no significant influence from baseline breathlessness intensity, patient diagnosis, lung function, health status, anxiety or depression. The TEC elicited 34 priorities from stakeholders. Seven priorities received high agreement and consensus, reflecting stakeholders’ (n = 74) views that services should be person-centred and multiprofessional, share their breathlessness management skills with others, and recognise the roles and support needs of informal carers.
Limitations
The evidence synthesis draws predominantly from UK services and may not be generalisable to other settings. Some meta-analyses were restricted by reporting biases and statistical heterogeneity.
Conclusions
Despite heterogeneity in composition and delivery, holistic breathlessness services are highly valued by recipients and can lead to significant improvements in the distress caused by breathlessness and depression. Outcomes of improved mastery and reduced distress caused by breathlessness are not influenced by patient diagnosis, lung function or health status. Stakeholders highlighted the need for improved access to person-centred, multiprofessional breathlessness services and support for informal carers.
Future work
Our research suggests that key therapeutic components of holistic breathlessness services be considered in clinical practice and models of delivery and educational strategies to address stakeholders’ priorities tested.
Study registration
This study is registered as PROSPERO CRD42017057508.
Funding
The National Institute for Health Research (NIHR) Health Services and Delivery programme. Matthew Maddocks, Wei Gao and Irene J Higginson are supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London; Matthew Maddocks is supported by a NIHR Career Development Fellowship (CDF-2017-009), William D-C Man is supported by the NIHR CLAHRC Northwest London and Irene J Higginson holds a NIHR Emeritus Senior Investigator Award.
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Affiliation(s)
- Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Lisa Jane Brighton
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Sara Booth
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Sophie Miller
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Lara Klass
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - India Tunnard
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - William D-C Man
- National Heart and Lung Institute, Imperial College London, London, UK
- Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
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12
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Swan F, English A, Allgar V, Hart SP, Johnson MJ. The Hand-Held Fan and the Calming Hand for People With Chronic Breathlessness: A Feasibility Trial. J Pain Symptom Manage 2019; 57:1051-1061.e1. [PMID: 30802635 DOI: 10.1016/j.jpainsymman.2019.02.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/18/2019] [Accepted: 02/18/2019] [Indexed: 11/29/2022]
Abstract
CONTEXT The battery-operated hand-held fan ("fan") and the Calming Hand (CH), a cognitive strategy, are interventions used in clinical practice to relieve chronic breathlessness. OBJECTIVE To test the feasibility of a Phase III randomized controlled trial (RCT) evaluating the impact of the fan and/or CH compared with exercise advice alone for the relief of chronic breathlessness due to respiratory conditions. METHODS A single-site, feasibility "2 × 2" factorial, nonblinded, mixed-methods RCT was performed. Participants randomly allocated to four groups: fan + exercise advice, CH + exercise advice, fan + CH + exercise advice, and exercise advice alone. Measures included recruitment, acceptability, data quality and study outcomes (baseline and day 28), modified Incremental Shuttle Walk Test (mISWT), recovery time from exertion-induced breathlessness, life-space questionnaire, General Self-Efficacy Scale, and breathlessness numerical rating scales. Willing participants and carers were interviewed at study end. RESULTS Recruitment/acceptability/data completion: 53 people were screened, 40 randomized and completed (mean age 72 years (SD 9.8), 70% male). There were few missing data (mISWT, n = 2). Recovery time (seconds) from exertion-induced breathlessness showed most improvement for the fan; mean reduction from baseline -33.5 vs. CH mean increase from baseline 5.7. This represents a recovery speed at day 28 (-20.4%) faster for the fan vs. 4.1% slower for the CH. Qualitative data indicated participants valued the faster recovery and identified the fan as a useful "medical" device but found the CH unhelpful. CONCLUSION A Phase III RCT is feasible. Mixed-methods data synthesis supports recovery time as a novel, meaningful outcome measure.
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Affiliation(s)
- Flavia Swan
- Wolfson Palliative Care Research Centre, Allam Medical Building, Hull York Medical School (HYMS), University of Hull, Hull, UK.
| | | | - Victoria Allgar
- Hull York Medical School (HYMS), Department of Health Sciences, University of York, Heslington, York, UK
| | - Simon P Hart
- Respiratory Research Group, Hull York Medical School, Castle Hill Hospital, Cottingham, Hull, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School (HYMS), University of Hull, Hull, UK
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13
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Julià-Torras J, Cuervo-Pinna MÁ, Cabezón-Gutiérrez L, Lara PC, Prats M, Margarit C, Porta-Sales J. Definition of Episodic Dyspnea in Cancer Patients: A Delphi-Based Consensus among Spanish Experts: The INSPIRA Study. J Palliat Med 2018; 22:413-419. [PMID: 30452307 DOI: 10.1089/jpm.2018.0273] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Episodic dyspnea is an increasingly recognized phenomenon that occurs frequently in patients with cancer. Although numerous definitions have been proposed to describe episodic dyspnea, to date, no common widely accepted definition in Spanish has yet emerged. Without a clear well-accepted definition, it is difficult to design rigorous clinical trials to evaluate candidate treatments for this emerging entity and to compare outcomes among studies. OBJECTIVE The aim of the study was to reach a consensus definition of episodic dyspnea in the Spanish language based on professional criteria in cancer patients. DESIGN A two-round Delphi study. SETTING/SUBJECTS Sixty-one Spanish specialists in medical oncology, radiation oncology, pneumology, palliative care, and pain management participated in the study. MEASUREMENTS Sixteen different questions on dyspnea-related terminology, including the definition of episodic dyspnea, were assessed. RESULTS The panel of experts reached a consensus on 75% of the 16 assessments proposed: 56.25% in agreement and 18.75% in disagreement. The term that most panelists considered most appropriate to define dyspnea exacerbation was dyspnea crisis. The panelists disagreed that dyspnea exacerbation is equivalent to dyspnea at effort and that the presence of dyspnea at rest is required for exacerbation to occur. However, there was wide agreement that exacerbation may or may not be predictable and can be triggered by comorbidities as well as emotional, environmental, or effort factors. CONCLUSIONS The broad consensus reached in this study is a necessary first step to design high-quality methodological studies to better understand episodic dyspnea and improve treatment.
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Affiliation(s)
- Joaquim Julià-Torras
- 1 Comprehensive Support Service-Palliative Care, Institut Català d'Oncologia , Badalona, Spain
| | | | - Luis Cabezón-Gutiérrez
- 3 Medical Oncology Service, Hospital Universitario de Torrejón , Torrejón de Ardoz, Spain
| | - Pedro C Lara
- 4 Radiation Oncology Service, Hospital Universitario San Roque/Universidad Fernando Pessoa Canarias, Spain
| | - Marisol Prats
- 5 Pneumology Service, Hospital Universitari Germans Trias i Pujol , Badalona, Catalonia, Spain
| | - César Margarit
- 6 Pain Unit, Hospital General Universitario de Alicante , Alicante, Spain
| | - Josep Porta-Sales
- 7 Palliative Care Service, Institut Català d'Oncologia (ICO), Bellvitge Biomedical Research Institute (IDIBELL) , WeCare Chair: End of Life Care, Universitat Internacional de Catalunya, Barcelona, Spain
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Palliative and end-of-life care for adults with advanced chronic obstructive pulmonary disease: a rapid review focusing on patient and family caregiver perspectives. Curr Opin Support Palliat Care 2018; 11:315-327. [PMID: 28957884 DOI: 10.1097/spc.0000000000000303] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW The aim of the review was to explore patient and family caregiver perspectives on key issues for ensuring quality of end-of-life care for people with chronic obstructive pulmonary disease (COPD). The growing evidence on the value of specialist palliative care services demonstrates significant improvements in treatments and provisions; however, much of the literature is generic in nature or centred on people with a cancer diagnosis. In this review, we examine the literature to ascertain the views and needs of patients and carers affected by advanced COPD, a highly debilitating condition that can have a profoundly negative impact on the quality of end-of-life experience. RECENT FINDINGS A total of 19 papers were included in the review. The main themes in the literature were Holistic Care, Illness Trajectory and Technology. SUMMARY Areas of unmet need emphasized across physical, psychosocial and spiritual domains were identified, particularly in relation to appropriate and timely conversations. Positive developments in the care and treatment of advanced COPD include the use of the STIOLTO Respimat inhaler, a brief educative and psychosocial intervention based on cognitive-behavioural therapy, and high-intensity exercise training. There is some evidence regarding the use of technology in end-stage COPD.
