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Johnson MJ, Pitel L, Currow DC, Forbes C, Soyiri I, Robinson L. Breathlessness limiting exertion in very old adults: findings from the Newcastle 85+ study. Age Ageing 2023; 52:afad155. [PMID: 37658750 PMCID: PMC10474592 DOI: 10.1093/ageing/afad155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/09/2023] [Indexed: 09/05/2023] Open
Abstract
INTRODUCTION Long-term breathlessness is more common with age. However, in the oldest old (>85 years), little is known about the prevalence, or impact of breathlessness. We estimated breathlessness limiting exertion prevalence and explored (i) associated characteristics; and (ii) whether breathlessness limiting exertion explains clinical and social/functional outcomes. METHODS Health and socio-demographic characteristics were extracted from the Newcastle 85+ Study cohort. Phase 1 (baseline) and follow-up data (18 months, Phase 2; 36 months, Phase 3; 60 months, Phase 4 after baseline) were examined using descriptive statistics and cross-sectional regression models. RESULTS Eight hundred seventeen participants provided baseline breathlessness data (38.2% men; mean 84.5 years; SD 0.4). The proportions with any limitation of exertion, or severe limitation by breathlessness were 23% (95% confidence intervals (CIs) 20-25%) and 9% (95%CIs 7-11%) at baseline; 20% (16-25%) and 5% (3-8%) at Phase 4. Having more co-morbidities (odds ratio (OR) 1.34, 1.18-1.54; P < 0.001), or self-reported respiratory (OR 1.88, 1.25-2.82; P = 0.003) or cardiovascular disease (OR 2.38, 1.58-3.58; P < 0.001) were associated with breathlessness limiting exertion. Breathlessness severely limiting exertion was associated with poorer self-rated health (OR 0.50, 029-0.86; P = 0.012), depression (beta-coefficient 0.11, P = 0.001), increased primary care contacts (beta-co-efficient 0.13, P = 0.001) and number of nights in hospital (OR 1.81; 1.02-3.20; P = 0.042). CONCLUSIONS Breathlessness limiting exertion appears to become less prevalent over time due to death or withdrawal of participants with cardio-respiratory illness. Breathlessness severely limiting exertion had a wide range of service utilisation and wellbeing impacts.
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Affiliation(s)
- Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lukas Pitel
- Hull Health Trials Unit, Hull York Medical School, University of Hull, Hull, UK
| | - David C Currow
- Department of Medicine and Health, University of Wollongong, Wollongong, NSW, Australia
| | - Cynthia Forbes
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | | | - Louise Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Kochovska S, Ekström M, Hansen-Flaschen J, Ferreira D, Similowski T, Johnson MJ, Currow DC. Hiding in plain sight: the evolving definition of chronic breathlessness and new ICD-11 wording. Eur Respir J 2023; 61:61/3/2300252. [PMID: 36997231 DOI: 10.1183/13993003.00252-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 03/31/2023]
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Ferreira DH, Kochovska S, McNeill R, Currow DC. Current pharmacological strategies for symptomatic reduction of persistent breathlessness - a literature review. Expert Opin Pharmacother 2023; 24:233-244. [PMID: 36525673 DOI: 10.1080/14656566.2022.2160239] [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: 12/23/2022]
Abstract
INTRODUCTION Persistent breathlessness is a debilitating symptom that is prevalent in the community, particularly in people with chronic and life-limiting illnesses. Treatment includes different steps, including pharmacological treatment aiming to improve the symptom and optimize people's wellbeing. AREAS COVERED PubMed and Google Scholar were screened using 'chronic breathlessness' OR 'persistent breathlessness,' AND 'pharmacological treatment,' OR 'opioids.' This review focuses on pharmacological treatments to reduce persistent breathlessness and discusses possible mechanisms involved in the process of breathlessness reduction through pharmacotherapy. Research gaps in the field of persistent breathlessness research are outlined, and future research directions are suggested. EXPERT OPINION Regular, low-dose (≤30 mg/day), sustained-release morphine is recommended as the first-line pharmacological treatment for persistent breathlessness. Inter-individual variation in response needs to be investigated in future studies in order to optimize clinical outcomes. This includes 1) better understanding the centrally mediated mechanisms associated with persisting breathlessness and response to pharmacological therapies, 2) understanding benefit from the perspective of people experiencing persistent breathlessness, small and meaningful gains in physical activity.
