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Lo SB, Svensson AD, Presley CJ, Andersen BL. A cognitive-behavioral model of dyspnea: Qualitative interviews with individuals with advanced lung cancer. Palliat Support Care 2023; 21:1-8. [PMID: 37249018 DOI: 10.1017/s1478951523000640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Shortness of breath, or dyspnea, is the subjective experience of breathing discomfort and is a common, distressing, and debilitating symptom of lung cancer. There are no efficacious pharmacological treatments, but there is suggestive evidence that cognitive-behavioral treatments could relieve dyspnea. For this, understanding the psychological, behavioral, and social factors that may affect dyspnea severity is critical. To this end, patients with dyspnea were interviewed with questions framed by the cognitive-behavioral model-emphasizing thoughts, emotions, and behaviors as contributors and outcomes of dyspnea. METHODS Two trained individuals conducted semi-structured interviews with lung cancer patients (N = 15) reporting current dyspnea. Interviews assessed patients' cognitive-behavioral experiences with dyspnea. Study personnel used a grounded theory approach for qualitative analysis to code the interviews. Inter-rater reliability of codes was high (κ = 0.90). RESULTS Thoughts: Most common were patients' catastrophic thoughts about their health and receiving enough oxygen when breathless. Emotions: Anxiety about dyspnea was the most common, followed by anger, sadness, and shame related to dyspnea. Behaviors: Patients rested and took deep breaths to relieve acute episodes of dyspnea. To reduce the likelihood of dyspnea, patients planned their daily activity or reduced their physical activity at the expense of engagement in hobbies and functional activities. SIGNIFICANCE OF RESULTS Patients identified cognitive-behavioral factors (thoughts, emotions, and behaviors) that coalesce with dyspnea. The data provide meaningful insights into potential cognitive-behavioral interventions that could target contributors to dyspnea.
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Affiliation(s)
- Stephen B Lo
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Aubrey D Svensson
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Carolyn J Presley
- Department of Internal Medicine, Division of Medical Oncology, The Ohio State University Comprehensive Cancer Center and The James Cancer Hospital/Solove Research Institute, Columbus, OH, USA
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2
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Breen LJ, Huseini T, Same A, Peddle-McIntyre CJ, Lee YCG. Living with mesothelioma: A systematic review of patient and caregiver psychosocial support needs. PATIENT EDUCATION AND COUNSELING 2022; 105:1904-1916. [PMID: 35260259 DOI: 10.1016/j.pec.2022.02.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 02/24/2022] [Accepted: 02/26/2022] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Practice guidelines emphasize the importance of investigating psychosocial distress in mesothelioma patients and family caregivers. We aimed to synthesize research on the psychosocial support needs of mesothelioma patients and their family caregivers. METHODS We conducted a systematic review with a narrative synthesis and quality assessment. The review process adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS MEDLINE, EMBASE, Scopus, PsychArticles, and PsycINFO were searched until December 2020 and 37 studies in English met inclusion criteria. Most (n = 24) included mesothelioma patients as a very small proportion of their cancer samples. A narrative synthesis was conducted on the 13 studies including only mesothelioma patients (n = 297) and/or caregivers (n = 82). Patients and caregivers want improvements in the diagnosis delivery and access to palliative care. Patients want emotional support, patient-centered treatment, improved information about illness progression and death, and to meet others with mesothelioma. Caregivers want one-on-one practical and emotional support. Study quality varied. CONCLUSIONS Few studies focus on the psychosocial support needs relevant to mesothelioma. Mesothelioma patients and family caregivers highlight targeted psychosocial care as an unmet need. PRACTICE IMPLICATIONS Efforts are required to design and test psychosocial interventions for this vulnerable and overlooked group. PROTOCOL REGISTRATION PROSPERO (registration number CRD42020167852).
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Affiliation(s)
- Lauren J Breen
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia; Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.
| | - Taha Huseini
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia; Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Anne Same
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
| | - Carolyn J Peddle-McIntyre
- Exercise Medicine Research Institute, Edith Cowan University, Perth, Western Australia, Australia; School of Medical and Health Sciences, Edith Cowan University, Perth, Western Australia, Australia
| | - Y C Gary Lee
- Department of Respiratory Medicine, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia; Centre for Respiratory Health, University of Western Australia, Perth, Western Australia, Australia
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3
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Demoule A, Hajage D, Messika J, Jaber S, Diallo H, Coutrot M, Kouatchet A, Azoulay E, Fartoukh M, Hraiech S, Beuret P, Darmon M, Decavèle M, Ricard JD, Chanques G, Mercat A, Schmidt M, Similowski T. Prevalence, Intensity and Clinical Impact of Dyspnea in Critically Ill Patients Receiving Invasive Ventilation. Am J Respir Crit Care Med 2022; 205:917-926. [DOI: 10.1164/rccm.202108-1857oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Alexandre Demoule
- Groupe Hospitalier Pitié Salpêtrière, Assistance Publique Hopitaux de Paris, Service de Pneumologie et Réanimation Médicale, Paris, France
| | | | - Jonathan Messika
- Hôpital Louis-Mourier, 26931, Service de Médecine Intensive - Réanimation, Colombes, France
| | - Samir Jaber
- University hospital. CHU de MONTPELLIER HOPITAL SAINT ELOI, Intensive Care Unit and transplantation-Departement of Anesthesiology DAR B, Montpellier Cedex 5, France
| | - Hassimiou Diallo
- University Hospital Pitié Salpêtrière, 26933, Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Maxime Coutrot
- Hopital Universitaire Pitie Salpetriere, 26933, Service de Medecine Intensive Réanimation - Institut de Cardiologie, Paris, France
| | - Achille Kouatchet
- Service de Reanimation Médicale et Médecine Hyperbare, Angers, France
| | | | - Muriel Fartoukh
- Assistance Publique Hopitaux de Paris. Sorbonne Université, Hôpital Tenon, Médecine intensive Réanimatio, Paris, France
| | - Sami Hraiech
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France
| | - Pascal Beuret
- CENTRE HOSPITALIER, SERVICE DE REANIMATION POLYVALENTE, ROANNE, France
| | | | - Maxens Decavèle
- Groupe Hospitalier La Pitié Salpêtrière-Charles Foix, 55577, Médecine Intensive Réanimation, Paris, France
| | | | - Gerald Chanques
- University of Montpellier Hospitals, Anesthesiology & Critical Care, Montpellier, France
| | - Alain Mercat
- Angers University Hospital, Departement de Reanimation medicale et medecine hyperbare, Angers, France
| | - Matthieu Schmidt
- Groupe Hospitalier Pitié-Salpêtrière, Service de réanimation médicale, Paris, France
| | - Thomas Similowski
- groupe hospitalier pitié-salpêtrière, Service de Pneumologie, PARIS, France
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4
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Mori M, Kawaguchi T, Imai K, Yokomichi N, Yamaguchi T, Suzuki K, Matsunuma R, Watanabe H, Maeda I, Matsumoto Y, Matsuda Y, Morita T. Visualizing How to Use Parenteral Opioids for Terminal Cancer Dyspnea: A Pilot, Multicenter, Prospective, Observational Study. J Pain Symptom Manage 2021; 62:936-948. [PMID: 33992759 DOI: 10.1016/j.jpainsymman.2021.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/28/2021] [Accepted: 05/01/2021] [Indexed: 10/21/2022]
Abstract
CONTEXT How physicians use opioids for dyspnea in imminently dying cancer patients (terminal dyspnea) varies markedly, which could hamper quality care. OBJECTIVES To examine the adherence to an algorithm-based treatment for terminal dyspnea, and explore its outcomes over 24 hours. METHODS This was a pre-planned subgroup analysis of a multicenter prospective observational study. Inclusion criteria were: advanced cancer patients admitted to palliative care units, ECOG performance status = 3-4, and a dyspnea intensity ≥2 on the Integrated Palliative care Outcome Scale (IPOS). We developed an algorithm to visualize how palliative care physicians would use parenteral opioids. Participating physicians (palliative care specialists) initiated parenteral opioids, choosing whether to use the algorithm based on their preference. We measured the adherence rate to the algorithm over 24 hours (predefined goal = 70%), and compared dyspnea IPOS scores and adverse events between patients with and without algorithm-based treatment. RESULTS Of 164 patients (median survival = 5 days), 71 (43%) received algorithm-based treatment, and 70 (99%; 95% confidence interval = 92%-100%) adhered to it over 24 hours. In a complete case analysis, mean dyspnea IPOS scores significantly decreased from 2.9 (standard error = 0.1) to 1.5 (0.1) in the algorithm group (n = 54; P < 0.001), and 2.9 (0.1) to 1.6 (0.1) in the non-algorithm group (n = 72; P < 0.001). There was no significant between-group difference in changes in dyspnea IPOS scores (P = 0.65). Adverse events were rare (n = 5). CONCLUSION The algorithm-based treatment was feasible, and might be as effective and safe as the usual care by palliative care specialists. Its implementation may help physicians provide quality care for terminal dyspnea.
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Affiliation(s)
- Masanori Mori
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan.