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15
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Stowe E, Wagland R. A qualitative exploration of distress associated with episodic breathlessness in advanced lung cancer. Eur J Oncol Nurs 2018; 34:76-81. [PMID: 29784142 DOI: 10.1016/j.ejon.2018.03.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 03/22/2018] [Accepted: 03/26/2018] [Indexed: 11/18/2022]
Abstract
PURPOSE Breathlessness is a distressing symptom, particularly common in those with advanced lung cancer. Previous research has identified the symptom occurrence of episodic breathlessness, identifying average frequency, duration and severity of episodes, but has not explored the distress specifically associated with these episodes. This study explored the distress associated with episodic breathlessness for adults with advanced cancer and the relative impact of three elements; frequency, duration or severity. METHODS Semi-structured interviews were conducted with four participants with advanced lung cancer. Analysis adopted an interpretative phenomenological approach. RESULTS A complex relationship existed between distress caused by episodic breathlessness and its frequency, duration and severity for study participants. Episodic breathlessness had a significant impact on participant's perceptions of self and previous experience effected how distressed they were by their breathlessness. The emotional work created by the symptom was considerable for individuals. CONCLUSION The study highlights the importance of recognizing symptoms as a combination of different experiences that may each cause different levels of distress. Initial evidence is provided that the emotional work involved for patients to self-manage each separate element of breathlessness should be considered in its treatment.
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Affiliation(s)
- Emily Stowe
- St Clare Hospice, Hastingwood Road, Hastingwood, Essex, CM17 9JX, United Kingdom.
| | - Richard Wagland
- Faculty of Health Sciences, Building 67, Highfield, University of Southampton, SO17 1BJ, United Kingdom.
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16
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Alpert CM, Smith MA, Hummel SL, Hummel EK. Symptom burden in heart failure: assessment, impact on outcomes, and management. Heart Fail Rev 2018; 22:25-39. [PMID: 27592330 DOI: 10.1007/s10741-016-9581-4] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Evidence-based management has improved long-term survival in patients with heart failure (HF). However, an unintended consequence of increased longevity is that patients with HF are exposed to a greater symptom burden over time. In addition to classic symptoms such as dyspnea and edema, patients with HF frequently suffer additional symptoms such as pain, depression, gastrointestinal distress, and fatigue. In addition to obvious effects on quality of life, untreated symptoms increase clinical events including emergency department visits, hospitalizations, and long-term mortality in a dose-dependent fashion. Symptom management in patients with HF consists of two key components: comprehensive symptom assessment and sufficient knowledge of available approaches to alleviate the symptoms. Successful treatment addresses not just the physical but also the emotional, social, and spiritual aspects of suffering. Despite a lack of formal experience during cardiovascular training, symptom management in HF can be learned and implemented effectively by cardiology providers. Co-management with palliative medicine specialists can add significant value across the spectrum and throughout the course of HF.
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Affiliation(s)
- Craig M Alpert
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael A Smith
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA.,Department of Pharmacy Services, University of Michigan Health System, Ann Arbor, MI, USA
| | - Scott L Hummel
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ellen K Hummel
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. .,Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA. .,University of Michigan Frankel Cardiovascular Center, 1500 East Medical Center Dr., SPC 5233, Ann Arbor, MI, 48109-5233, USA.
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Mercadante S. Episodic Breathlessness in Patients with Advanced Cancer: Characteristics and Management. Drugs 2018; 78:543-547. [DOI: 10.1007/s40265-018-0879-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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18
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Mercadante S, Fusco F, Caruselli A, Cartoni C, Masedu F, Valenti M, Aielli F. Background and episodic breathlessness in advanced cancer patients followed at home. Curr Med Res Opin 2017; 33:155-160. [PMID: 27707006 DOI: 10.1080/03007995.2016.1240668] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The aim of this study was to assess the phenomenon of episodic breathlessness in advanced cancer patients followed by palliative care services at home. METHODS A consecutive sample of patients with advanced cancer, admitted to home care for a period of six months, was surveyed. The presence of background breathlessness and episodic breathlessness, their intensity, and drugs used for their treatment were collected. Factors inducing episodic breathlessness, and its influence on daily activities were investigated. RESULTS Three hundred forty-seven advanced cancer patients admitted to home palliative care were surveyed. The prevalence of breathlessness was 35.3%. The mean intensity of breathlessness was 3.8 (SD 1.96), out of a maximum score of 10 for worst imaginable. Sixty patients (49.2%) were receiving drugs for background breathlessness. In the multivariate analysis the risk of breathlessness increased with cardiovascular disease, chronic obstructive pulmonary disease, and lung cancer while it decreased in patients with a better performance status. The prevalence of episodic breathlessness in patients with background breathlessness was 79.5% and its mean intensity was 7.1 (SD 1.5, range 2-10). The mean duration of episodic breathlessness was 28.6 minutes (SD 47.1, range 1-300 minutes). Forty-three patients (44.3%) were receiving one or more drugs as needed. The majority of episodic breathlessness events were triggered by activity. Episodic breathlessness was interfering with daily activities in 65 patients (67%). Episodic breathlessness wasn't associated with any variable taken into consideration. CONCLUSION This study showed that episodic breathlessness frequently occurs in advanced cancer patients admitted to home care, is severe in intensity, is triggered in most cases by activity, and is characterized by a short duration which requires rapid measures.