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Affiliation(s)
- Diana H Ferreira
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia
| | - Slavica Kochovska
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia.,IMPACCT, Faculty of Health, University of Technology Sydney, 2007, Ultimo, Australia
| | - Richard McNeill
- Department of palliative care, Nurse Maude Hospice, 8014, Christchurch, New Zealand.,Department of Medicine, University of Otago, 8011, Christchurch, New Zealand
| | - David C Currow
- Faculty of Science, Medicine and Health, University of Wollongong, 2522, Wollongong, Australia
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Schloesser K, Bergmann A, Eisenmann Y, Pauli B, Hellmich M, Oberste M, Hamacher S, Tuchscherer A, Frank KF, Randerath W, Herkenrath S, Simon ST. Only I Know Now, of Course, How to Deal With it, or Better to Deal With it: A Mixed Methods Phase II Study of a Cognitive and Behavioral Intervention for the Management of Episodic Breathlessness. J Pain Symptom Manage 2022; 63:758-768. [PMID: 34793948 DOI: 10.1016/j.jpainsymman.2021.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/29/2021] [Accepted: 11/08/2021] [Indexed: 10/19/2022]
Abstract
CONTEXT Episodic breathlessness is characterized by increased breathlessness intensity, and it is burdensome for patients. A vicious cycle of breathlessness-anxiety/panic-breathlessness leads to emergencies that can rarely be alleviated by drugs. Non-pharmacological interventions seem to be beneficial: Can a brief cognitive and behavioral intervention help patients to better manage episodic breathlessness? OBJECTIVES To evaluate the feasibility, safety, acceptability, and potential effects of a brief cognitive and behavioral intervention for the management of episodic breathlessness. METHODS Between February 2019 and February 2020, 49 patients with life-limiting diseases suffering from episodic breathlessness were enrolled in the single-arm phase II study. The baseline assessment was followed by the one- to two-hour intervention. In weeks two, four, and six after the intervention, the outcomes (main outcome of potential effects: mastery of breathlessness) were assessed, and in week six, a qualitative interview, and the final assessment took place. A mixed-methods approach was used to evaluate mainly the feasibility, including interviewing informal carers. RESULTS 46/49 patients (24 female; 36 with COPD; mean age: 66.0 years) participated in the baseline assessment, 38 attended the intervention, 32 completed the final assessment, and 22 were interviewed. Study procedures and the intervention were feasible and mainly well accepted and patients did not experience burdens caused by it (28/32). In the interviews, patients described a positive change in their competencies in managing episodic breathlessness and feelings of anxiety during the episode. Mastery of breathlessness improved after the intervention. CONCLUSION The brief cognitive and behavioral intervention and the study procedures are feasible, safe, and well accepted. We can describe a change for better management of episodic breathlessness in patients after the intervention, still, this needs to be evaluated in a Phase III trial for inclusion in the management of episodic breathlessness.
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Affiliation(s)
- Karlotta Schloesser
- Department of Palliative Medicine, Faculty of Medicine and University Hospital (K.S., Y.E., B.P., S.T.S.), University of Cologne, Cologne, Germany
| | - Anja Bergmann
- Department of Nursing Science, Faculty of Medicine and University Hospital (A.B.), University of Cologne, Cologne, Germany
| | - Yvonne Eisenmann
- Department of Palliative Medicine, Faculty of Medicine and University Hospital (K.S., Y.E., B.P., S.T.S.), University of Cologne, Cologne, Germany
| | - Berenike Pauli
- Department of Palliative Medicine, Faculty of Medicine and University Hospital (K.S., Y.E., B.P., S.T.S.), University of Cologne, Cologne, Germany
| | - Martin Hellmich
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital (M.H., M.O., S.H.), University of Cologne, Cologne, Germany
| | - Max Oberste
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital (M.H., M.O., S.H.), University of Cologne, Cologne, Germany
| | - Stefanie Hamacher
- Institute of Medical Statistics and Computational Biology, Faculty of Medicine and University Hospital (M.H., M.O., S.H.), University of Cologne, Cologne, Germany
| | - Armin Tuchscherer
- Department I of Internal Medicine, Center for Integrated Oncology Aachen Bonn Cologne Duesseldorf, Faculty of Medicine and University Hospital (A.T.), University of Cologne, Cologne, Germany
| | - Konrad F Frank
- Department III of Internal Medicine, Section Pneumology, Faculty of Medicine and University Hospital (K.F.F.), University of Cologne, Cologne, Germany
| | - Winfried Randerath
- Center for Sleep Medicine and Respiratory Care, Clinic for Pneumology and Allergology, Bethanien Hospital, Solingen, Germany and Institute for Pneumology at the University of Cologne (W.R., S.H.), Cologne, Germany
| | - Simon Herkenrath
- Center for Sleep Medicine and Respiratory Care, Clinic for Pneumology and Allergology, Bethanien Hospital, Solingen, Germany and Institute for Pneumology at the University of Cologne (W.R., S.H.), Cologne, Germany
| | - Steffen T Simon
- Center for Integrated Oncology, Faculty of Medicine and University Hospital, University of Cologne (S.T.S.), Cologne, Germany.