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Naosuke Yokomichi
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Medical Center, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-chuo Hospital, Osaka, Japan
| | - Yoshihisa Matsumoto
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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5
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Mori M, Kawaguchi T, Imai K, Yokomichi N, Yamaguchi T, Suzuki K, Matsunuma R, Watanabe H, Maeda I, Uehara Y, Morita T. How Successful Is Parenteral Oxycodone for Relieving Terminal Cancer Dyspnea Compared With Morphine? A Multicenter Prospective Observational Study. J Pain Symptom Manage 2021; 62:336-345. [PMID: 33290857 DOI: 10.1016/j.jpainsymman.2020.11.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Revised: 11/20/2020] [Accepted: 11/28/2020] [Indexed: 12/17/2022]
Abstract
CONTEXT Parenteral morphine is widely used for dyspnea of imminently dying cancer patients (terminal dyspnea). However, the efficacy of other opioids such as oxycodone remains largely unknown. OBJECTIVES To explore the efficacy of parenteral oxycodone vs. morphine by continuous infusion over 24 hours in cancer patients with terminal dyspnea. METHODS This was a pre-planned subgroup analysis of a multicenter prospective observational study. Inclusion criteria were advanced cancer patients admitted to palliative care units, Eastern Cooperative Oncology Group performance status = 3-4, and a dyspnea intensity ≥2 on the Integrated Palliative care Outcome Scale (IPOS) for which oxycodone or morphine was initiated by continuous infusion. We measured dyspnea IPOS scores over 24 hours. RESULTS We analyzed 164 patients who received oxycodone (n = 26) and morphine (n = 138) for dyspnea (median survival = 5 days). The mean age was 70 years, 58 patients (35%) had lung cancer, and 97 (59%) had lung metastases. Complete case analysis revealed that mean dyspnea IPOS scores decreased from 3.0 (standard deviation = 0.7) to 1.5 (0.7) in the oxycodone group (difference in means = 1.5; P < 0.001), and from 2.9 (0.7) to 1.6 (1.0) in the morphine group (difference in means = 1.3; P < 0.001). No significant between-group differences existed in the IPOS scores at 24 hours (P = 0.753). Adverse events were seen in no and 5 patients in the oxycodone and morphine groups, respectively. CONCLUSION Parenteral oxycodone may be equally effective and safe as morphine in the treatment of terminal dyspnea in cancer patients. Future randomized controlled trials should confirm the efficacy and safety of opioids other than morphine for terminal dyspnea.
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Affiliation(s)
- Masanori Mori
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan.
| | - Takashi Kawaguchi
- Department of Practical Pharmacy, School of Pharmacy, Tokyo University of Pharmacy and Life Sciences, Tokyo, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Naosuke Yokomichi
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Takashi Yamaguchi
- Division of Palliative Care, Department of Medicine, Konan Hospital, Kobe, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Isseki Maeda
- Department of Palliative Care, Senri-chuo Hospital, Osaka, Japan
| | - Yuko Uehara
- Department of Palliative Medicine, National Cancer Center Hospital East, Chiba, Japan; Department of Palliative Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tatsuya Morita
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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6
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Banzett RBB, Sheridan AR, Baker KM, Lansing RW, Stevens JP. 'Scared to death' dyspnoea from the hospitalised patient's perspective. BMJ Open Respir Res 2021; 7:7/1/e000493. [PMID: 32169831 PMCID: PMC7069254 DOI: 10.1136/bmjresp-2019-000493] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/22/2019] [Accepted: 12/05/2019] [Indexed: 11/04/2022] Open
Abstract
Because dyspnoea is seldom experienced by healthy people, it can be hard for clinicians and researchers to comprehend the patient’s experience. We collected patients’ descriptions of dyspnoea in their own words during a parent study in which 156 hospitalised patients completed a quantitative multidimensional dyspnoea questionnaire. These volunteered comments describe the severity and wide range of experiences associated with dyspnoea and its impacts on a patients’ life. They provide insights not conveyed by structured rating scales. We organised these comments into the most prominent themes, which included sensory experiences, emotional responses, self-blame and precipitating events. Patients often mentioned air hunger (‘Not being able to get air is the worst thing that could ever happen to you.’), anxiety, and fear (‘Scared. I thought the world was going to end, like in a box.’). Their value in patient care is suggested by one subject’s comment: ‘They should have doctors experience these symptoms, especially dyspnoea, so they understand what patients are going through.’ Patients’ own words can help to bridge this gap of understanding.
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Affiliation(s)
- Robert B B Banzett
- Pulmonary, Critical Care, and Sleep Medicine, and Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA .,Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Andrew R Sheridan
- Pulmonary, Critical Care, and Sleep Medicine, and Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Kathy M Baker
- Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Robert W Lansing
- Pulmonary, Critical Care, and Sleep Medicine, and Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Jennifer P Stevens
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA.,Pulmonary, Critical Care, and Sleep Medicine; Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
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7
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Lansing RW, Hoit JD. A Conceptual Framework for Understanding Speaking Dyspnea. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2021; 30:844-851. [PMID: 33734811 DOI: 10.1044/2020_ajslp-20-00179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Purpose A conceptual framework is proposed to better understand the experience of people who have dyspnea (breathing discomfort) when speaking: its nature, its physiological mechanisms, and its impacts on their lives. Method The components of the framework are presented in their natural order. They are a Speaking Domain (Speaking Activities and Speaking Variables), a Physiological Domain (Speech Breathing Variables and Physiological Mechanisms), a Perceptual Domain (Dyspnea), a Symptom Impact Domain (Emotional Responses, Immediate Behavioral Responses, and Long-Term Behavioral Response), and a Life Impact Domain (Short-Term Impacts and Long-Term Impacts). Results We discuss literature that most directly supports these components and includes findings from healthy people and those with disorders in whom speaking dyspnea was either evoked or measured. Caveats are noted where information is limited and further study is needed. A case example is provided to illustrate how to apply the framework. Conclusions This framework provides a broader view of the elements that contribute to the experience of speaking dyspnea. It is meant to guide researchers, clinicians, instructors, caregivers, and those for whom speaking dyspnea is a daily or even a life-long challenge.
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Affiliation(s)
| | - Jeannette D Hoit
- Department of Speech, Language, and Hearing Sciences, University of Arizona, Tucson
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8
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Kochovska S, Ferreira DH, Garcia MV, Phillips JL, Currow DC. Perspectives on palliative oxygen for breathlessness: systematic review and meta-synthesis. Eur Respir J 2021; 58:13993003.04613-2020. [PMID: 33653807 DOI: 10.1183/13993003.04613-2020] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 02/15/2021] [Indexed: 12/16/2022]
Abstract
Oxygen therapy is frequently prescribed for the palliation of breathlessness, despite lack of evidence for its effectiveness in people who are not hypoxaemic. This study aimed to compare and contrast patients', caregivers' and clinicians' experiences of palliative oxygen use for the relief of chronic breathlessness in people with advanced life-limiting illnesses, and how this shapes prescribing.A systematic review and meta-synthesis of qualitative data was conducted. MEDLINE, CINAHL and PsycINFO were searched for peer-reviewed studies in English (2000-April 2019) reporting perspectives on palliative oxygen use for reducing breathlessness in people with advanced illnesses in any healthcare setting. After data extraction, thematic synthesis used line-by-line coding of raw data (quotes) to generate descriptive and analytical themes.Of 457 articles identified, 22 met the inclusion criteria by reporting perspectives of patients (n=337), caregivers (n=91) or clinicians (n=616). Themes common to these perspectives were: 1) benefits and burdens of palliative oxygen use, 2) knowledge and perceptions of palliative oxygen use beyond the guidelines, and 3) longitudinal trajectories of palliative oxygen use.There are differing perceptions regarding the benefits and burdens of using palliative oxygen. Clinicians should be aware that oxygen use may generate differing goals of therapy for patients and caregivers. These perceptions should be taken into consideration when prescribing oxygen for the symptomatic relief of chronic breathlessness in patients who do not quality for long-term oxygen therapy.
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Affiliation(s)
- Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia.,These authors are joint first authors
| | - Diana H Ferreira
- Palliative and Supportive Services, Flinders University, Adelaide, Australia.,These authors are joint first authors
| | - Maja V Garcia
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Jane L Phillips
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Sydney, Australia .,Wolfson Palliative Care Research Centre, University of Hull, Hull, UK
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Abstract
The sensation that develops as a long breath hold continues is what this article is about. We term this sensation of an urge to breathe "air hunger." Air hunger, a primal sensation, alerts us to a failure to meet an urgent homeostatic need maintaining gas exchange. Anxiety, frustration, and fear evoked by air hunger motivate behavioral actions to address the failure. The unpleasantness and emotional consequences of air hunger make it the most debilitating component of clinical dyspnea, a symptom associated with respiratory, cardiovascular, and metabolic diseases. In most clinical populations studied, air hunger is the predominant form of dyspnea (colloquially, shortness of breath). Most experimental subjects can reliably quantify air hunger using rating scales, that is, there is a consistent relationship between stimulus and rating. Stimuli that increase air hunger include hypercapnia, hypoxia, exercise, and acidosis; tidal expansion of the lungs reduces air hunger. Thus, the defining experimental paradigm to evoke air hunger is to elevate the drive to breathe while mechanically restricting ventilation. Functional brain imaging studies have shown that air hunger activates the insular cortex (an integration center for perceptions related to homeostasis, including pain, food hunger, and thirst), as well as limbic structures involved with anxiety and fear. Although much has been learned about air hunger in the past few decades, much remains to be discovered, such as an accepted method to quantify air hunger in nonhuman animals, fundamental questions about neural mechanisms, and adequate and safe methods to mitigate air hunger in clinical situations. © 2021 American Physiological Society. Compr Physiol 11:1449-1483, 2021.