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Affiliation(s)
| | - Flavio Fusco
- b Palliative Home Care Unit , ASL 3 , Genova , Italy
| | | | - Claudio Cartoni
- d Home Care Service of the Rome Section of the Italian Association Against Leukemias , Rome , Italy
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19
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Simon ST, Higginson IJ, Booth S, Harding R, Weingärtner V, Bausewein C. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev 2016; 10:CD007354. [PMID: 27764523 PMCID: PMC6464146 DOI: 10.1002/14651858.cd007354.pub3] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND This is an updated version of the original Cochrane review published in Issue 1, 2010, on 'Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults'. Breathlessness is one of the most common symptoms experienced in the advanced stages of malignant and non-malignant disease. Benzodiazepines are widely used for the relief of breathlessness in advanced diseases and are regularly recommended in the literature. At the time of the previously published Cochrane review, there was no evidence for a beneficial effect of benzodiazepines for the relief of breathlessness in people with advanced cancer and chronic obstructive pulmonary disease (COPD). OBJECTIVES The primary objective of this review was to determine the efficacy of benzodiazepines for the relief of breathlessness in people with advanced disease. Secondary objectives were to determine the efficacy of different benzodiazepines, different doses of benzodiazepines, different routes of application, adverse effects of benzodiazepines, and the efficacy in different disease groups. SEARCH METHODS This is an update of a review published in 2010. We searched 14 electronic databases up to September 2009 for the original review. We checked the reference lists of all relevant studies, key textbooks, reviews, and websites. For the update, we searched CENTRAL, MEDLINE, and EMBASE and registers of clinical trials for further ongoing or unpublished studies, up to August 2016. We contacted study investigators and experts in the field of palliative care asking for further studies, unpublished data, or study details when necessary. SELECTION CRITERIA We included randomised controlled trials (RCTs) and controlled clinical trials (CCTs) assessing the effect of benzodiazepines compared with placebo or active control in relieving breathlessness in people with advanced stages of cancer, chronic obstructive pulmonary disease (COPD), chronic heart failure (CHF), motor neurone disease (MND), and idiopathic pulmonary fibrosis (IPF). DATA COLLECTION AND ANALYSIS Two review authors independently assessed identified titles and abstracts. Three review authors independently performed assessment of all potentially relevant studies (full text), data extraction, and assessment of methodological quality. We carried out meta-analysis where appropriate. MAIN RESULTS Overall, we identified eight studies for inclusion: seven in the previous review and an additional study for this update. We also identified two studies awaiting classification in this update. The studies were small (a maximum number of 101 participants) and comprised data from a total of 214 participants with advanced cancer or COPD, which we analysed. There was only one study of low risk of bias. Most of the studies had an unclear risk of bias due to lack of information on random sequence generation, concealment, and attrition. Analysis of all studies did not show a beneficial effect of benzodiazepines for the relief of breathlessness (the primary outcome) in people with advanced cancer and COPD (8 studies, 214 participants) compared to placebo, midazolam, morphine, or promethazine. Furthermore, we observed no statistically significant effect in the prevention of episodic breathlessness (breakthrough dyspnoea) in people with cancer (after 48 hours: risk ratio of 0.76 (95% CI 0.53 to 1.09; 2 studies, 108 participants)) compared to morphine. Sensitivity analyses demonstrated no statistically significant differences regarding type of benzodiazepine, dose, route and frequency of delivery, duration of treatment, or type of control. Benzodiazepines caused statistically significantly more adverse events, particularly drowsiness and somnolence, when compared to placebo (risk difference 0.74 (95% CI 0.37, 1.11); 3 studies, 38 participants). In contrast, two studies reported that morphine caused more adverse events than midazolam (RD -0.18 (95% CI -0.31, -0.04); 194 participants). AUTHORS' CONCLUSIONS Since the last version of this review, we have identified one new study for inclusion, but the conclusions remain unchanged. There is no evidence for or against benzodiazepines for the relief of breathlessness in people with advanced cancer and COPD. Benzodiazepines caused more drowsiness as an adverse effect compared to placebo, but less compared to morphine. Benzodiazepines may be considered as a second- or third-line treatment, when opioids and non-pharmacological measures have failed to control breathlessness. There is a need for well-conducted and adequately powered studies.
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Affiliation(s)
- Steffen T Simon
- Institute of Palliative Care (ipac)Jägerstr. 64‐66OldenburgGermany26121
- University Hospital of CologneDepartment of Palliative MedicineCologneGermany
- King's College LondonDepartment of Palliative Care, Policy and Rehabilitation, Cicely Saunders InstituteLondonUK
| | - Irene J Higginson
- King's College LondonDepartment of Palliative Care, Policy and Rehabilitation, Cicely Saunders InstituteLondonUK
| | - Sara Booth
- Cambridge University HospitalsDepartment of Palliative CareCambridgeUK
| | - Richard Harding
- King's College LondonDepartment of Palliative Care, Policy and Rehabilitation, Cicely Saunders InstituteLondonUK
| | - Vera Weingärtner
- University Hospital of CologneDepartment of Palliative MedicineCologneGermany
| | - Claudia Bausewein
- LMU MunichDepartment of Palliative Medicine, Munich University HospitalMarchioninistr. 15MunichGermany81377
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Smith AK, Currow DC, Abernethy AP, Johnson MJ, Miao Y, Boscardin WJ, Ritchie CS. Prevalence and Outcomes of Breathlessness in Older Adults: A National Population Study. J Am Geriatr Soc 2016; 64:2035-2041. [PMID: 27603500 DOI: 10.1111/jgs.14313] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence and outcomes of breathlessness in older Americans. SETTING Community-dwelling older adults. PARTICIPANTS Individuals aged 70 and older in the nationally representative Health and Retirement Study (2008, follow-up through 2012) (N = 3,671; mean age 78). MEASUREMENTS Breathlessness was assessed by asking the question, "How often do you become short of breath while awake?" Responses of often or sometimes were considered to represent a level of breathlessness sufficient to warrant clinical attention. The prevalence of breathlessness is described overall and in subpopulations, then rates of associated symptoms, well-being, and health services use of participants who were breathless are compared with rates of those who were not. The risk of decline in activities of daily living (ADLs) and death through 2012 was estimated by creating a multivariable Cox proportional hazards model, adjusting for age, sex, race and ethnicity, and education. RESULTS Twenty-five percent of participants reported breathlessness. The prevalence of breathlessness was higher in certain subpopulations: chronic lung disease (63%), multimorbidity (≥2 chronic conditions) (45%), current smokers (38%), heart disease (36%), obesity (body mass index ≥30.0 kg/m2 ) (33%), and education less than high school (32%). Breathlessness was associated with higher rates of depression, anxiety, and severe fatigue; lower ratings of well-being; and higher rates of clinic and emergency department visits and hospitalizations (all P < .001). Breathlessness predicted ADL decline over 5 years (adjusted hazard ratio (aHR) = 1.43, 95% confidence interval (CI) = 1.22-1.68) and death (aHR 1.62, 95% CI = 1.32-2.02). CONCLUSION One in four adults aged 70 and older in the United States experiences breathlessness, which is associated with lack of well-being, greater health services use, and a 40% greater risk of worsened function and 60% greater risk of death over the next 5 years.
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Affiliation(s)
- Alexander K Smith
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California. .,San Francisco Veterans Affairs Medical Center, San Francisco, California.
| | - David C Currow
- Discipline of Supportive and Palliative Care, Flinders University, Bedford Park, South Australia, Australia
| | - Amy P Abernethy
- Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.,Division of Medical Oncology, Department of Medicine, Duke University, Durham, North Carolina
| | - Miriam J Johnson
- Hull York Medical School, The University of Hull, Hull, East Yorkshire, United Kingdom
| | - Yinghui Miao
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Discipline of Supportive and Palliative Care, Flinders University, Bedford Park, South Australia, Australia
| | - W John Boscardin
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Christine S Ritchie
- Division of Geriatrics, Department of Medicine, University of California, San Francisco, San Francisco, California.,Jewish Home of San Francisco, San Francisco, California
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21
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Cabezón-Gutiérrez L, Khosravi-Shahi P, Custodio-Cabello S, Muñiz-González F, Cano-Aguirre MDP, Alonso-Viteri S. Opioids for management of episodic breathlessness or dyspnea in patients with advanced disease. Support Care Cancer 2016; 24:4045-55. [PMID: 27334130 DOI: 10.1007/s00520-016-3316-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Accepted: 06/13/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Episodic breathlessness (EB) or dyspnea is a common symptom with a very negative impact on the quality of life of patients with cancer and with non-oncological advanced diseases, mainly cardiorespiratory and neurological. OBJECTIVE The purpose of this non-systematic review is to ascertain the role played by opioids in the management of episodic breathlessness. METHODS A non-systematic literature review was done in the databases MEDLINE, COCHRANE, and DATABASE, and articles of greater scientific rigor, mainly reviews or prospective studies/randomized clinical trials published to date (August 2015), were selected. Terms used in the search included episodic breathlessness, acute breathlessness, episodic dyspnea, opioids, morphine, fentanyl, oxycodone, and breakthrough dyspnea. CONCLUSIONS Although the pathophysiology and mechanism of action of opioids for management of breathlessness, and specifically EB, are not fully known, there is scientific evidence, and particularly great clinical evidence, of the benefit of this drug class for dyspnea management. It is important to differentiate hospitalized patients from outpatients because venous or subcutaneous access is easier in hospitalized patients, but use of transmucosal fentanyl, especially in faster formulations like intranasal application, opens up new possibilities to manage outpatients due to its fast onset of action. The main problem is the lack of data available and the multitude of unanswered questions about opioid type, administration route, safety, and dose titration.