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Currow DC, Chang S, Ekström M, Hutchinson A, Luckett T, Kochovska S, Hay P, Touyz S, Dal Grande E, Johnson MJ. Health service utilisation associated with chronic breathlessness: random population sample. ERJ Open Res 2021; 7:00415-2021. [PMID: 34651042 PMCID: PMC8503326 DOI: 10.1183/23120541.00415-2021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Most health service utilisation studies are of people with specific diagnoses or demographic characteristics, and rarely of specific chronic symptoms. The aim of this study was to establish whether population-level health service utilisation increases in people with chronic breathlessness. METHODS A cross-sectional analysis was carried out of the South Australian Health Omnibus Survey 2017, a multi-stage, clustered area, systematic sampling survey of adults where questions are administered face-to-face in respondents' homes. Self-report of health service utilisation in the previous 3 months (medical consultations, emergency department, hospital admission), chronic breathlessness (severity, duration, modified Medical Research Council (mMRC) breathlessness scale) and demographic data were used to predict self-reported health service utilisation. RESULTS A total of 2898 people were included (49.0% male; median age 48.0 years (IQR 32.0-63.0); 64.1% educated beyond school; 55.4% in work; 73.5% had outpatient contact; 6.3% had a hospital admission in the previous 3 months). Chronic breathlessness (mMRC ≥1) was reported by 8.8% of respondents. In bivariable analyses, people with greater contact with health services were older, and a higher proportion were overweight/obese and had more severe chronic breathlessness. In multivariable analyses, chronic breathlessness and older age were positively associated with outpatient care and inpatient care, and people with chronic breathlessness were hospitalised for longer (incidence rate ratio 2.5; 95% CI 1.4-4.5). CONCLUSION There is a significant association between worse chronic breathlessness and increased health service utilisation. There is a need for greater understanding of factors that initiate contact with health services.
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Affiliation(s)
- David C. Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Sungwon Chang
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Magnus Ekström
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
- Dept of Clinical Sciences, Division of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
| | - Ann Hutchinson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Tim Luckett
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
| | - Phillipa Hay
- Translational Health Research Institute, School of Medicine, Western Sydney University, Penrith South, NSW, Australia
| | - Stephen Touyz
- School of Psychology, University of Sydney, Camperdown, NSW, Australia
| | | | - Miriam J. Johnson
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, NSW, Australia
- Dept of Clinical Sciences, Division of Respiratory Medicine and Allergology, Lund University, Lund, Sweden
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Lewthwaite H, Jensen D, Ekström M. How to Assess Breathlessness in Chronic Obstructive Pulmonary Disease. Int J Chron Obstruct Pulmon Dis 2021; 16:1581-1598. [PMID: 34113091 PMCID: PMC8184148 DOI: 10.2147/copd.s277523] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 05/09/2021] [Indexed: 12/17/2022] Open
Abstract
Activity-related breathlessness is the most problematic symptom of chronic obstructive pulmonary disease (COPD), arising from complex interactions between peripheral pathophysiology (both pulmonary and non-pulmonary) and central perceptual processing. To capture information on the breathlessness experienced by people with COPD, many different instruments exist, which vary in applicability depending on the purpose and context of assessment. We reviewed common breathlessness assessment instruments, providing recommendations around how to assess the severity of, or change in, breathlessness in people with COPD in daily life or in response to exercise provocation. A summary of 14 instruments for the assessment of breathlessness severity in daily life is presented, with 11/14 (79%) instruments having established minimal clinically importance differences (MCIDs) to assess and interpret breathlessness change. Instruments varied in their scope of assessment (functional impact of breathlessness or the severity of breathlessness during different activities, focal periods, or alongside other common COPD symptoms), dimensions of breathlessness assessed (uni-/multidimensional), rating scale properties and intended method of administration (self-administered versus interviewer led). Assessing breathlessness in response to an acute exercise provocation overcomes some limitations of daily life assessment, such as recall bias and lack of standardized exertional stimulus. To assess the severity of breathlessness in response to an acute exercise provocation, unidimensional or multidimensional instruments are available. Borg's 0-10 category rating scale is the most widely used instrument and has estimates for a MCID during exercise. When assessing the severity of breathlessness during exercise, measures should be taken at a standardized submaximal point, whether during laboratory-based tests like cardiopulmonary exercise testing or field-based tests, such as the 3-min constant rate stair stepping or shuttle walking tests. Recommendations are provided around which instruments to use for breathlessness assessment in daily life and in relation to exertion in people with COPD.