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Affiliation(s)
- Robert B Banzett
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Lansing
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Andrew P Binks
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, Virginia, USA
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10
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Mori M, Yamaguchi T, Matsuda Y, Suzuki K, Watanabe H, Matsunuma R, Kako J, Imai K, Usui Y, Matsumoto Y, Hui D, Currow D, Morita T. Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer. ESMO Open 2020; 5 Suppl 1:e000603. [PMID: 33558034 PMCID: PMC7046422 DOI: 10.1136/esmoopen-2019-000603] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/01/2019] [Accepted: 02/04/2020] [Indexed: 12/14/2022] Open
Abstract
Breathlessness is among the most common and deteriorating symptoms in patients with advanced cancer, which may worsen towards the end of life. Breathlessness in patients with estimated life expectancy of weeks to days has unique clinical features: it tends to worsen rapidly over days to hours as death approaches often despite current symptom control measures. Breathlessness in patients during the last weeks to days of life can be called ‘terminal breathlessness’. While evidence has accumulated for the management of breathlessness in patients with cancer who are not dying, such evidence may not be fully applied to terminal breathlessness. Only a few studies have investigated the best practice of terminal breathlessness in patients with cancer. In this paper, we summarise the current evidence for the management of terminal breathlessness, and propose future directions of clinical research.
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Affiliation(s)
- Masanori Mori
- Palliative Care Team, Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan.
| | | | - Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Kozue Suzuki
- Department of Palliative Care, Tokyo Metropolitan Cancer and Infectious Disease Center Komagome Hospital, Tokyo, Japan
| | - Hiroaki Watanabe
- Department of Palliative Care, Komaki City Hospital, Komaki, Japan
| | - Ryo Matsunuma
- Department of Palliative Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Jun Kako
- Division of Nursing Science, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kengo Imai
- Seirei Hospice, Seirei Mikatahara General Hospital, Hamamatsu, Japan
| | - Yuko Usui
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - Yoshihisa Matsumoto
- Department of Palliative Medicine, National Cancer Center Hospital East, Kashiwa, Japan
| | - David Hui
- Department of Palliative Care, Rehabilitation and Integrative Medicine, MD Anderson Cancer Center, Houston, Texas, USA
| | - David Currow
- Faculty of Health, University of Technology, Sydney, New South Wales, Australia
| | - Tatsuya Morita
- Division of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu, Japan
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11
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Ferreira DH, Louw S, McCloud P, Fazekas B, McDonald CF, Agar MR, Clark K, McCaffrey N, Ekström M, Currow DC. Controlled-Release Oxycodone vs. Placebo in the Treatment of Chronic Breathlessness-A Multisite Randomized Placebo Controlled Trial. J Pain Symptom Manage 2020; 59:581-589. [PMID: 31655189 DOI: 10.1016/j.jpainsymman.2019.10.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2019] [Revised: 10/14/2019] [Accepted: 10/16/2019] [Indexed: 11/12/2022]
Abstract
CONTEXT Chronic breathlessness is a clinical syndrome that results in significant distress and disability. Morphine can reduce chronic breathlessness when the contributing etiologies are optimally treated. OBJECTIVES Does oxycodone reduce chronic breathlessness compared with placebo? METHODS A multisite, randomized, placebo-controlled, double-blind, parallel-arm, fixed-dose trial of oral controlled-release oxycodone 15 mg (5 mg, eight hourly) or placebo (ACTRN12609000806268 at www.anzctr.org.au). As-needed immediate-release morphine (2.5 mg per dose; six and less doses/day) was available for both arms as required by one ethics committee overseeing the trial. Recruitment occurred from 2010 to 2014 in 14 inpatient and outpatient respiratory, cardiology, and palliative care services across Australia. Participants were adults, with chronic breathlessness (modified Medical Research Council Scale 3 or 4), who were opioid naive. The primary end point was the proportion of people with greater than 15% reduction from baseline in the intensity of breathlessness now (0-100 mm visual analogue scale) comparing arms Days 5-7. Secondary end points were average and worst breathlessness, quality of life, function, and harms. RESULTS Of 157 participants randomized, 155 were included (74 oxycodone and 81 placebo), but the study did not reach target recruitment. There was difference in neither between groups for the primary outcome (P = 0.489) nor any of the prespecified secondary outcomes. Placebo participants used more as-needed morphine (mean 7.0 vs. 4.2 doses; P ≤ 0.001). Oxycodone participants reported more nausea (P < 0.001). CONCLUSION There was no signal of benefit from oxycodone over placebo. Future research should focus on investigating the existence of an opioid class effect on the reduction of chronic breathlessness.
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Affiliation(s)
- Diana H Ferreira
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Sandra Louw
- McCloud Consulting Group, Narabang Way, Belrose, New South Wales, Australia
| | - Philip McCloud
- McCloud Consulting Group, Narabang Way, Belrose, New South Wales, Australia
| | - Belinda Fazekas
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Christine F McDonald
- Austin Health, Heidelberg, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | - Meera R Agar
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Katherine Clark
- Northern Sydney Local Health District, St Leonards, New South Wales, Australia; University of Sydney, Glebe, New South Wales, Australia
| | - Nikki McCaffrey
- Deakin Health Economics, School of Health and Social Development, Deakin University, Melbourne, Victoria, Australia
| | - Magnus Ekström
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia; Department of Clinical Sciences Lund, Lund University, Faculty of Medicine, Respiratory Medicine and Allergology, Lund, Sweden
| | - David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia; IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.
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Abstract
PURPOSE OF REVIEW In ICU patients, dyspnea is one of the most prominent and distressing symptom. We sought to summarize current data on the prevalence and prognostic influence of dyspnea in the ICU setting and to provide concise and useful information for dyspnea detection and management. RECENT FINDINGS As opposed to pain, dyspnea has been a neglected symptom with regard to detection and management. Many factors contribute to the pathogenesis of dyspnea. Among them, ventilator settings seem to play a major role. Dyspnea affects half of mechanically ventilated patient and causes immediate intense suffering [median dyspnea visual analog scale of 5 (4-7)]. In addition, it is associated with delayed extubation and with an increased risk of intubation and mortality in those receiving noninvasive ventilation. However, one-third of critically ill patients are noncommunicative, and therefore, at high risk of misdiagnosis. Heteroevaluation scales based on physical and behavioral signs of respiratory discomfort are reliable and promising alternatives to self-report. SUMMARY Dyspnea is frequent and severe in critically ill patients. Implementation of observational scale will help physicians to access to noncommunicative patient's respiratory suffering and tailor its treatment. Further studies on the prognostic impact and management strategies are needed.
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Mori M, Morita T, Matsuda Y, Yamada H, Kaneishi K, Matsumoto Y, Matsuo N, Odagiri T, Aruga E, Watanabe H, Tatara R, Sakurai H, Kimura A, Katayama H, Suga A, Nishi T, Shirado AN, Watanabe T, Kuchiba A, Yamaguchi T, Iwase S. How successful are we in relieving terminal dyspnea in cancer patients? A real-world multicenter prospective observational study. Support Care Cancer 2019; 28:3051-3060. [DOI: 10.1007/s00520-019-05081-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 09/16/2019] [Indexed: 12/19/2022]
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Cavalheri V, Burtin C, Formico VR, Nonoyama ML, Jenkins S, Spruit MA, Hill K. Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer. Cochrane Database Syst Rev 2019; 6:CD009955. [PMID: 31204439 PMCID: PMC6571512 DOI: 10.1002/14651858.cd009955.pub3] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Decreased exercise capacity and health-related quality of life (HRQoL) are common in people following lung resection for non-small cell lung cancer (NSCLC). Exercise training has been demonstrated to confer gains in exercise capacity and HRQoL for people with a range of chronic conditions, including chronic obstructive pulmonary disease and heart failure, as well as in people with prostate and breast cancer. A programme of exercise training may also confer gains in these outcomes for people following lung resection for NSCLC. This systematic review updates our 2013 systematic review. OBJECTIVES The primary aim of this review was to determine the effects of exercise training on exercise capacity and adverse events in people following lung resection (with or without chemotherapy) for NSCLC. The secondary aims were to determine the effects of exercise training on other outcomes such as HRQoL, force-generating capacity of peripheral muscles, pressure-generating capacity of the respiratory muscles, dyspnoea and fatigue, feelings of anxiety and depression, lung function, and mortality. SEARCH METHODS We searched for additional randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2019, Issue 2 of 12), MEDLINE (via PubMed) (2013 to February 2019), Embase (via Ovid) (2013 to February 2019), SciELO (The Scientific Electronic Library Online) (2013 to February 2019), and PEDro (Physiotherapy Evidence Database) (2013 to February 2019). SELECTION CRITERIA We included RCTs in which participants with NSCLC who underwent lung resection were allocated to receive either exercise training, which included aerobic exercise, resistance exercise, or a combination of both, or no exercise training. DATA COLLECTION AND ANALYSIS Two review authors screened the studies and identified those eligible for inclusion. We used either postintervention values (with their respective standard deviation (SD)) or mean changes (with their respective SD) in the meta-analyses that reported results as mean difference (MD). In meta-analyses that reported results as standardised mean difference (SMD), we placed studies that reported postintervention values and those that reported mean changes in separate subgroups. We assessed the certainty of evidence for each outcome by downgrading or upgrading the evidence according to GRADE criteria. MAIN RESULTS Along with the three RCTs included in the original version of this review (2013), we identified an additional five RCTs in this update, resulting in a total of eight RCTs involving 450 participants (180 (40%) females). The risk of selection bias in the included studies was low and the risk of performance bias high. Six studies explored the effects of combined aerobic and resistance training; one explored the effects of combined aerobic and inspiratory muscle training; and one explored the effects of combined aerobic, resistance, inspiratory muscle training and balance training. On completion of the intervention period, compared to the control group, exercise capacity expressed as the peak rate of oxygen uptake (VO2peak) and six-minute walk distance (6MWD) was greater in the intervention group (VO2peak: MD 2.97 mL/kg/min, 95% confidence interval (CI) 1.93 to 4.02 mL/kg/min, 4 studies, 135 participants, moderate-certainty evidence; 6MWD: MD 57 m, 95% CI 34 to 80 m, 5 studies, 182 participants, high-certainty evidence). One adverse event (hip fracture) related to the intervention was reported in one of the included studies. The intervention group also achieved greater improvements in the physical component of general HRQoL (MD 5.0 points, 95% CI 2.3 to 7.7 points, 4 studies, 208 participants, low-certainty evidence); improved force-generating capacity of the quadriceps muscle (SMD 0.75, 95% CI 0.4 to 1.1, 4 studies, 133 participants, moderate-certainty evidence); and less dyspnoea (SMD -0.43, 95% CI -0.81 to -0.05, 3 studies, 110 participants, very low-certainty evidence). We observed uncertain effects on the mental component of general HRQoL, disease-specific HRQoL, handgrip force, fatigue, and lung function. There were insufficient data to comment on the effect of exercise training on maximal inspiratory and expiratory pressures and feelings of anxiety and depression. Mortality was not reported in the included studies. AUTHORS' CONCLUSIONS Exercise training increased exercise capacity and quadriceps muscle force of people following lung resection for NSCLC. Our findings also suggest improvements on the physical component score of general HRQoL and decreased dyspnoea. This systematic review emphasises the importance of exercise training as part of the postoperative management of people with NSCLC.