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Affiliation(s)
- Luis Cabezón-Gutiérrez
- Medical Oncology Department, Hospital Universitario de Torrejón, Mateo Inurria Street s/n, CP 28850, Torrejón de Ardoz, Madrid, Spain.
| | - Parham Khosravi-Shahi
- Medical Oncology Department, Hospital Universitario de Torrejón, Mateo Inurria Street s/n, CP 28850, Torrejón de Ardoz, Madrid, Spain
| | - Sara Custodio-Cabello
- Medical Oncology Department, Hospital Universitario de Torrejón, Mateo Inurria Street s/n, CP 28850, Torrejón de Ardoz, Madrid, Spain
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Simon ST, Weingärtner V, Higginson IJ, Benalia H, Gysels M, Murtagh FEM, Spicer J, Linde P, Voltz R, Bausewein C. "I Can Breathe Again!" Patients' Self-Management Strategies for Episodic Breathlessness in Advanced Disease, Derived From Qualitative Interviews. J Pain Symptom Manage 2016; 52:228-34. [PMID: 27220949 DOI: 10.1016/j.jpainsymman.2016.02.016] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2015] [Revised: 01/22/2016] [Accepted: 02/13/2016] [Indexed: 01/21/2023]
Abstract
CONTEXT Episodic breathlessness causes additional distress to breathless patients with advanced disease, but management is still insufficient and there is a lack of knowledge on effective coping strategies. OBJECTIVES The aim was to explore patients' self-management strategies for episodic breathlessness. METHODS In-depth interviews with patients suffering from episodic breathlessness as a result of chronic heart failure, chronic obstructive pulmonary disease, lung cancer, or motor neuron disease were conducted. Interviews were transcribed verbatim and analyzed guided by the analytic hierarchy of Framework analysis. RESULTS A total of 51 participants were interviewed (15 chronic heart failure, 14 chronic obstructive pulmonary disease, 13 lung cancer, and nine motor neuron disease; age, mean [SD], 68 [12], 41% women, median Karnofsky index 60%). They described six main strategies for coping with episodes of breathlessness: reduction of physical exertion, cognitive and psychological strategies, breathing techniques and positions, air and oxygen, drugs and medical devices, and environmental and other strategies. Some strategies were used in an opposing way, e.g., concentrating on the breathing vs. distraction from any thoughts of breathlessness or laying down flat vs. standing up and raising hands. CONCLUSION Patients used a number of different strategies to cope with episodic breathlessness, adding more detailed understanding of existing strategies for breathlessness. The findings, therefore, may provide a valuable aid for health care providers, affected patients, and their relatives.
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Affiliation(s)
- Steffen T Simon
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany; Center of Integrated Oncology (CIO) Cologne/Bonn, University Hospital of Cologne, Cologne, Germany; Institute of Palliative Care, Oldenburg, Germany.
| | - Vera Weingärtner
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany
| | - Irene J Higginson
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation-WHO Collaborating Centre for Palliative Care and Older People, King's College London, London, United Kingdom
| | - Hamid Benalia
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation-WHO Collaborating Centre for Palliative Care and Older People, King's College London, London, United Kingdom
| | - Marjolein Gysels
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation-WHO Collaborating Centre for Palliative Care and Older People, King's College London, London, United Kingdom
| | - Fliss E M Murtagh
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation-WHO Collaborating Centre for Palliative Care and Older People, King's College London, London, United Kingdom
| | - James Spicer
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation-WHO Collaborating Centre for Palliative Care and Older People, King's College London, London, United Kingdom; Division of Cancer Studies, King's College London, London, United Kingdom
| | - Philipp Linde
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany; Center of Integrated Oncology (CIO) Cologne/Bonn, University Hospital of Cologne, Cologne, Germany
| | - Raymond Voltz
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany; Center of Integrated Oncology (CIO) Cologne/Bonn, University Hospital of Cologne, Cologne, Germany
| | - Claudia Bausewein
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation-WHO Collaborating Centre for Palliative Care and Older People, King's College London, London, United Kingdom; Department for Palliative Medicine, University Hospital Munich, Munich, Germany
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Johnson MJ, Booth S, Currow DC, Lam LT, Phillips JL. A Mixed-Methods, Randomized, Controlled Feasibility Trial to Inform the Design of a Phase III Trial to Test the Effect of the Handheld Fan on Physical Activity and Carer Anxiety in Patients With Refractory Breathlessness. J Pain Symptom Manage 2016; 51:807-15. [PMID: 26880253 DOI: 10.1016/j.jpainsymman.2015.11.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Revised: 11/27/2015] [Accepted: 12/01/2015] [Indexed: 11/26/2022]
Abstract
CONTEXT The handheld fan is an inexpensive and safe way to provide facial airflow, which may reduce the sensation of chronic refractory breathlessness, a frequently encountered symptom. OBJECTIVES To test the feasibility of developing an adequately powered, multicenter, multinational randomized controlled trial comparing the efficacy of a handheld fan and exercise advice with advice alone in increasing activity in people with chronic refractory breathlessness from a variety of medical conditions, measuring recruitment rates; data quality; and potential primary outcome measures. METHODS This was a Phase II, multisite, international, parallel, nonblinded, mixed-methods randomized controlled trial. Participants were centrally randomized to fan or control. All received breathlessness self-management/exercise advice and were followed up weekly for four weeks. Participants/carers were invited to participate in a semistructured interview at the study's conclusion. RESULTS Ninety-seven people were screened, 49 randomized (mean age 68 years; 49% men), and 43 completed the study. Site recruitment varied from 0.25 to 3.3/month and screening:randomization from 1.1:1 to 8.5:1. There were few missing data except for the Chronic Obstructive Pulmonary Disease Self-Efficacy Scale (two-thirds of data missing). No harms were observed. Three interview themes included 1) a fan is a helpful self-management strategy, 2) a fan aids recovery, and 3) a symptom control trial was welcome. CONCLUSION A definitive, multisite trial to study the use of the handheld fan as part of self-management of chronic refractory breathlessness is feasible. Participants found the fan useful. However, the value of information for changing practice or policy is unlikely to justify the expense of such a trial, given perceived benefits, the minimal costs, and an absence of harms demonstrated in this study.
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Affiliation(s)
- Miriam J Johnson
- Palliative Medicine, Hull York Medical School, University of Hull, Hull, United Kingdom.