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Affiliation(s)
- Hayley Lewthwaite
- School of Environmental & Life Sciences, College of Engineering, Science and Environment, University of Newcastle, Ourimbah, Australia
- UniSA: Allied Health and Human Performance, Innovation, Implementation and Clinical Translation in Health, University of South Australia, Adelaide, Australia
| | - Dennis Jensen
- Department of Kinesiology and Physical Education, McGill University, Montréal, Québec, Canada
- Research Institute of the McGill University Health Centre, Faculty of Medicine, McGill University, Montréal, Québec, Canada
- Research Centre for Physical Activity and Health, Faculty of Education, McGill University, Montréal, Canada
| | - Magnus Ekström
- Faculty of Medicine, Department of Clinical Sciences Lund, Respiratory Medicine and Allergology, Lund University, Lund, Sweden
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Northgraves M, Cohen J, Allgar V, Currow D, Hart S, Hird K, Hodge A, Johnson M, Mason S, Swan F, Hutchinson A. A feasibility cluster randomised controlled trial of a paramedic-administered breathlessness management intervention for acute-on-chronic breathlessness (BREATHE). ERJ Open Res 2021; 7:00955-2020. [PMID: 33816602 PMCID: PMC8005684 DOI: 10.1183/23120541.00955-2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Accepted: 01/07/2021] [Indexed: 11/19/2022] Open
Abstract
Chronic breathlessness, persistent and disabling despite optimal treatment of underlying causes, is a prevalent and frightening symptom and is associated with many emergency presentations and admission to hospital. Breathlessness management techniques used by paramedics may reduce the need for conveyance to hospital. The Breathlessness RElief AT HomE study (BREATHE) aims to explore the feasibility of conducting a definitive cluster randomised controlled trial (cRCT) for people with acute-on-chronic breathlessness who have called an ambulance, to evaluate the effectiveness and cost-effectiveness of a paramedic-administered non-pharmacological breathlessness intervention. The trial is a mixed-methods feasibility cRCT. Eight paramedics will be randomised 1:1 to deliver either the BREATHE intervention in addition to usual care or usual care alone at call-outs for acute-on-chronic breathlessness. Sixty participants will be recruited to provide access to routine data relating to the index call-out with optional follow-up questionnaires at 14 days, 1 month and 6 months. An in-depth interview will be conducted with a subgroup. Feasibility outcomes relating to recruitment, data quality (especially candidate primary outcomes), and intervention acceptability and fidelity will be collected as well as providing data to estimate a sample size for a definitive trial. Yorkshire and The Humber–Sheffield Research Ethics Committee approved the trial protocol (19/YH/0314). The study results will inform progression to, or not, and design of a main trial according to predetermined stop-go criteria. Findings will be disseminated to relevant stakeholders and submitted for publication in a peer-reviewed journal. Acute-on-chronic breathlessness initiates many emergency presentations. The BREATHE protocol describes a feasibility, cluster randomised controlled trial of a paramedic breathlessness management intervention.https://bit.ly/2LZg72w
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Affiliation(s)
| | - Judith Cohen
- Hull Health Trials Unit, University of Hull, Hull, UK
| | - Victoria Allgar
- Hull York Medical School / Health Sciences, University of York, York, UK
| | - David Currow
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Simon Hart
- Respiratory Research Group, Hull York Medical School, Cottingham, UK
| | - Kelly Hird
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Andrew Hodge
- Yorkshire Ambulance Service NHS Trust, Wakefield, UK
| | - Miriam Johnson
- Wolfson Palliative Care Research Group, Hull York Medical School, Hull, UK
| | - Suzanne Mason
- CURE group, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Flavia Swan
- Wolfson Palliative Care Research Group, Hull York Medical School, Hull, UK
| | - Ann Hutchinson
- Wolfson Palliative Care Research Group, Hull York Medical School, Hull, UK
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Philip J, Collins A, Smallwood N, Chang YK, Mo L, Yang IA, Corte T, McDonald CF, Hui D. Referral criteria to palliative care for patients with respiratory disease: a systematic review. Eur Respir J 2021; 58:13993003.04307-2020. [PMID: 33737407 DOI: 10.1183/13993003.04307-2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Advanced non-malignant respiratory diseases are associated with significant patient morbidity, yet access to palliative care occurs late, if at all. AIM To examine referral criteria for palliative care among patients with advanced non-malignant respiratory disease, with a view to developing a standardised set of referral criteria. DESIGN Systematic review of all studies reporting on referral criteria to palliative care in