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Affiliation(s)
- Vinicius Cavalheri
- Curtin UniversitySchool of Physiotherapy and Exercise Science, Faculty of Health SciencesKent StreetPerthWestern AustraliaAustralia6102
- Sir Charles Gairdner HospitalInstitute for Respiratory HealthPerthWestern AustraliaAustralia
| | - Chris Burtin
- Hasselt UniversityReval Rehabilitation Research Center, BIOMED, Faculty of Rehabilitation SciencesAgoralaan Gebouw ADiepenbeekLimburgBelgium3590
| | - Vittoria R Formico
- Universidade Estadual Paulista (UNESP)Physiotherapy Department, Faculdade de Ciências e TecnologiaPresidente PrudenteBrazil
| | - Mika L Nonoyama
- University of Ontario Institute of TechnologyFaculty of Health Sciences2000 Simcoe Street NorthOshawaONCanadaL1H 7K4
| | - Sue Jenkins
- Curtin UniversitySchool of Physiotherapy and Exercise Science, Faculty of Health SciencesKent StreetPerthWestern AustraliaAustralia6102
- Sir Charles Gairdner HospitalPhysiotherapy DepartmentHospital AvenuePerthAustralia
| | - Martijn A. Spruit
- Hasselt UniversityReval Rehabilitation Research Center, BIOMED, Faculty of Rehabilitation SciencesAgoralaan Gebouw ADiepenbeekLimburgBelgium3590
- CIROResearch and EducationHornerheide 1HornNetherlands6085 NM
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical CenterRespiratory MedicineMaastrichtNetherlands6202 AZ
| | - Kylie Hill
- Curtin UniversitySchool of Physiotherapy and Exercise Science, Faculty of Health SciencesKent StreetPerthWestern AustraliaAustralia6102
- Sir Charles Gairdner HospitalInstitute for Respiratory HealthPerthWestern AustraliaAustralia
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Lovell N, Etkind SN, Bajwah S, Maddocks M, Higginson IJ. Control and Context Are Central for People With Advanced Illness Experiencing Breathlessness: A Systematic Review and Thematic Synthesis. J Pain Symptom Manage 2019; 57:140-155.e2. [PMID: 30291949 DOI: 10.1016/j.jpainsymman.2018.09.021] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 12/01/2022]
Abstract
CONTEXT Breathlessness is common and distressing in advanced illness. It is a challenge to assess, with few effective treatment options. To evaluate new treatments, appropriate outcome measures that reflect the concerns of people experiencing breathlessness are needed. OBJECTIVES The objective of this study was to systematically review and synthesize the main concerns of people with advanced illness experiencing breathlessness to guide comprehensive clinical assessment and inform future outcome measurement in clinical practice and research. METHODS This is a systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. MEDLINE (1946-2017), PsycINFO (1806-2017), and EMBASE (1974-2017), as well as key journals, gray literature, reference lists, and citation searches, identified qualitative studies exploring the concerns of people living with breathlessness. Included studies were quality-assessed using the Critical Appraisal Skills Program checklist and analyzed using thematic synthesis. RESULTS We included 38 studies with 672 participants. Concerns were identified across six domains of "total" breathlessness: physical, emotional, spiritual, social, control, and context (chronic and episodic breathlessness). Four of these have been previously identified in the concept of "total dyspnea." Control and context have been newly identified as important, particularly in their influence on coping and help-seeking behavior. The importance of social participation, impact on relationships, and loss of perceived role within social and spiritual domains also emerged as being significant to individuals. CONCLUSION People with advanced illness living with breathlessness have concerns in multiple domains, supporting a concept of "total breathlessness." This adapted model can help to guide comprehensive clinical assessment and inform future outcome measurement in clinical practice and research.
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Affiliation(s)
- Natasha Lovell
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom.
| | - Simon N Etkind
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, United Kingdom
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Looijmans M, van Manen AS, Traa MJ, Kloover JS, Kessels BLJ, de Vries J. Psychosocial consequences of diagnosis and treatment of lung cancer and evaluation of the need for a lung cancer specific instrument using focus group methodology. Support Care Cancer 2018; 26:4177-4185. [PMID: 29948393 PMCID: PMC6209000 DOI: 10.1007/s00520-018-4291-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Accepted: 05/23/2018] [Indexed: 12/18/2022]
Abstract
OBJECTIVES Patients with lung cancer (LC) have high rates of psychosocial symptoms and international guidelines recommend regular psychosocial screening during treatment. This study evaluates psychosocial consequences of diagnosis and treatment of LC in a qualitative way and evaluates the need for a LC specific screening instrument. METHODS Focus group meetings with LC patients were divided by treatment type. Patients discussed psychological and social consequences of diagnosis and treatment. Major themes were identified using content analysis. Themes were re-evaluated in a subsequent focus group, in accordance with the European Organization for Research and Treatment of Cancer (EORTC) guidelines. RESULTS Patients reported a range of psychosocial consequences, such as frustration due to physical limitations, fear of recurrence, sadness of leaving behind partner and children, and disappointing social support. Patients treated with palliative intent specifically indicated insecurities about the future. Patients from all treatment modalities indicated a need for family support during treatment. No themes specific to LC arose. CONCLUSIONS Patients with LC are coping with a range of psychosocial consequences, independent of the type of treatment they receive. Fear of recurrence/metastasis and insecurity about the future were more prominent in patients receiving palliative chemotherapy. Themes were not specific to LC; therefore, a screening instrument specific for the LC population does not seem required. However, the current standard for screening is considered insufficiently sensitive and a stepped screening approach with specific screening tools and a clinical interview is suggested as usual care.
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Affiliation(s)
- Milou Looijmans
- CoRPS - Center of Research on Psychology in Somatic diseases, Department of Medical and Clinical Psychology, Tilburg University, PO Box 90153, 5000, Tilburg, LE, The Netherlands
| | - Annick S van Manen
- CoRPS - Center of Research on Psychology in Somatic diseases, Department of Medical and Clinical Psychology, Tilburg University, PO Box 90153, 5000, Tilburg, LE, The Netherlands
| | - Marjan J Traa
- CoRPS - Center of Research on Psychology in Somatic diseases, Department of Medical and Clinical Psychology, Tilburg University, PO Box 90153, 5000, Tilburg, LE, The Netherlands
- Department of Medical Psychology, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | - Jeroen S Kloover
- Department of Respiratory Diseases, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | - Bart L J Kessels
- Department of Respiratory Diseases, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands
| | - Jolanda de Vries
- CoRPS - Center of Research on Psychology in Somatic diseases, Department of Medical and Clinical Psychology, Tilburg University, PO Box 90153, 5000, Tilburg, LE, The Netherlands.
- Department of Medical Psychology, Elisabeth Tweesteden Hospital, Tilburg, The Netherlands.
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17
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Currow DC, Ekström M, Louw S, Hill J, Fazekas B, Clark K, Davidson PM, McDonald C, Sajkov D, McCaffrey N, Doogue M, Abernethy AP, Agar M. Sertraline in symptomatic chronic breathlessness: a double blind, randomised trial. Eur Respir J 2018; 53:13993003.01270-2018. [DOI: 10.1183/13993003.01270-2018] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 10/03/2018] [Indexed: 11/05/2022]
Abstract
Does sertraline provide symptomatic relief for chronic breathlessness in people with advanced disease whose underlying cause(s) are optimally treated?223 participants with chronic breathlessness (modified Medical Research Council breathlessness scale ≥2) who had optimal treatment of underlying cause(s) were randomised 1:1 to sertraline 25–100 mg (titrated upwards over 9 days) or placebo for 4 weeks. The primary outcome was the proportion who had an improvement in intensity of current breathlessness >15% from baseline on a 100-mm visual analogue scale.The proportion of people responding to sertraline was similar to placebo for current breathlessness on days 26–28 (OR 1.00, 95% CI 0.71–1.40) and for other measures of breathlessness. Quality of life in the sertraline arm had a higher likelihood of improving than in the placebo arm over the 4 weeks (OR 0.21, 95% CI 0.01–0.41; p=0.044). No differences in performance status, anxiety and depression, or survival were observed. Adverse event rates were similar between arms.Sertraline does not appear to provide any benefit over placebo in the symptomatic relief of chronic breathlessness in this patient population.