| | - Sara Booth
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
| | - David C Currow
- Palliative & Supportive Services, Flinders University, Daw Park, South Australia, Australia
| | - Lawrence T Lam
- Department of Health and Education, The Hong Kong Institute of Education, Hong Kong SAR, China
| | - Jane L Phillips
- Centre for Cardiovascular and Chronic Care, Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia
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Johnson MJ, Close L, Gillon SC, Molassiotis A, Lee PH, Farquhar MC. Use of the modified Borg scale and numerical rating scale to measure chronic breathlessness: a pooled data analysis. Eur Respir J 2016; 47:1861-4. [PMID: 26989107 DOI: 10.1183/13993003.02089-2015] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 01/24/2016] [Indexed: 02/04/2023]
Affiliation(s)
| | | | | | - Alex Molassiotis
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Paul H Lee
- School of Nursing, The Hong Kong Polytechnic University, Hung Hom, Hong Kong
| | - Morag C Farquhar
- Primary Care Unit, Dept of Public Health and Primary Care, University of Cambridge, Institute of Public Health, Cambridge, UK
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Mercadante S, Aielli F, Adile C, Valle A, Fusco F, Ferrera P, Caruselli A, Cartoni C, Marchetti P, Bellavia G, Cortegiani A, Masedu F, Valenti M, Porzio G. Epidemiology and Characteristics of Episodic Breathlessness in Advanced Cancer Patients: An Observational Study. J Pain Symptom Manage 2016; 51:17-24. [PMID: 26416339 DOI: 10.1016/j.jpainsymman.2015.07.020] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 06/29/2015] [Accepted: 07/13/2015] [Indexed: 11/15/2022]
Abstract
CONTEXT Episodic breathlessness is a relevant aspect in patients with advanced cancer. OBJECTIVES The aim of this study was to assess the different aspects of this clinical phenomenon. METHODS A consecutive sample of patients with advanced cancer admitted to different settings for a period of six months was surveyed. The presence of background breathlessness and episodic breathlessness, their intensity (numerical scale 0-10), and drugs used for treatment were collected. Factors inducing episodic breathlessness and its influence on daily activities were investigated. RESULTS Of 921 patients, 29.3% (n = 269) had breathlessness and 134 patients (49.8%) were receiving drugs for background breathlessness. In the multivariate analysis, the risk of breathlessness increased with chronic obstructive pulmonary disease, although it decreased in patients receiving disease-oriented therapy and patients with gastrointestinal tumors. The prevalence of episodic breathlessness was 70.9% (n = 188), and its mean intensity was 7.1 (SD 1.6). The mean duration of untreated episodic breathlessness was 19.9 minutes (SD 35.3); 41% of these patients were receiving drugs for episodic breathlessness. The majority of episodic breathlessness events (88.2%) were triggered by activity. In the multivariate analysis, higher Karnofsky Performance Status levels were significantly related to episodic breathlessness, although patients receiving disease-oriented therapy were less likely to have episodic breathlessness. CONCLUSION This study showed that episodic breathlessness frequently occurs in patients with breathlessness in the advanced stage of disease, has a severe intensity, and is characterized by rapid onset and short duration, which require rapid measures.
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Affiliation(s)
| | - Federica Aielli
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy; "L'Aquila per la Vita" Home Care Unit, L'Aquila, Italy
| | - Claudio Adile
- Pain Relief and Supportive Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | | | | | - Patrizia Ferrera
- Pain Relief and Supportive Care Unit, La Maddalena Cancer Center, Palermo, Italy
| | | | - Claudio Cartoni
- Division of Hematology, Department of Cellular Biotechnologies and Hematology, Policlinico Umberto I, Home Care Service of the Rome Section of the Italian Association Against Leukemias (Rome AIL), Rome, Italy
| | - Paolo Marchetti
- Clinical and Molecular Medicine Department, Sapienza University, Sant'Andrea Hospital, Rome, Italy
| | | | - Andrea Cortegiani
- Section of Anesthesia, Analgesia, Intensive Care and Emergency, Department of Biopathology, Medical and Forensic Biotechnologies, Policlinico "P. Giaccone", University of Palermo, Palermo, Italy
| | - Francesco Masedu
- Section of Clinical Epidemiology and Environmental Medicine, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marco Valenti
- Section of Clinical Epidemiology and Environmental Medicine, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Giampiero Porzio
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy; "L'Aquila per la Vita" Home Care Unit, L'Aquila, Italy
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Greer JA, MacDonald JJ, Vaughn J, Viscosi E, Traeger L, McDonnell T, Pirl WF, Temel JS. Pilot Study of a Brief Behavioral Intervention for Dyspnea in Patients With Advanced Lung Cancer. J Pain Symptom Manage 2015; 50:854-60. [PMID: 26166181 DOI: 10.1016/j.jpainsymman.2015.06.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2015] [Revised: 06/07/2015] [Accepted: 06/27/2015] [Indexed: 10/23/2022]
Abstract
CONTEXT Dyspnea is a common symptom in patients with advanced cancer that interferes with functional ability and quality of life (QOL). Although few evidence-based treatments for dyspnea exist, prior studies show support for nonpharmacological interventions that include elements of cognitive-behavioral therapy. OBJECTIVES To examine the feasibility and utility of delivering a brief behavioral intervention for dyspnea in patients with lung cancer. METHODS For this single-group pilot study, eligible patients included those with advanced lung cancer (Stage III or IV non-small cell or extensive-stage small cell lung cancer) receiving outpatient cancer treatment who reported at least moderate breathlessness. The manualized intervention consisted of two sessions in which nurse practitioners taught participants breathing and relaxation techniques within the infusion clinic and encouraged home practice. Participants completed measures of breathlessness (Modified Medical Research Council Dyspnea Scale), QOL (Functional Assessment of Cancer Therapy-Lung Trial Outcome Index), and anxiety and depression symptoms (Hospital Anxiety and Depression Scale) at baseline and within six weeks after enrollment. RESULTS Of the 32 patients enrolled in the study (56.3% females; mean age 63.34 [SD] = 7.96 years), 84.4% (N = 27) completed all study procedures. Comparing the baseline to postassessments, we found significant improvements in Modified Medical Research Council Dyspnea Scale (P < 0.001), Functional Assessment of Cancer Therapy-Lung Trial Outcome Index (P = 0.01), and Hospital Anxiety and Depression Scale-depression subscale (P < 0.001) scores. CONCLUSION In this sample of patients with advanced lung cancer and dyspnea, we observed a high completion rate for the two-session behavioral intervention. Patients also reported improvements in dyspnea, QOL, and mood. Follow-up randomized controlled trials are needed to examine the efficacy of brief behavioral interventions for cancer-related dyspnea.
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Affiliation(s)
- Joseph A Greer
- Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA.
| | - James J MacDonald
- Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Jeanne Vaughn
- Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Elene Viscosi
- Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Lara Traeger
- Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Theresa McDonnell
- Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
| | - William F Pirl
- Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Massachusetts General Hospital Cancer Center & Harvard Medical School, Boston, Massachusetts, USA
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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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Gysels M, Reilly CC, Jolley CJ, Pannell C, Spoorendonk F, Bellas H, Madan P, Moxham J, Higginson IJ, Bausewein C. How does a new breathlessness support service affect patients? Eur Respir J 2015; 46:1515-8. [PMID: 26381516 DOI: 10.1183/13993003.00751-2015] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 07/31/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Marjolein Gysels
- King's College London, Cicely Saunders Institute, Dept of Palliative Care, Policy and Rehabilitation, London, UK Centre for Social Science and Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles C Reilly
- King's College London, Cicely Saunders Institute, Dept of Palliative Care, Policy and Rehabilitation, London, UK Physiotherapy, King's College Hospital NHS Foundation Trust, London, UK
| | - Caroline J Jolley
- King's College London, Dept of Asthma, Allergy and Respiratory Science, London, UK Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Caty Pannell
- King's College London, Cicely Saunders Institute, Dept of Palliative Care, Policy and Rehabilitation, London, UK
| | - Femke Spoorendonk
- King's College London, Cicely Saunders Institute, Dept of Palliative Care, Policy and Rehabilitation, London, UK
| | - Helene Bellas
- Physiotherapy, King's College Hospital NHS Foundation Trust, London, UK
| | - Preety Madan
- Occupational Therapy, King's College Hospital NHS Foundation Trust, London, UK
| | - John Moxham
- King's College London, Dept of Asthma, Allergy and Respiratory Science, London, UK Respiratory Medicine, King's College Hospital NHS Foundation Trust, London, UK
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute, Dept of Palliative Care, Policy and Rehabilitation, London, UK
| | - Claudia Bausewein
- King's College London, Cicely Saunders Institute, Dept of Palliative Care, Policy and Rehabilitation, London, UK Dept of Palliative Medicine, University Hospital Munich, Munich, Germany
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Kloke M, Cherny N. Treatment of dyspnoea in advanced cancer patients: ESMO Clinical Practice Guidelines. Ann Oncol 2015; 26 Suppl 5:v169-73. [PMID: 26314777 DOI: 10.1093/annonc/mdv306] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2023] Open
Affiliation(s)
- M Kloke
- Department of Palliative Medicine and Institute for Palliative Care, Kliniken Essen-Mitte, Academic Teaching Hospital University Essen-Duisburg, Essen, Germany
| | - N Cherny
- Department of Medical Oncology, Shaare Zedek Medical Center, Jerusalem, Israel
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Management of acute breathlessness in the person with chronic refractory breathlessness. Curr Opin Support Palliat Care 2015; 9:212-6. [PMID: 26147913 DOI: 10.1097/spc.0000000000000153] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to synthesize the current literature on classification and management of acute breathlessness that occurs in patients who are living with chronic refractory breathlessness related to cancer, cardiopulmonary, or neuromuscular disease. RECENT FINDINGS In the context of chronic refractory breathlessness, acute breathlessness can be classified as either episodic breathlessness or breathlessness crisis. Episodic breathlessness is characterized by the severity, duration, and predictability of the symptom, and by the presence or absence of a trigger such as exertion, emotion, or an environmental factor. Breathlessness crisis is more sustained, occurs at rest, and overwhelms the patient's and caregivers' coping abilities, similar to the nontriggered unpredictable types of episodic breathlessness. Treatment of acute breathlessness focuses on alleviating the episode as quickly as possible without escalating medical intervention that may not be consistent with the patient's treatment preferences. SUMMARY Attention to breathlessness in the published literature has increased exponentially in the past two decades. The challenge is now to translate the research findings into relief of symptoms, suffering, and distress in those who suffer from acute and chronic breathlessness because of chronic illness.