advanced non-malignant respiratory disease, with a focus on chronic obstructive pulmonary disease and interstitial lung disease. DATA SOURCES A systematic review conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guideline was undertaken using electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed). RESULTS Searches yielded 2052 unique titles, which were screened for eligibility resulting in 62 studies addressing referral criteria to palliative care in advanced non-malignant respiratory disease. Of 18 categories put forward for referral to palliative care, the most commonly discussed factors were hospital use (69% of papers), indicators of poor respiratory status (47%), physical and emotional symptoms (37%), functional decline (29%), need for advanced respiratory therapies (27%), and disease progression (26%). CONCLUSION Clinicians consider referral to specialist palliative care for a wide range of disease- and needs-based criteria. Our findings highlight the need to standardise palliative care access by developing consensus referral criteria for patients with advanced non-malignant respiratory illnesses.
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Affiliation(s)
- Jennifer Philip
- Department of Medicine, University of Melbourne, Parkville, Australia .,Palliative Care Service, St Vincent's Hospital, Fitzroy, Australia.,Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, Australia
| | - Anna Collins
- Department of Medicine, University of Melbourne, Parkville, Australia
| | - Natasha Smallwood
- Department of Medicine, University of Melbourne, Parkville, Australia.,Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, Australia
| | - Yuchieh Kathryn Chang
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX, USA
| | - Li Mo
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX, USA.,The Center of Gerontology and Geriatrics, National Clinical Research Center of Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Ian A Yang
- Thoracic Program, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia.,UQ Thoracic Research Centre, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Tamera Corte
- Respiratory Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia.,Department of Medicine, University of Sydney, Sydney, Australia.,Centre of Research Excellence for Pulmonary Fibrosis, National Health and Medical Research Council, New South Wales, Australia
| | - Christine F McDonald
- Department of Medicine, University of Melbourne, Parkville, Australia.,Department of Respiratory & Sleep Medicine, Austin Health, Heidelberg, Victoria, Australia.,Institute for Breathing and Sleep, Heidelberg, Victoria, Australia
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, TX, USA
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Barnes-Harris MMM, Daniel S, Venkateswaran C, Hutchinson A, Johnson MJ. How Physicians in South India Recognize, Assess, and Manage People with Chronic Breathlessness Syndrome: A Thematic Analysis. Indian J Palliat Care 2021; 27:54-61. [PMID: 34035618 PMCID: PMC8121231 DOI: 10.4103/ijpc.ijpc_139_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/01/2020] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Chronic breathlessness syndrome has been defined to help clinicians actively seek, and patients legitimately present with, persistent breathlessness, and to drive services and research. However, views from low- to middle-income countries were not included. We aimed to explore the views of hospital physicians regarding chronic breathlessness syndrome, its recognition and management. METHODS This was a secondary analysis of qualitative data collected during a service development project. Three focus groups of physicians caring for patients with chronic breathlessness in a single tertiary hospital in South India were conducted in English, audio-recorded, transcribed, and subjected to thematic analysis. RESULTS Fifteen physicians from oncology, palliative care, cardiology, and respiratory specialties participated. Three major themes (impact, invisibility, and purpose) were generated. Findings mirrored those in high-income countries. Chronic breathlessness, as defined, was seen as prevalent, with a major impact on patients, families, and physicians. Nonpalliative care physicians described therapeutic helplessness with poor awareness and/or ability to manage breathlessness accompanied by active avoidance. This helplessness, a perceived lack of assessment tools and lack of access to palliative care contributed to the "invisibility" of chronic breathlessness. Most participants agreed with the name of chronic breathlessness syndrome. All agreed that systematic identification would foster education regarding assessment and management and support service development and research. CONCLUSIONS Chronic breathlessness syndrome is recognized in South India but, as in higher-income countries, risks being invisible due to the lack of awareness of therapeutic interventions. A named and defined syndrome was seen as a way to improve identification and management.