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18
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Stevens JP, Dechen T, Schwartzstein R, O'Donnell C, Baker K, Howell MD, Banzett RB. Prevalence of Dyspnea Among Hospitalized Patients at the Time of Admission. J Pain Symptom Manage 2018; 56:15-22.e2. [PMID: 29476798 PMCID: PMC6317868 DOI: 10.1016/j.jpainsymman.2018.02.013] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2017] [Revised: 02/14/2018] [Accepted: 02/14/2018] [Indexed: 11/22/2022]
Abstract
CONTEXT Dyspnea is an uncomfortable and distressing sensation experienced by hospitalized patients. OBJECTIVES There is no large-scale study of the prevalence and intensity of patient-reported dyspnea at the time of admission to the hospital. METHODS Between March 2014 and September 2016, we conducted a prospective cohort study among all consecutive hospitalized patients at a single tertiary care center in Boston, MA. During the first 12 hours of admission to medical-surgical and obstetric units, nurses at our institution routinely collect a patient's 1) current level of dyspnea on a 0-10 scale with 10 anchored at "unbearable," 2) worst dyspnea in the past 24 hours before arrival at the hospital on the same 0-10 scale, and 3) activities that were associated with dyspnea before admission. The prevalence of dyspnea was identified, and tests of difference were performed across patient characteristics. RESULTS We analyzed 67,362 patients, 12% of whom were obstetric patients. Fifty percent of patients were admitted to a medical-surgical unit after treatment in the emergency department. Among all noncritically ill inpatients, 16% of patients experienced dyspnea in the 24 hours before the admission. Twenty-three percent of patients admitted through the emergency department reported any dyspnea in the past 24 hours. Eleven percent experienced some current dyspnea when interviewed within 12 hours of admission with 4% of patients experiencing dyspnea that was rated 4 or greater. Dyspnea of 4 or more was present in 43% of patients admitted with respiratory diagnoses and 25% of patients with cardiovascular diagnoses. After multivariable adjustment for severity of illness and patient comorbidities, patients admitted on the weekend or during the overnight nursing shift were more likely to report dyspnea on admission. CONCLUSION Dyspnea is a common symptom among all hospitalized patients. Routine documentation of dyspnea is feasible in a large tertiary care center.
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Affiliation(s)
- Jennifer P Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
| | - Tenzin Dechen
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Richard Schwartzstein
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Carl O'Donnell
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
| | - Kathy Baker
- Lois E. Silverman Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Michael D Howell
- Center for Healthcare Delivery Science and Innovation, University of Chicago Medicine, Chicago, Illinois, USA; Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Robert B Banzett
- Division for Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA
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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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Hutchinson A, Barclay-Klingle N, Galvin K, Johnson MJ. Living with breathlessness: a systematic literature review and qualitative synthesis. Eur Respir J 2018; 51:51/2/1701477. [PMID: 29467199 DOI: 10.1183/13993003.01477-2017] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Accepted: 12/09/2017] [Indexed: 02/03/2023]
Abstract
What is the experience of people living with breathlessness due to medical conditions, those caring for them and those treating them, with regard to quality of life and the nature of clinical interactions?Electronic databases (Ovid MEDLINE, Embase, CINAHL Plus and PsycINFO) were searched (January 1987 to October 2017; English language), for qualitative studies exploring the experience of chronic breathlessness (patients, carers and clinicians). Two independent reviewers screened titles, abstracts and papers retrieved against inclusion criteria. Disagreements were resolved with a third reviewer. Primary qualitative data were extracted and synthesised using thematic synthesis.Inclusion and synthesis of 101 out of 2303 international papers produced four descriptive themes: 1) widespread effects of breathlessness; 2) coping; 3) help-seeking behaviour; and 4) clinicians' responsiveness to the symptom of breathlessness. The themes were combined to form the concept of "breathing space", to show how engaged coping and appropriate help-seeking (patient) and attention to symptom (clinician) helps maximise the patient's quality of living with breathlessness.Breathlessness has widespread impact on both patient and carer and affects breathing space. The degree of breathing space is influenced by interaction between the patient's coping style, their help-seeking behaviour and their clinician's responsiveness to breathlessness itself, in addition to managing the underlying disease.
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Damani A, Ghoshal A, Salins N, Deodhar J, Muckaden M. Prevalence and Intensity of Dyspnea in Advanced Cancer and its Impact on Quality of Life. Indian J Palliat Care 2018; 24:44-50. [PMID: 29440806 PMCID: PMC5801629 DOI: 10.4103/ijpc.ijpc_114_17] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
CONTEXT Dyspnea is a subjective, multidimensional experience of breathing discomfort, commonly seen in patients with advanced cancer. To find the impact of dyspnea on the quality of life in this population, it is important to understand the prevalence and factors influencing dyspnea. AIMS This study aimed to determine the prevalence, intensity, and factors influencing dyspnea in advanced cancer and determine its impact on overall quality of life. SETTINGS AND DESIGN This was a prospective cross-sectional study. The prevalence of dyspnea and its impact on quality of life was determined in 500 patients registered with palliative medicine outpatient department. SUBJECTS AND METHODS The patients were asked to fill a set of questionnaires, which included the Cancer Dyspnea Scale (translated and validated Hindi and Marathi versions), visual analog scale for dyspnea and EORTC QLQ C 15 PAL. Details of demographics, symptomatology, and medical data were collected from the case record sheets of the patients. STATISTICAL ANALYSIS USED Descriptive statistics, univariate, and multiple regression analysis were used to calculate the results. RESULTS About 44.37% of the patients experienced dyspnea. Dyspnea increased with worsening anxiety, depression, fatigue, appetite, well-being, pain, lung involvement by primary or metastatic cancer, performance status, and deteriorating overall quality of life and emotional wellbeing. CONCLUSIONS The prevalence of dyspnea in advanced cancer patients is as high as 44.37% and has a negative impact on their overall quality of life.
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Affiliation(s)
- Anuja Damani
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Arunangshu Ghoshal
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - Jayita Deodhar
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
| | - MaryAnn Muckaden
- Department of Palliative Medicine, Tata Memorial Hospital, Mumbai, Maharashtra, India
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22
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Damani A, Ghoshal A, Salins N, Deodhar J, Muckaden M. Validation of "Cancer Dyspnea Scale" in Patients With Advanced Cancer in a Palliative Care Setting in India. J Pain Symptom Manage 2017; 54:715-720.e1. [PMID: 28797864 DOI: 10.1016/j.jpainsymman.2017.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 05/15/2017] [Accepted: 06/07/2017] [Indexed: 10/19/2022]
Abstract
CONTEXT Assessment of dyspnea in patients with advanced cancer is challenging. Cancer Dyspnea Scale (CDS) is a multidimensional scale developed for the measurement of dyspnea. It is available only in Japanese, English, and Swedish and has not been validated before in the Indian languages. OBJECTIVE The objective was to describe the process of validation and reliability testing of CDS in Indian advanced cancer patients. METHODS This is a prospective observational study conducted in the palliative care clinic of a tertiary cancer center in Mumbai. The English version of CDS was translated into Indian languages-Hindi (CDS-H) and Marathi (CDS-M). One hundred twenty newly registered eligible patients (60 for CDS-H and 60 for CDS-M) were enrolled into the study consecutively. They were asked to fill CDS (translated version) and Visual Analogue Scale for dyspnea. Only baseline measures were used. RESULTS Validity was separately analyzed for CDS-H and CDS-M. The results showed good construct validity between CDS-H and CDS-M. Intersubscale correlation was done by calculating the Pearson's correlation coefficient (mean r = 0.64 and 0.764 for CDS-H and CDS-M, respectively). Convergent validity was calculated by computing the correlation of each factor with VAS-D scores and was found statistically significant (P < 0.001; average r ranging from 0.706 to 0.714). Reliability of the scale was determined by its internal consistency (Cronbach's alpha coefficient ranging from 0.716 to 0.879). CONCLUSION This study demonstrates that CDS-H and CDS-M are valid and reliable multidimensional scales, which can be used to assess dyspnea in patients with advanced cancer.
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Affiliation(s)
- Anuja Damani
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Arunangshu Ghoshal
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Naveen Salins
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - Jayita Deodhar
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
| | - MaryAnn Muckaden
- Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India.
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Currow D, Watts GJ, Johnson M, McDonald CF, Miners JO, Somogyi AA, Denehy L, McCaffrey N, Eckert DJ, McCloud P, Louw S, Lam L, Greene A, Fazekas B, Clark KC, Fong K, Agar MR, Joshi R, Kilbreath S, Ferreira D, Ekström M. A pragmatic, phase III, multisite, double-blind, placebo-controlled, parallel-arm, dose increment randomised trial of regular, low-dose extended-release morphine for chronic breathlessness: Breathlessness, Exertion And Morphine Sulfate (BEAMS) study protocol. BMJ Open 2017; 7:e018100. [PMID: 28716797 PMCID: PMC5726102 DOI: 10.1136/bmjopen-2017-018100] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Accepted: 06/07/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Chronic breathlessness is highly prevalent and distressing to patients and families. No medication is registered for its symptomatic reduction. The strongest evidence is for regular, low-dose, extended- release (ER) oral morphine. A recent large phase III study suggests the subgroup most likely to benefit have chronic obstructive pulmonary disease (COPD) and modified Medical Research Council breathlessness scores of 3 or 4. This protocol is for an adequately powered, parallel-arm, placebo-controlled, multisite, factorial, block-randomised study evaluating regular ER morphine for chronic breathlessness in people with COPD. METHODS AND ANALYSIS The primary question is what effect regular ER morphine has on worst breathlessness, measured daily on a 0-10 numerical rating scale. Uniquely, the coprimary outcome will use a FitBit to measure habitual physical activity. Secondary questions include safety and, whether upward titration after initial benefit delivers greater net symptom reduction. Substudies include longitudinal driving simulation, sleep, caregiver, health economic and pharmacogenetic studies. Seventeen centres will recruit 171 participants from respiratory and palliative care. The study has five phases including three randomisation phases to increasing doses of ER morphine. All participants will receive placebo or active laxatives as appropriate. Appropriate statistical analysis of primary and secondary outcomes will be used. ETHICS AND DISSEMINATION Ethics approval has been obtained. Results of the study will be submitted for publication in peer-reviewed journals, findings presented at relevant conferences and potentially used to inform registration of ER morphine for chronic breathlessness. TRIAL REGISTRATION NUMBER NCT02720822; Pre-results.