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Weingärtner V, Scheve C, Gerdes V, Schwarz-Eywill M, Prenzel R, Otremba B, Mühlenbrock J, Bausewein C, Higginson IJ, Voltz R, Herich L, Simon ST. Characteristics of episodic breathlessness as reported by patients with advanced chronic obstructive pulmonary disease and lung cancer: Results of a descriptive cohort study. Palliat Med 2015; 29:420-8. [PMID: 25634633 DOI: 10.1177/0269216314563428] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Episodic breathlessness is one form of refractory breathlessness. Better understanding of the symptom is necessary for effective management. AIM The aim was to describe the characteristics of episodic breathlessness in patients with advanced chronic obstructive pulmonary disease or lung cancer. DESIGN This is a longitudinal cohort study. Outcomes were assessed monthly by up to 13 telephone interviews: peak severity (modified Borg scale: 0-10), duration, frequency, and timing of breathlessness episodes. Data from each episode were pooled and analyzed using descriptive statistics. Associations between outcomes were explored by correlation coefficients. SETTING/PARTICIPANTS Patients with chronic obstructive pulmonary disease (Global Initiative for Chronic Obstructive Lung Disease classification stage III or IV) or primary lung cancer (any stage) were recruited in two inpatient units (internal medicine) and two outpatient clinics in Oldenburg, Germany. RESULTS A total of 82 patients (50 chronic obstructive pulmonary disease, 32 lung cancer), mean age (standard deviation) 67 years (8 years) and 36% female, were included reporting on 592 breathlessness episodes (chronic obstructive pulmonary disease: 403, lung cancer: 189). Peak severity was perceived significantly higher in chronic obstructive pulmonary disease patients than in lung cancer patients (mean (standard deviation) Borg scale: 6.2 (2.1) vs 4.2 (1.9); p < 0.001). Episodes described by chronic obstructive pulmonary disease patients were longer than those described by lung cancer patients (median (range): 7 min (0-600) vs 5 min (0.3-120), p = 0.002)). Frequency was similar and most often daily in both groups. Severity and frequency of episodes were correlated in lung cancer patients (r = 0.324, p = 0.009). CONCLUSION Most breathlessness episodes are short (minutes) and severe with significant differences between chronic obstructive pulmonary disease and lung cancer patients. Effective management strategies are warranted to improve symptom relief and coping.
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Affiliation(s)
- Vera Weingärtner
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany Institute of Palliative Care (ipac) e.V. (BMBF 16KT0951), Oldenburg, Germany
| | - Christine Scheve
- Institute of Palliative Care (ipac) e.V. (BMBF 16KT0951), Oldenburg, Germany Department of Palliative Medicine, Protestant Hospital Oldenburg, Oldenburg, Germany
| | - Verena Gerdes
- Institute of Palliative Care (ipac) e.V. (BMBF 16KT0951), Oldenburg, Germany
| | | | - Regina Prenzel
- Clinic for Internal Medicine, Pius-Hospital Oldenburg, Oldenburg, Germany
| | | | - Juliane Mühlenbrock
- Department of Palliative Medicine, Protestant Hospital Oldenburg, Oldenburg, Germany
| | - Claudia Bausewein
- Institute of Palliative Care (ipac) e.V. (BMBF 16KT0951), Oldenburg, Germany Department for Palliative Medicine, University Hospital Munich, Munich, Germany
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation-WHO Collaborating Centre for Palliative Care and Older People, King's College London, London, UK
| | - Raymond Voltz
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany Clinical Trials Unit (BMBF 01KN1106), University Hospital of Cologne, Cologne, Germany Centre for Integrated Oncology (CIO) Köln Bonn, University Hospital of Cologne, Cologne, Germany
| | - Lena Herich
- Institute of Medical Statistics, Informatics and Epidemiology (IMSIE), University Hospital of Cologne, Cologne, Germany
| | - Steffen T Simon
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany Institute of Palliative Care (ipac) e.V. (BMBF 16KT0951), Oldenburg, Germany Clinical Trials Unit (BMBF 01KN1106), University Hospital of Cologne, Cologne, Germany Centre for Integrated Oncology (CIO) Köln Bonn, University Hospital of Cologne, Cologne, Germany
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Reply: Episodic breathlessness: a clinically relevant and rising issue. Ann Am Thorac Soc 2014; 11:274-5. [PMID: 24575999 DOI: 10.1513/annalsats.201312-437le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Abstract
The aim of this paper is to review the evidence for a role for opioids as an intervention for exertion induced breathlessness with regard to exercise tolerance and breathlessness intensity. Current knowledge about exogenous opioids in exertion-induced breathlessness due to disease comes from a variety of phase 2 feasibility or pilot designs with differing duration, doses, drugs, exercise regimes, underlying aetiologies, and outcome measures. They provide interesting data but firm conclusions for either breathlessness severity or exercise endurance cannot be drawn. There are no adequately powered phase 3 trials of opioids which show improved exercise tolerance and/or exertion induced breathlessness. Low dose oral morphine seems well tolerated by most, and is beneficial for breathlessness intensity. Current work to investigate the effect on exercise tolerance is ongoing.
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Affiliation(s)
- Miriam J. Johnson
- Hull York Medical School, The University of Hull, Hull, United Kingdom
| | - David Hui
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David C. Currow
- Discipline, Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia
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Weingaertner V, Scheve C, Gerdes V, Schwarz-Eywill M, Prenzel R, Bausewein C, Higginson IJ, Voltz R, Herich L, Simon ST. Breathlessness, functional status, distress, and palliative care needs over time in patients with advanced chronic obstructive pulmonary disease or lung cancer: a cohort study. J Pain Symptom Manage 2014; 48:569-81.e1. [PMID: 24613784 DOI: 10.1016/j.jpainsymman.2013.11.011] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 11/13/2013] [Accepted: 11/21/2013] [Indexed: 11/30/2022]
Abstract
CONTEXT Breathlessness is a distressing symptom in advanced disease. Understanding its patterns, burden, and palliative care (PC) needs over time is important to improve patients' quality of life. OBJECTIVES To describe and compare the courses of refractory breathlessness, functional status, distress, and PC needs in patients with advanced chronic obstructive pulmonary disease (COPD) or lung cancer (LC) over time. METHODS This was a cohort study of patients with COPD (Stage III/IV) or LC. Data were assessed monthly with up to 12 telephone interviews, using the modified Borg Scale, Karnofsky Performance Status Scale, Distress Thermometer, and Palliative care Outcome Scale as outcomes measures. Descriptive analysis compared all outcomes between COPD and LC at baseline and over time (forward from study entry and backward from death). RESULTS A total of 82 patients (50 COPD and 32 LC), mean (SD) age of 67.2 (7.8), and 36% female were included (8 COPD and 23 LC deceased). The patients with COPD perceived higher levels of breathlessness and distress at lower functional status steadily over time. The LC patients' breathlessness, distress, and PC needs increased, whereas functional status decreased toward death. The PC needs were similar between disease groups. Breathlessness was negatively correlated with functional status (COPD=mean r=-0.20, P=0.012; LC=mean r=-0.277, P=0.029) and positively correlated with PC needs in COPD patients (mean r=0.343, P<0.001). Death was significantly predicted by diagnosis (LC: hazard ratio=7.84, P<0.001) and functional status (10% decline: hazard ratio=1.52, P=0.001). CONCLUSION The PC needs of patients with advanced COPD are comparable with LC patients, and breathlessness severity and distress are even higher. The care for COPD patients requires further improvement to address symptom burden and PC needs.