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Affiliation(s)
- Matilda MM Barnes-Harris
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, HU6 7RX, UK
| | - Sunitha Daniel
- Department of Palliative Medicine, General Hospital Ernakulam, Kochi, India
- Wolfson Palliative Care Research Centre, University of Hull, Hull, HU6 7RX, UK
| | - Chitra Venkateswaran
- Department of Psychiatry, Believers Church Medical College, Thiruvalla, Kerala, India
| | - Ann Hutchinson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, HU6 7RX, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, HU6 7RX, UK
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Currow DC, Kochovska S, Ferreira D, Johnson M. Morphine for the symptomatic reduction of chronic breathlessness: the case for controlled release. Curr Opin Support Palliat Care 2020; 14:177-181. [PMID: 32740277 DOI: 10.1097/spc.0000000000000520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Clinicians who seek to reduce the symptomatic burden of chronic breathlessness by initiating regular low-dose morphine has the choice of immediate or sustained-release formulations - which will be better for this often frail population, and which has the more robust evidence to inform its prescription? Both formulations can be used. RECENT FINDINGS For chronic breathlessness, three factors consistently favour the use of regular, low-dose, sustained-release morphine over immediate-release formulations: SUMMARY: As the evidence base expands for the symptomatic reduction of chronic breathlessness, pharmacological interventions will play a part. Using the best available evidence underpins patient-centred approaches that seek to predictably maximize the net effect.As such, the weight of evidence in patient-centred clinical care favours the use of regular, low-dose sustained-release morphine for the symptomatic reduction of chronic breathlessness.
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Affiliation(s)
- David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Diana Ferreira
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Discipline, Palliative and Supportive Services, Flinders University, South Australia, Australia
| | - Miriam Johnson
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
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11
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Hutchinson A, Galvin K, Johnson MJ. "So, I try not to go …" Acute-On-Chronic Breathlessness and Presentation to the Emergency Department: In-depth Interviews With Patients, Carers, and Clinicians. J Pain Symptom Manage 2020; 60:316-325. [PMID: 32247055 DOI: 10.1016/j.jpainsymman.2020.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 03/12/2020] [Accepted: 03/17/2020] [Indexed: 12/31/2022]
Abstract
CONTEXT People with acute-on-chronic breathlessness due to cardiorespiratory conditions frequently present to the emergency department (ED) causing burden for the person concerned, their care takers, and emergency services. OBJECTIVE To understand the reasons for ED presentation for acute-on-chronic breathlessness and how optimal care might avoid presentations. METHODS Qualitative in-depth linked interviews were conducted as part of a mixed-methods study. Transcripts of audio-recordings were subjected to thematic analysis. Consenting patients presenting to a single tertiary hospital ED with acute-on-chronic breathlessness able to be interviewed were eligible. Patient-participants (n = 18) were purposively sampled for maximum variation. Patient-participant-nominated carers (n = 9) and clinicians (n = 8) were recruited. RESULTS Theme 1: "The context for the decision to present to the ED" is the experience of acute-on-chronic breathlessness, in which a person faces an existential crisis not knowing where the next breath is coming from, and previous help-seeking experiences. Theme 2 ("Reasons for presentation"): Some were reluctant to seek help until crisis when family carers were often involved in the decision to present. Others had previous poor experiences of help-seeking for breathlessness in the community and turned to the ED by default. Some had supportive primary clinicians and presented to the ED either on their clinician's recommendation or because their clinician was unavailable. CONCLUSIONS The decision to present to the ED is made in the context of serious crisis and previous experiences. Discussion of the reason for presentation may enable better management of chronic breathlessness and reduce the need for future emergency presentation.