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Affiliation(s)
- David Currow
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Gareth John Watts
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, Australia
| | - Miriam Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
- Hull York Medical School, University of Hull, Hull, UK
| | - Christine F McDonald
- Department of Austin Health, Respiratory and Sleep Medicine, Austin Hospital, Heidelberg, Australia
| | - John O Miners
- Clinical Pharmacology School of Medicine, Flinders University, Adelaide, Australia
| | - Andrew A Somogyi
- Department of Clinical Pharmacology, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Linda Denehy
- School of Health Sciences, University of Melbourne, Parkville, Victoria, Australia
| | - Nicola McCaffrey
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
| | - Danny J Eckert
- Neuroscience Research Australia (NeRA) Randwick, New South Wales, Australia
| | - Philip McCloud
- MCloud Consulting Group, Belrose, New South Wales, Australia
| | - Sandra Louw
- MCloud Consulting Group, Belrose, New South Wales, Australia
| | - Lawrence Lam
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Aine Greene
- Southern Adelaide Palliative Services, Adelaide, South Australia, Australia
| | - Belinda Fazekas
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
| | - Katherine C Clark
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, Australia
- School of Medicine and Public Health, The University if Newcastle, Newcastle, New South Wales, Australia
| | - Kwun Fong
- Thoracic Research Centre, The Prince Charles Hospital School of Medicine, University of Queensland, Australia
| | - Meera R Agar
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
- Faculty of Health, University of Technology Sydney, Sydney, Australia
- Clinical Trials, Ingham Institute of Applied Medical Research, Sydney, Australia
- South West Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Rohit Joshi
- Department of Medical Oncology, University of Adelaide Lyell MEwin Hospital, Adelaide, Australia
| | - Sharon Kilbreath
- Faculty of Health, University of Technology Sydney, Sydney, Australia
| | - Diana Ferreira
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
| | - Magnus Ekström
- Discipline, Palliative and Supportive Services, Flinders University, Adelaide, Australia
- Department of Respiratory Medicine and Allergology, Institution for Clinical Sciences, Lund University, Sweden
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Feasibility of objectively measured physical activity and sedentary behavior in patients with malignant pleural effusion. Support Care Cancer 2017; 25:3133-3141. [PMID: 28455548 DOI: 10.1007/s00520-017-3721-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 04/17/2017] [Indexed: 01/15/2023]
Abstract
PURPOSE Malignant pleural effusion (MPE) affects 1 million people worldwide annually and can significantly impair physical activity. Accelerometry is a validated method of objectively assessing physical activity. The purpose of this study was to determine the compliance in patients with MPE to accelerometry and describe their activity. METHODS Patients with MPE wore an Actigraph GT3X accelerometer over a 7-day continuous wear protocol. Compliance was measured as the percent of patients who had ≥4 valid days (i.e., 8-h/day of waking wear-time). Eastern Cooperative Oncology Group performance status was documented the day of actigraphy initialization. RESULTS Forty-six patients with MPE received accelerometers; 44 (95.7%) returned their device. No complications were reported on their use. Forty subjects (90.9%) had ≥4 valid days of wear-time. Patients spent most of their waking hours sedentary [mean 11.0 h (SD 1.95)], with limited participation in moderate and vigorous physical activity [mean 9.5 min (SD 14.16)]. Compared to patients with better performance status (n = 32), patients with poorer performance status (n = 11) spent significantly more hours/day sedentary [mean difference 2.1 (CI 0.86-3.32); p = 0.001], as did those who survived <3 months (n = 5) compared to >12 months (n = 27) [mean difference 2.6 (CI 0.49-4.77); p = 0.013). CONCLUSION Accelerometry was applied successfully in patients with MPE with high compliance and no adverse events. This is the first reported objectively measured physical activity in patients with MPE and revealed high sedentary behavior and low physical activity. The data reflected patient performance status and discriminated between survival groups. Accelerometry can provide a useful measure for future interventional studies in patients with MPE.
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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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Watts GJ, Clark K, Agar M, Davidson PM, McDonald C, Lam LT, Sajkov D, McCaffrey N, Doogue M, Abernethy AP, Currow DC. Study protocol: a phase III randomised, double-blind, parallel arm, stratified, block randomised, placebo-controlled trial investigating the clinical effect and cost-effectiveness of sertraline for the palliative relief of breathlessness in people with chronic breathlessness. BMJ Open 2016; 6:e013177. [PMID: 27899400 PMCID: PMC5168508 DOI: 10.1136/bmjopen-2016-013177] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Breathlessness remains a highly prevalent and distressing symptom for many patients with progressive life-limiting illnesses. Evidence-based interventions for chronic breathlessness are limited, and there is an ongoing need for high-quality research into developing management strategies for optimal palliation of this complex symptom. Previous studies have suggested that selective serotonin reuptake inhibitors such as sertraline may have a role in reducing breathlessness. This paper presents the protocol for a large, adequately powered randomised study evaluating the use of sertraline for chronic breathlessness in people with progressive life-limiting illnesses. METHODS AND ANALYSIS A total of 240 participants with modified Medical Research Council Dyspnoea Scale breathlessness of level 2 or higher will be randomised to receive either sertraline or placebo for 28 days in this multisite, double-blind study. The dose will be titrated up every 3 days to a maximum of 100 mg daily. The primary outcome will be to compare the efficacy of sertraline with placebo in relieving the intensity of worst breathlessness as assessed by a 0-100 mm Visual Analogue Scale. A number of other outcome measures and descriptors of breathlessness as well as caregiver assessments will also be recorded to ensure adequate analysis of participant breathlessness and to allow an economic analysis to be performed. Participants will also be given the option of continuing blinded treatment until either study data collection is complete or net benefit ceases. Appropriate statistical analysis of primary and secondary outcomes will be used to describe the wealth of data obtained. ETHICS AND DISSEMINATION Ethics approval was obtained at all participating sites. Results of the study will be submitted for publication in peer-reviewed journals and the key findings presented at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12610000464066.
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Affiliation(s)
- Gareth J Watts
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
| | - Katherine Clark
- Department of Palliative Care, Calvary Mater Newcastle, Newcastle, New South Wales, Australia
- School of Medicine and Public Health, The University of Newcastle, Newcastle, New South Wales, Australia
| | - Meera Agar
- Faculty of Health and Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- Clinical Trials, Ingham Institute of Applied Medical Research, Sydney, New South Wales, Australia
- Department of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
- South West Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Patricia M Davidson
- Faculty of Health and Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
- School of Nursing, Johns Hopkins University, Baltimore, Maryland, USA
| | - Christine McDonald
- Austin Health, Respiratory and Sleep Medicine, Austin Hospital, Heidelberg, Victoria, Australia
| | - Lawrence T Lam
- Faculty of Health and Graduate School of Health, University of Technology Sydney, Sydney, New South Wales, Australia
| | - Dimitar Sajkov
- Australian Respiratory and Sleep Medicine Institute, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Nicola McCaffrey
- Department of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
| | - Matthew Doogue
- Department of Clinical Pharmacology, University of Otago, Christchurch, New Zealand
| | - Amy P Abernethy
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - David C Currow
- Department of Palliative and Supportive Services, Flinders University, Adelaide, South Australia, Australia
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Predictors of response to corticosteroids for dyspnea in advanced cancer patients: a preliminary multicenter prospective observational study. Support Care Cancer 2016; 25:1169-1181. [DOI: 10.1007/s00520-016-3507-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 11/21/2016] [Indexed: 12/19/2022]
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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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A randomised study comparing the effectiveness of acupuncture or morphine versus the combination for the relief of dyspnoea in patients with advanced non-small cell lung cancer and mesothelioma. Eur J Cancer 2016; 61:102-10. [DOI: 10.1016/j.ejca.2016.03.078] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 03/21/2016] [Indexed: 11/23/2022]
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Affiliation(s)
- Robert B Banzett
- 1 Division of Pulmonary, Critical Care & Sleep Medicine Beth Israel Deaconess Medical Center Boston, Massachusetts and.,2 Department of Medicine Harvard Medical School Boston, Massachusetts
| | - Richard M Schwartzstein
- 1 Division of Pulmonary, Critical Care & Sleep Medicine Beth Israel Deaconess Medical Center Boston, Massachusetts and.,2 Department of Medicine Harvard Medical School Boston, Massachusetts
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Stevens JP, Baker K, Howell MD, Banzett RB. Prevalence and Predictive Value of Dyspnea Ratings in Hospitalized Patients: Pilot Studies. PLoS One 2016; 11:e0152601. [PMID: 27070144 PMCID: PMC4829144 DOI: 10.1371/journal.pone.0152601] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 03/16/2016] [Indexed: 11/18/2022] Open
Abstract
Background Dyspnea (breathing discomfort) can be as powerfully aversive as pain, yet is not routinely assessed and documented in the clinical environment. Routine identification and documentation of dyspnea is the first step to improved symptom management and it may also identify patients at risk of negative clinical outcomes. Objective To estimate the prevalence of dyspnea and of dyspnea-associated risk among hospitalized patients. Design Two pilot prospective cohort studies. Setting Single academic medical center. Patients Consecutive patients admitted to four inpatient units: cardiology, hematology/oncology, medicine, and bariatric surgery. Measurements In Study 1, nurses documented current and recent patient-reported dyspnea at the time of the Initial Patient Assessment in 581 inpatients. In Study 2, nurses documented current dyspnea at least once every nursing shift in 367 patients. We describe the prevalence of burdensome dyspnea, and compare it to pain. We also compared dyspnea ratings with a composite of adverse outcomes: 1) receipt of care from the hospital’s rapid response system, 2) transfer to the intensive care unit, or 3) death in hospital. We defined burdensome dyspnea as a rating of 4 or more on a 10-point scale. Results Prevalence of burdensome current dyspnea upon admission (Study 1) was 13% (77 of 581, 95% CI 11%-16%). Prevalence of burdensome dyspnea at some time during the hospitalization (Study 2) was 16% (57 of 367, 95% CI 12%-20%). Dyspnea was associated with higher odds of a negative outcome. Conclusions In two pilot studies, we identified a significant symptom burden of dyspnea in hospitalized patients. Patients reporting dyspnea may benefit from a more careful focus on symptom management and may represent a population at greater risk for negative outcomes.