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Affiliation(s)
- Vera Weingaertner
- Department of Palliative Medicine, Clinical Trials Unit (BMBF 01KN1106), and Centre for Integrated Oncology Cologne/Bonn (CIO), University Hospital of Cologne, Germany; Institute of Palliative Care (BMBF 16KT0951), Oldenburg, Germany
| | - Christine Scheve
- Institute of Palliative Care (BMBF 16KT0951), Oldenburg, Germany
| | - Verena Gerdes
- Institute of Palliative Care (BMBF 16KT0951), Oldenburg, Germany
| | | | - Regina Prenzel
- Clinic for Internal Medicine, Pius-Hospital Oldenburg, Oldenburg, Germany
| | - Claudia Bausewein
- Institute of Palliative Care (BMBF 16KT0951), Oldenburg, Germany; Department for Palliative Medicine, University Hospital Munich, Munich, Germany
| | - Irene J Higginson
- Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation-WHO Collaborating Centre for Palliative Care and Older People, King's College London, London, United Kingdom
| | - Raymond Voltz
- Department of Palliative Medicine, Clinical Trials Unit (BMBF 01KN1106), and Centre for Integrated Oncology Cologne/Bonn (CIO), University Hospital of Cologne, Germany
| | - Lena Herich
- Institute of Medical Statistics, Informatics and Epidemiology, University Hospital of Cologne, Cologne, Germany
| | - Steffen T Simon
- Department of Palliative Medicine, Clinical Trials Unit (BMBF 01KN1106), and Centre for Integrated Oncology Cologne/Bonn (CIO), University Hospital of Cologne, Germany; Institute of Palliative Care (BMBF 16KT0951), Oldenburg, Germany.
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Simon ST, Weingärtner V, Higginson IJ, Voltz R, Bausewein C. Definition, categorization, and terminology of episodic breathlessness: consensus by an international Delphi survey. J Pain Symptom Manage 2014; 47:828-38. [PMID: 24095285 DOI: 10.1016/j.jpainsymman.2013.06.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Revised: 06/10/2013] [Accepted: 06/16/2013] [Indexed: 01/15/2023]
Abstract
CONTEXT Episodic breathlessness is a common and distressing symptom in patients with advanced disease. Still, it is not yet clearly defined. OBJECTIVES The aim of this work was to develop an international definition, categorization, and terminology of episodic breathlessness. METHODS An online Delphi survey was conducted with international breathlessness experts. We used a structured questionnaire to identify specific aspects and reach agreement on a definition, categorization, and terminology (five-point Likert scale). Consensus was defined in advance as ≥70% agreement. RESULTS Thirty-one of 68 (45.6%), 29 of 67 (43.3%), and 33 of 67 (49.3%) experts responded in the first, second, and third rounds, respectively. Participants were 20-79 years old, about 60% male, and more than 75% rated their own breathlessness expertise as moderate to high. After three rounds, consensus was reached on a definition, categorization, and terminology (84.4%, 96.3%, and 92.9% agreement). The final definition includes general and qualitative aspects of the symptom, for example, time-limited severe worsening of intensity or unpleasantness of breathlessness in the patient's perception. Categories are predictable or unpredictable, depending on whether any triggers can be identified. CONCLUSION There is high agreement on clinical and operational aspects of episodic breathlessness in advanced disease among international experts. The consented definition and categorization may serve as a catalyst for clinical and basic research to improve symptom control and patients' quality of life.
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Affiliation(s)
- Steffen T Simon
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany; Centre for Integrated Oncology Cologne/Bonn, Clinical Trials Centre Cologne (BMBF 01KN1106), Cologne, Germany.
| | - Vera Weingärtner
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany
| | - Irene J Higginson
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation-WHO Collaborating Centre for Palliative Care and Older People, London, United Kingdom
| | - Raymond Voltz
- Department of Palliative Medicine, University Hospital of Cologne, Cologne, Germany; Centre for Integrated Oncology Cologne/Bonn, Clinical Trials Centre Cologne (BMBF 01KN1106), Cologne, Germany
| | - Claudia Bausewein
- King's College London, Cicely Saunders Institute, Department of Palliative Care, Policy and Rehabilitation-WHO Collaborating Centre for Palliative Care and Older People, London, United Kingdom; Department for Palliative Medicine, University Hospital of Munich, Munich, Germany
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Hadjiphilippou S, Odogwu SE, Dand P. Doctors’ attitudes towards prescribing opioids for refractory dyspnoea: a single-centred study. BMJ Support Palliat Care 2014; 4:190-192. [DOI: 10.1136/bmjspcare-2013-000565] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 01/06/2014] [Accepted: 02/13/2014] [Indexed: 11/04/2022]
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Simon ST, Altfelder N, Alt-Epping B, Bausewein C, Weingärtner V, Voltz R, Ostgathe C, Radbruch L, Lindena G, Nauck F. Is breathlessness what the professional says it is? Analysis of patient and professionals’ assessments from a German nationwide register. Support Care Cancer 2014; 22:1825-32. [DOI: 10.1007/s00520-014-2131-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 01/13/2014] [Indexed: 10/25/2022]
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Simon ST, Köskeroglu P, Gaertner J, Voltz R. Fentanyl for the relief of refractory breathlessness: a systematic review. J Pain Symptom Manage 2013; 46:874-86. [PMID: 23742735 DOI: 10.1016/j.jpainsymman.2013.02.019] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2012] [Revised: 02/03/2013] [Accepted: 02/18/2013] [Indexed: 11/30/2022]
Abstract
CONTEXT Fentanyl is a potent opioid that has been proven to provide effective treatment for breakthrough cancer pain. Although opioids are the only drug group with evidence for the symptomatic treatment of breathlessness, evidence about the efficacy of fentanyl for the relief of breathlessness is unknown. OBJECTIVES We performed a systematic review to evaluate the current evidence for the use of fentanyl for the relief of breathlessness. METHODS The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendation for systematic reviews. Four databases (MEDLINE, EMBASE, Cochrane Library, International Pharmaceutical Abstracts) were screened using "fentanyl" and "dyspnoea" (and synonyms) as search terms. Hand search and contact with relevant authors completed the search. RESULTS A total of 622 references were retrieved, 13 of which met the inclusion criteria for this review. Two randomized controlled trials (RCTs) evaluated fentanyl for breathlessness, but one only included two patients. The other studies were before-after (n = 2) and case studies (n = 9). All studies reported successful relief of breathlessness after fentanyl application, but the only (pilot-) RCT failed to demonstrate a statistically significant difference compared with placebo. The nature and incidence of adverse events were comparable with other opioids, and no respiratory depression was observed. CONCLUSION Descriptive studies yielded promising results for the use of fentanyl for the relief of breathlessness; however, efficacy trials are lacking. Fully powered RCTs are warranted to determine the efficacy of fentanyl for breathlessness relief, but these require pilot studies to evaluate effective size, study procedures, and outcome measures.