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Johnson MJ, Nabb S, Booth S, Kanaan M. Openness Personality Trait Associated With Benefit From a Nonpharmacological Breathlessness Intervention in People With Intrathoracic Cancer: An Exploratory Analysis. J Pain Symptom Manage 2020; 59:1059-1066.e2. [PMID: 32006612 DOI: 10.1016/j.jpainsymman.2020.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 01/13/2020] [Accepted: 01/14/2020] [Indexed: 10/25/2022]
Abstract
CONTEXT Breathlessness is common in people with lung cancer. Nonpharmacological breathlessness interventions reduce distress because of and increase mastery over breathlessness. OBJECTIVES Identify patient characteristics associated with response to breathlessness interventions. METHODS Exploratory secondary trial data analysis. Response defined as a one-point improvement in 0-10 Numerical Rating Scale of worst breathlessness/last 24 hours (response-worst) or a 0.5-point improvement in the Chronic Respiratory Questionnaire (CRQ) mastery (response-mastery) at four weeks. Univariable regression explored relationships with plausible demographic, clinical, and psychological variables followed by multivariable regression for associated (P < 0.05) variables. RESULTS About 158 participants with intrathoracic cancer (mean age 69.4 [SD 9.35] years; 40% women) were randomized to one or three breathlessness training sessions. About 91 participants had evaluable data for response-worst and 107 for response-mastery. In the univariable analyses, the personality trait openness was associated with response-worst (odds ratio [OR] 1.99 [95% CI 1.08-3.67]; P = 0.028) and response-mastery (OR 1.84 [95% CI 1.04-3.23]; P = 0.035). Higher CRQ-fatigue (OR 0.61 [95% CI 0.41-0.91]; P = 0.015), CRQ-emotion (OR 0.68 [95% CI 0.47-0.96]; P = 0.030), and worse CRQ-mastery (OR 0.61 [95% CI 0.42-0.88]; P = 0.008), and the presence of metastases and fatigue were associated with reduced odds of response-mastery. In the adjusted response-mastery model, only openness remained (OR 1.73 [95% CI 0.95-3.15]; P = 0.072). CONCLUSION Worse baseline health, worse breathlessness mastery, but not severity, and openness were associated with a better odds of response. Breathlessness services must be easy to access, and patients should be encouraged and supported to attend.
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Affiliation(s)
- Miriam J Johnson
- Palliative Medicine, Wolfson Palliative Care Research Centre, University of Hull, Hull, UK.
| | - Samantha Nabb
- Student Wellbeing Learning and Welfare Support, University of Hull, Hull, UK; Humber Teaching NHS Foundation Trust, Willerby Hill, Hull, UK
| | - Sara Booth
- Cicely Saunders Institute, University of Cambridge, Kings College London, London, UK
| | - Mona Kanaan
- Department of Health Sciences, Applied Health Research (Statistics), University of York, York, UK
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Patient perspectives on how to optimise benefits from a breathlessness service for people with COPD. NPJ Prim Care Respir Med 2020; 30:16. [PMID: 32269222 PMCID: PMC7142111 DOI: 10.1038/s41533-020-0172-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2019] [Accepted: 03/12/2020] [Indexed: 12/03/2022] Open
Abstract
This study aimed to inform understanding of how to optimise patient-perceived benefits from a breathlessness service designed for patients with moderate to very severe chronic obstructive pulmonary disease (COPD). The Westmead Breathlessness Service (WBS) trains patients to self-manage over an 8-week programme, with multidisciplinary input and home visits. A qualitative approach was taken, using semi-structured telephone interviews. Each transcript was globally rated as suggesting ‘significant’, ‘some’ or ‘no’ impact from WBS, and thematic analysis used an integrative approach. Forty-one consecutive participants were interviewed to reach ‘information power’. Eighteen (44%) participants reported ‘significant’ impact, 17 (41%) ‘some’ impact, and two (5%) ‘no’ impact. Improvements to breathlessness were usually in the affective and impact dimensions but, more uncommonly, also sensory-perceptual. Participants who benefited in self-esteem, confidence and motivation attributed this to one-to-one multidisciplinary coaching and home visits. Further research should test whether including/excluding more intensive programme elements based on individual need might improve cost-effectiveness.