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Affiliation(s)
- Jennifer P. Stevens
- Center for Healthcare Delivery Science, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Department of Medicine, Division for Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
- * E-mail:
| | - Kathy Baker
- Department of Nursing, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
| | - Michael D. Howell
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, United States of America
- Center for Healthcare Delivery Science and Innovation, University of Chicago, Chicago, Illinois, United States of America
| | - Robert B. Banzett
- Department of Medicine, Division for Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States of America
- Harvard Medical School, Boston, Massachusetts, United States of America
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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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Increasing Physical Activity and Exercise in Lung Cancer: Reviewing Safety, Benefits, and Application: Erratum. J Thorac Oncol 2015; 10:1712. [PMID: 26709480 DOI: 10.1097/jto.0000000000000681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Increasing Physical Activity and Exercise in Lung Cancer. J Thorac Oncol 2015. [DOI: 10.1016/s1556-0864(15)35093-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
Pulmonary rehabilitation, as a quality of life intervention, has a role to play in palliative care for lung cancer patients. Combining the art and skills of clinical care, physiological, and behavioral tools, pulmonary rehabilitation can serve to rebuild the functional capacity of patients limited by breathlessness and deconditioning. Exercise programs are the primary tool used to restore and rebuild the patient's endurance by challenging the entire pathway of oxygen transport and improving gas exchange. Other tools of pulmonary rehabilitation include breathing retraining, self-management skills, airway clearance techniques, bronchodilitation, smoking cessation and oxygen therapy. Pulmonary rehabilitation is now becoming a part of supportive care for patients undergoing chemotherapy and radiation therapy. The ability to be more active without suffering the consequences of dyspnea on exertion boosts the patient's self-efficacy and allows for an improved quality of life, so that lung cancer patients can participate in their family lives during this therapeutic challenge.
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Sharma P, Morris NR, Adams L. The effect of different exercise modalities on dyspnea and leg fatigue in healthy subjects. Respir Physiol Neurobiol 2015; 210:44-50. [DOI: 10.1016/j.resp.2015.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 02/06/2015] [Accepted: 02/09/2015] [Indexed: 11/26/2022]
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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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Affiliation(s)
- Robert B Banzett
- Dept of Medicine, Harvard Medical School, Boston, MA, USA Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Carl R O'Donnell
- Dept of Medicine, Harvard Medical School, Boston, MA, USA Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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Sharma P, Morris NR, Adams L. Effect of induced leg muscle fatigue on exertional dyspnea in healthy subjects. J Appl Physiol (1985) 2015; 118:48-54. [DOI: 10.1152/japplphysiol.00393.2014] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The genesis of dyspnea is complex. It appears to be related to central respiratory drive although prevailing leg fatigue could independently potentiate dyspnea. We hypothesized that experimentally induced leg fatigue generates more intense exertional dyspnea for a given level of ventilatory drive. Following familiarization, 19 healthy subjects (32.2 ± 7.6 yr; 11 men) performed a 5-min treadmill test (speed: ∼4 km/h; grade: ∼25%) on two separate days randomized between control (C) and experimentally induced leg fatigue (E) achieved by repeated knee extension against 40% body weight until task failure. Oxygen uptake (V̇o2, l/min), carbon dioxide output (V̇co2, l/min), ventilation (V̇e, l/min), and respiratory rate (fR) were measured breath by breath. Heart rate (HR) and perceived dyspnea intensity (0–10 numerical scale) were recorded continuously. Data were averaged over 30-s intervals. Exertional dyspnea during E was statistically significantly higher (E vs. C: 4.2 ± 0.2 vs. 3.4 ± 0.2, P < 0.001) and accompanied by a significant increase in V̇e (E vs. C: 61.7 ± 3.7 vs. 55.3 ± 2.8, P = 0.005) and fR (E vs. C: 26.7 ± 1.0 vs. 24.2 ± 1.3, P = 0.036). Dyspnea following E remained significantly higher after allowing for the V̇e confound (ANCOVA, P = 0.003). V̇o2, V̇co2, and HR were not significantly different between two conditions. However, the slopes for dyspnea vs. V̇o2 and dyspnea vs. V̇e were similar between E and C, which suggested that gain in dyspnea per unit change in V̇o2 or V̇e was not altered by leg fatigue. These findings support the hypothesis that the intensity of exertional dyspnea is exacerbated by peripheral afferent information from fatigued leg muscles.
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Affiliation(s)
- Pramod Sharma
- School of Allied Health Sciences/Heart Foundation Research Centre, Griffith University, Gold Coast Campus, Queensland, Australia
| | - Norman R. Morris
- School of Allied Health Sciences/Heart Foundation Research Centre, Griffith University, Gold Coast Campus, Queensland, Australia
| | - Lewis Adams
- School of Allied Health Sciences/Heart Foundation Research Centre, Griffith University, Gold Coast Campus, Queensland, Australia
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Shin JA, Kosiba JD, Traeger L, Greer JA, Temel JS, Pirl WF. Dyspnea and panic among patients with newly diagnosed non-small cell lung cancer. J Pain Symptom Manage 2014; 48:465-70. [PMID: 24766738 PMCID: PMC4163506 DOI: 10.1016/j.jpainsymman.2013.10.021] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2013] [Revised: 10/21/2013] [Accepted: 10/30/2013] [Indexed: 10/25/2022]
Abstract
CONTEXT Among patients with lung cancer, dyspnea is associated with psychological distress, fatigue, and poor coping. Respiratory symptoms are also a common trigger for panic attacks in the general population. Minimal research has addressed the prevalence of panic disorder or the association of dyspnea with the risk of panic disorder in lung cancer. OBJECTIVES We explored the frequency of panic disorder symptoms and the association of dyspnea with the risk of panic disorder symptoms among patients with newly diagnosed non-small cell lung cancer. METHODS During 2006-2010, consecutive patients presenting for initial consultation at a thoracic oncology clinic completed a survey of current symptoms, including dyspnea and panic disorder symptoms. We evaluated the frequency of panic disorder symptoms. Logistic regression was used to test the association of dyspnea with the risk of panic disorder symptoms, adjusting for age, gender, disease stage, performance status, and major depression symptoms. RESULTS Among 624 patients (mean age=63.7; standard deviation=12.1; 52.6% female), 48.1% reported that breathing was at least somewhat difficult and 11.2% endorsed panic disorder symptoms. Dyspnea was independently associated with higher risk of panic disorder symptoms (odds ratio=2.19, 95% confidence interval=1.11-4.31, P=0.02). Younger age and major depression symptoms also were associated with higher risk (P<0.01). CONCLUSION Almost half of the patients with newly diagnosed non-small cell lung cancer reported dyspnea, and patients with dyspnea were more than twice as likely to endorse panic disorder symptoms relative to patients without dyspnea. Results highlight the need to differentiate panic disorder symptoms among patients who report dyspnea, particularly those who are younger or experiencing major depression symptoms.
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Affiliation(s)
- Jennifer A Shin
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA.
| | - Jesse D Kosiba
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lara Traeger
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joseph A Greer
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jennifer S Temel
- Department of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - William F Pirl
- Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
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Moody CM, Chua B, Weary DM. The effect of carbon dioxide flow rate on the euthanasia of laboratory mice. Lab Anim 2014; 48:298-304. [PMID: 25097256 DOI: 10.1177/0023677214546509] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Laboratory rodents are commonly euthanized by exposure to gradually increasing concentrations of carbon dioxide (CO2). Current recommended flow rates range between 10 and 30% chamber vol/min and result in insensibility before exposure to painful concentrations (<40%). However, this method causes dyspnea, indicated by deep, rapid breathing. In humans dyspnea is associated with a negative affective experience. Sensations of dyspnea may explain why rodents find CO2 concentrations >3% aversive. This study aimed to assess the effect of CO2 flow rates on time between the onset of dyspnea and various measures of insensibility (recumbency, loss of the righting reflex and loss of the pedal withdrawal reflex) to identify flow rates that minimize the potential experience of dyspnea. The results of this study indicate that a flow rate of 50% chamber vol/min, while holding the CO2 cage concentration just below 40%, minimizes the interval between the onset of labored breathing and recumbency. Using a 50% flow rate this interval averaged (± SE) 30.3 ± 2.9 s versus 49.7 ± 2.9 s at 20% chamber vol/min (F3,22 = 7.83, P = 0.0013). Similarly, the interval between the onset of labored breathing and loss of the righting reflex averaged 38.2 ± 2.4 s at a flow rate of 50% versus 59.2 ± 2.4 s at 20% chamber vol/min of CO2 (F3,22 = 13.62, P < 0.0001). We conclude that higher flow rates reduce the duration of dyspnea, but even at the highest flow rate mice experience more than 30 s between the onset of dyspnea and the most conservative estimate of insensibility.