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Affiliation(s)
- Steffen T Simon
- Center of Palliative Medicine and Clinical Trials Unit (BMBF 01KN1106), University Hospital of Cologne, Cologne, Germany; Center for Integrated Oncology Cologne-Bonn, University Hospital of Cologne, Cologne, Germany.
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Weingärtner V, Bausewein C, Higginson IJ, Scheve C, Murtagh FEM, Voltz R, Simon ST. Characterizing episodic breathlessness in patients with advanced disease. J Palliat Med 2013; 16:1275-9. [PMID: 24053592 DOI: 10.1089/jpm.2013.0087] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Episodic breathlessness is a common and distressing symptom in advanced cancer and nonmalignant diseases but there is a lack of evidence on the characteristics of the symptom. OBJECTIVE The aim of this study was to determine the duration, severity, frequency and timing of breathlessness episodes in patients with advanced diseases. METHODS Explorative analysis of pooled cross-sectional data on episodic breathlessness collected in personal interviews with patients suffering from chronic obstructive pulmonary disease, lung cancer, chronic heart failure, or motor neuron disease. Interviews were conducted as part of two studies in the UK and in Germany that included the same questions on duration, frequency, timing, and peak severity of breathlessness episodes. Severity was measured on the modified Borg scale (0-10). RESULTS One hundred and twenty-nine patients, 61% male, mean age of 67 years (SD 9.8), were included. The episodes described were mainly short (75%≤10 min), severe (mean 6.5 (SD 2.4), and occurred mostly daily. Frequency of episodes triggered by exertion could hardly be determined as these varied depending on patients' activity. CONCLUSION Our study reveals clinically important information on the characteristics of episodic breathlessness in patients with advanced diseases. Findings have implications for the treatment of episodic breathlessness since most short-acting drugs in use have a longer onset of action compared to the duration of episodes. We need to determine patient-relevant therapeutic targets for future evaluation of adequate pharmacological and nonpharmacological management options that are urgently warranted.
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Affiliation(s)
- Vera Weingärtner
- 1 Department of Palliative Medicine, Center of Integrated Oncology (BMBF O1KN1106), Cologne/Bonn and Clinical Trials Unit, University Hospital of Cologne , Cologne, Germany
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Bausewein C, Simon ST. Shortness of breath and cough in patients in palliative care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2013; 110:563-71; quiz 572. [PMID: 24069091 DOI: 10.3238/arztebl.2013.0563] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Accepted: 06/19/2013] [Indexed: 01/11/2023]
Abstract
BACKGROUND Shortness of breath and cough are common, disturbing symptoms in patients receiving palliative care. They arise in 10% to 70% of patients with advanced cancer and in 60% to nearly 100% of patients with non-malignant underlying diseases, depending on the type of disease. METHODS This review is based on a selective literature search in the Medline, Embase, and PsycInfo databases and on current recommendations from Germany and other countries, as well as on the authors' personal experience. RESULTS Some general measures to address these problems are reassurance, development of an emergency plan, physical activity, and relaxation exercises. Supportive non-pharmacological measures may include the use of a rollator (level of evidence [LoE] 1-), a cool draft of air as from a handheld fan (LoE 1-), physiotherapy, and respiratory therapy. There is good evidence (LoE 1+) to support the administration of opioids as the medications of choice; benzodiazepines are often used, but a meta-analysis did not reveal any statistically significant benefit (LoE 1+). Expectorants can help patients who cough with marked sputum formation. Antitussants suppress the cough reflex both peripherally and centrally (LoE 1+ to 3). Opioids, including morphine (LoE 1-) and dextromethorphan (LoE 1-), are effective antitussants with low toxicity. CONCLUSION In most patients, shortness of breath and cough can be relieved by a series of therapeutic measures.
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Malik FA, Gysels M, Higginson IJ. Living with breathlessness: a survey of caregivers of breathless patients with lung cancer or heart failure. Palliat Med 2013; 27:647-56. [PMID: 23703238 DOI: 10.1177/0269216313488812] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Breathlessness is a common, distressing symptom in patients with advanced disease. With increasing focus on home death for patients, carers are expected to support breathless people at home. Little is known about how carers experience breathlessness and the differences in caring for someone with breathlessness and malignant or non-malignant disease. AIM To compare experiences of caring for a breathless patient with lung cancer versus those with heart failure and to examine factors associated with caregiver burden and positive caring experiences. DESIGN Cross-sectional survey of caregivers of breathless patients. SETTING/PARTICIPANTS Participants were recruited from two London hospitals. INCLUSION CRITERIA caregivers of patients with breathlessness and heart failure or lung cancer. Measures included self-completion of Short Form version of Zarit Burden Interview, a 'positive caring experiences' scale and Palliative Care Outcome Scale. We compared caregiver reports between heart failure and lung cancer. Multiple regression analyses were used to examine factors related to burden and positive caring experiences. RESULTS In total, 51 heart failure and 50 lung cancer caregivers were recruited. Most were spouses (72%) and women (80%). Severity of patient breathlessness was similar in both groups. Caregiver concerns were mostly similar across conditions. Higher burden was associated with poorer 'quality of patient care' and worse carer psychological health (R (2) = 0.37, F = 12.2, p = 0.01). Caregiver depression and looking after more breathless patients were associated with fewer positive caring experiences (R (2) = 0.15, F = 4.4, p = 0.04). CONCLUSIONS Those who care for breathless patients report high levels of unmet needs and burden, equally severe for heart failure and lung cancer caregivers. Caregivers of patients with more severe breathlessness report fewer positive caring experiences and should be targeted by services with increased support in managing this symptom.
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Affiliation(s)
- Farida A Malik
- The Department of Palliative Care, Policy & Rehabilitation, King's College School of Medicine, Cicely Saunders Institute, London SE5 9JP, UK.
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Simon ST, Higginson IJ, Benalia H, Gysels M, Murtagh FE, Spicer J, Bausewein C. Episodes of breathlessness: types and patterns - a qualitative study exploring experiences of patients with advanced diseases. Palliat Med 2013; 27:524-32. [PMID: 23486931 DOI: 10.1177/0269216313480255] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite the high prevalence and impact of episodic breathlessness, information about characteristics and patterns is scarce. AIM To explore the experience of patients with advanced disease suffering from episodic breathlessness, in order to describe types and patterns. DESIGN AND PARTICIPANTS Qualitative design using in-depth interviews with patients suffering from advanced stages of chronic heart failure, chronic obstructive pulmonary disease, lung cancer or motor neurone disease. As part of the interviews, patients were asked to draw a graph to illustrate typical patterns of breathlessness episodes. Interviews were tape-recorded, transcribed verbatim and analysed using Framework Analysis. The graphs were grouped according to their patterns. RESULTS Fifty-one participants (15 chronic heart failure, 14 chronic obstructive pulmonary disease, 13 lung cancer and 9 motor neurone disease) were included (mean age 68.2 years, 30 of 51 men, mean Karnofsky 63.1, mean breathlessness intensity 3.2 of 10). Five different types of episodic breathlessness were described: triggered with normal level of breathlessness, triggered with predictable response (always related to trigger level, e.g. slight exertion causes severe breathlessness), triggered with unpredictable response (not related to trigger level), non-triggered attack-like (quick onset, often severe) and wave-like (triggered or non-triggered, gradual onset). Four patterns of episodic breathlessness could be identified based on the graphs with differences regarding onset and recovery of episodes. These did not correspond with the types of breathlessness described before. CONCLUSION Patients with advanced disease experience clearly distinguishable types and patterns of episodic breathlessness. The understanding of these will help clinicians to tailor specific management strategies for patients who suffer from episodes of breathlessness.
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Affiliation(s)
- Steffen T Simon
- Department of Palliative Care, Policy & Rehabilitation - WHO Collaborating Centre for Palliative Care and Older People, Cicely Saunders Institute, King's College London, London, UK.
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