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Raymond B, Luckett T, Johnson M, Hutchinson A, Lovell M, Phillips J. Low-intensity educational interventions supporting self-management to improve outcomes related to chronic breathlessness: a systematic review. NPJ Prim Care Respir Med 2019; 29:41. [PMID: 31784524 PMCID: PMC6884574 DOI: 10.1038/s41533-019-0152-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 10/29/2019] [Indexed: 12/18/2022] Open
Abstract
Chronic breathlessness is debilitating and frightening, often resulting in emergency department presentations with acute-on-chronic breathlessness. Self-management is complex, involving 14 components as identified by the Practical Systematic Review in Self-Management Support (PRISMS). Low-intensity educational interventions that support breathlessness self-management through written/visual educational materials, alongside limited health professional support, are available. Our aim was to describe components of low-intensity educational interventions that support and improve self-management for adults with chronic breathlessness and evaluate their efficacy for improving breathlessness-related outcomes. A systematic review was conducted, including RCTs that compared these interventions with usual care in adults with chronic disease. Synthesis took a narrative approach utilizing the PRISMS taxonomy and Template for Intervention Description and Replication (TIDieR) checklist. Of the 1948 articles identified, 7 met criteria reporting 7 RCTs using 6 interventions. Studies utilized 12 out of 14 PRISMS components, the most frequent being training/rehearsal for psychological strategies. Evidence for effectiveness was inconsistent and attempts to identify beneficial components were confounded by intervention complexity and heterogeneity. The optimal content and delivery of low-intensity educational interventions that support self-management to improve chronic breathlessness-related outcomes in adults cannot be defined from current published literature. Future research should incorporate more detailed, standardized reporting to enable comparison and meta-analysis.
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Affiliation(s)
- Bronwyn Raymond
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, 235-253 Jones Street, Ultimo, NSW, 2007, Australia
| | - Tim Luckett
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, 235-253 Jones Street, Ultimo, NSW, 2007, Australia.
| | - Miriam Johnson
- Hull York Medical School, University of York, John Hughlings Jackson Building, Heslington, York, Y010 5DD, UK
| | - Ann Hutchinson
- Hull York Medical School, University of York, John Hughlings Jackson Building, Heslington, York, Y010 5DD, UK
| | - Melanie Lovell
- HammondCare, 95-115 River Road, Greenwich, NSW, 2065, Australia.,Faculty of Medicine and Health, The University of Sydney, Science Road, Camperdown, NSW, 2050, Australia
| | - Jane Phillips
- IMPACCT - Improving Palliative, Aged and Chronic Care through Clinical Research and Translation, Faculty of Health, University of Technology Sydney, 235-253 Jones Street, Ultimo, NSW, 2007, Australia
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Booth S, Johnson MJ. Improving the quality of life of people with advanced respiratory disease and severe breathlessness. Breathe (Sheff) 2019; 15:198-215. [PMID: 31508158 PMCID: PMC6717608 DOI: 10.1183/20734735.0200-2019] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Advanced respiratory disease imposes a greater symptom burden than many cancers but not does have comparable recognition of the need for supportive and palliative care or the infrastructure for its systematic delivery. Consequently, many people with advanced respiratory disease (and those closest to them) have a poor quality of life, disabled by chronic breathlessness, fatigue and other symptoms. They are socially isolated by the consequences of long-term illness and are often financially impoverished. The past decade has seen an increasing realisation that care for this group must improve and that symptom management must be prioritised. Clinical guidelines recommend person-centred care, including access to supportive and palliative care as needed, as part of standard medical practice. Advanced lung disease clinics and specialist breathlessness services (pioneered within palliative care) are developing within respiratory medicine services but are provided inconsistently. This review covers the comprehensive assessment of the patient with advanced respiratory disease, the importance of supporting carers and the current best practice in the management of breathlessness, fatigue and cough. It also suggests ways to incorporate person-centred care into the general respiratory clinic, assisted by better liaison with specialist palliative and primary care. Emerging evidence shows that excellent symptom management leads to better clinical outcomes and reduces inappropriate use of emergency medical services. Improving quality of life in people with chronic breathlessness, with a combination of (mostly) non-drug and drug interventions, improves clinical outcomes and reduces patient/carer suffering and futile use of medical serviceshttp://bit.ly/30s9ckh
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Affiliation(s)
- Sara Booth
- Cambridge Breathlessness Intervention Service, Cambridge University Hospitals NHS Foundation Trust, University of Cambridge, Cambridge, UK.,Cicely Saunders Institute, King's College London, London, UK
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
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