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Affiliation(s)
- C M Moody
- Animal Welfare Program, Faculty of Land and Food Systems, University of British Columbia, Vancouver, Canada
| | - B Chua
- Centre for Comparative Medicine, University of British Columbia, Vancouver, Canada
| | - D M Weary
- Animal Welfare Program, Faculty of Land and Food Systems, University of British Columbia, Vancouver, Canada
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Exercise training for people following lung resection for non-small cell lung cancer – A Cochrane systematic review. Cancer Treat Rev 2014; 40:585-94. [DOI: 10.1016/j.ctrv.2013.11.001] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 10/06/2013] [Accepted: 11/01/2013] [Indexed: 12/31/2022]
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Riolfi M, Buja A, Zanardo C, Marangon CF, Manno P, Baldo V. Effectiveness of palliative home-care services in reducing hospital admissions and determinants of hospitalization for terminally ill patients followed up by a palliative home-care team: a retrospective cohort study. Palliat Med 2014; 28:403-11. [PMID: 24367058 DOI: 10.1177/0269216313517283] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND It has been demonstrated that most patients in the terminal stages of cancer would benefit from palliative home-care services. AIM The aim of this study was to assess the effectiveness of appropriate palliative home-care services in reducing hospital admissions, and to identify factors predicting the likelihood of patients treated at home being hospitalized. DESIGN Retrospective cohort study. SETTING/PARTICIPANTS We enrolled all 402 patients listed by the Local Health Authority No. 5, Veneto Region (North-East Italy), as dying of cancer in 2011. RESULTS Of the cohort considered, 39.9% patients had been taken into care by a palliative home-care team. Irrespective of age, gender, and type of tumor, patients taken into care by the palliative home-care team were more likely to die at home, less likely to be hospitalized, and spent fewer days in hospital in the last 2 months of their life. Among the patients taken into care by the palliative home-care team, those with hematological cancers and hepatocellular carcinoma were more likely to be hospitalized, and certain symptoms (such as dyspnea and delirium) were predictive of hospitalization. CONCLUSIONS Our study confirms the effectiveness of palliative home care in enabling patients to spend the final period of their lives at home. The services of a palliative home-care team reduced the consumption of hospital resources. This study also provided evidence of some types of cancer (e.g. hematological cancers and hepatocellular carcinoma) being more likely to require hospitalization, suggesting the need to reconsider the pathways of care for these diseases.
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Affiliation(s)
- Mirko Riolfi
- 1Palliative Care Team, Distretto Socio Sanitario Azienda ULSS 5 Ovest Vicentino, Arzignano, Italy
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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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Refsgaard B, Frederiksen K. Illness-related emotional experiences of patients living with incurable lung cancer: a qualitative metasynthesis. Cancer Nurs 2014; 36:221-8. [PMID: 23051865 DOI: 10.1097/ncc.0b013e318268f983] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Living with incurable lung cancer often drastically changes the patients' lives physically, socially, psychologically, and spiritually. The emotional experiences of patients with incurable lung cancer have been studied with a qualitative approach, but the findings are yet to be synthesized. OBJECTIVE The objective of this study was to synthesize interpreted knowledge on the illness-related emotional experiences of patients with incurable lung cancer. METHODS A qualitative metasynthesis was carried out to integrate the findings from 10 qualitative studies conducted between 1995 and 2011. The studies were critically appraised according to the method defined by Sandelowski and Barroso, and the findings were extracted, edited, and abstracted. The concept "loss" was imported as a method to synthesize the findings. RESULTS Eight themes of emotional experiences emerged: "guilt, blame, shame, and stigmatization," "hope and despair," "loneliness," "changing in self-image and self-worth," "uselessness and dependency," "uncertainty and worries," "anxiety and fear," and "loss." The loss experiences were categorized as unrecognized and clear losses. CONCLUSION This study supports that patients with incurable lung cancer undergo illness-related emotions that can be identified as losses. Further studies are required to determine the best way for nurses to implement emotional care. IMPLICATIONS FOR PRACTICE Nurses play an important role in the acknowledgement of unrecognized and clear losses while caring for patients with incurable lung cancer.
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Affiliation(s)
- Birgit Refsgaard
- Department of Respiratory Diseases, Aarhus University Hospital, Denmark.
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Abstract
BACKGROUND Lung cancer (LC) is often diagnosed late when curative intervention is no longer viable. However, current referral guidelines (e.g. UK National Institute for Health and Care Excellence guidelines) for suspected LC are based on a weak evidence base. Aim. The purpose of this systematic review is to identify symptoms that are independently associated with LC and to identify the key methodological issues relating to symptomatic diagnosis research in LC. METHODS Medline, Ovid and Cumulative Index to Nursing and Allied Health Literature were searched for the period between 1946 and 2012 using the MeSH terms 'lung cancer' and 'symptom*'. Quality of each paper was assessed using Scottish Intercollegiate Guidelines Network and Consolidated Criteria for Reporting Qualitative Research Checklists and checked by a second and third reviewer. RESULTS Evidence regarding the diagnostic values of most symptoms was inconclusive; haemoptysis was the only symptom consistently indicated as a predictor of LC. Generally, evidence was weakened by methodological issues such as the lack of standardized data collection (recording bias) and the lack of comparability of findings across the different studies that extend beyond the spectrum of disease. Qualitative studies indicated that patients with LC experienced symptoms months before diagnosis but did not interpret them as serious enough to seek health care. Therefore, early LC symptoms might be under-represented in primary care clinical notes. CONCLUSION Current evidence is insufficient to suggest a symptom profile for LC across the disease stages, nor can it be concluded that classical LC symptoms are predictors of LC apart from, perhaps, haemoptysis. Prospective studies are now needed that systematically record symptoms and explore their predictive values for LC diagnosis.
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Maguire R, Stoddart K, Flowers P, McPhelim J, Kearney N. An Interpretative Phenomenological Analysis of the lived experience of multiple concurrent symptoms in patients with lung cancer: a contribution to the study of symptom clusters. Eur J Oncol Nurs 2014; 18:310-5. [PMID: 24685125 DOI: 10.1016/j.ejon.2014.02.004] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 02/05/2014] [Accepted: 02/14/2014] [Indexed: 11/30/2022]
Abstract
PURPOSE OF THE RESEARCH To explore the lived experience of multiple concurrent symptoms in people with advanced lung cancer to contribute to the understanding of the experience of symptom clusters. METHODS AND SAMPLE Purposive sampling recruited ten people with advanced lung cancer who were experiencing three or more concurrent symptoms, were at least 18 years of age and were able to provide written informed consent. The participants took part in two consecutive, in-depth interviews, 3-5 weeks apart. Interpretative Phenomenological Analysis was used to analyse the data. FINDINGS Participants experienced 4-11 concurrent symptoms with fatigue, cough, pain and breathlessness featuring prominently in their interviews. The participants commonly identified associations between the symptoms that they experienced, with the occurrence of one symptom often used to explain the occurrence of another. Reductions in physical and social functioning were often associated with the experience of multiple concurrent symptoms, particularly at times of high symptom severity. The participants' highlighted breathlessness and cough as being of particular salience, due to the association of these symptoms with fear of death and visibility and embarrassment in public. CONCLUSIONS People with lung cancer experience multiple concurrent symptoms and perceive relationships between the symptoms experienced. Within the experience of multiple symptoms, people with lung cancer highlight individual symptoms that are of particular importance, based on their concomitant meanings. Such findings provide vital information for the future development of meaning-based symptom cluster interventions.
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Affiliation(s)
- Roma Maguire
- School of Health and Social Care, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey GU2 7TE, UK.
| | - Kathleen Stoddart
- School of Nursing, Midwifery and Health, University of Stirling, Stirling FK9 4LA, UK.
| | - Paul Flowers
- School of Health and Life Sciences, Glasgow Caledonian University, Cowcaddens Road, Glasgow G4 OBA, Scotland, UK.
| | - John McPhelim
- Hairmyres Hospital, NHS Lanarkshire, Eaglesham Road, East Kilbride, G75 8RG, UK.
| | - Nora Kearney
- School of Health and Social Care, Faculty of Health and Medical Sciences, University of Surrey, Guildford, Surrey GU2 7TE, UK.
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Abstract
PURPOSE OF REVIEW Lung cancer is the leading cause of cancer mortality in men and women. Most patients present with advanced disease and face significant morbidity, with many reporting distressing symptoms throughout the course of their illness. The purpose of this review is to highlight the recent studies that support the integration of early palliative care into the standard oncology care of patients with advanced lung cancer. RECENT FINDINGS Historically, palliative care was provided predominantly as a hospital-based consultation service; however, recent data support an outpatient delivery model of early palliative care alongside standard oncology care. In two randomized controlled trials, patients with advanced cancer who were assigned to early palliative care reported improved quality of life and mood. Numerous organizations have published guidelines to support the integration of palliative care into the routine care of patients with lung cancer. SUMMARY Palliative care is appropriate for patients at any point in a serious illness. Unlike hospice, palliative care is not limited by prognosis and may be provided at the same time as disease-directed therapies. There is strong evidence underscoring the importance of integrating palliative care across the trajectory of lung cancer. The primary oncology team should routinely assess for pain and other symptoms, and regularly inquire about a patient's understanding of his disease and his goals of care. Specialty palliative care can provide an extra layer of support for patients with lung cancer and their families by helping with more challenging symptom management, psychosocial support, complex decision-making, advance care planning, and transitions in care.
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Cavalheri V, Tahirah F, Nonoyama M, Jenkins S, Hill K. Exercise training undertaken by people within 12 months of lung resection for non-small cell lung cancer. Cochrane Database Syst Rev 2013:CD009955. [PMID: 23904353 DOI: 10.1002/14651858.cd009955.pub2] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Decreased exercise capacity and impairments in health-related quality of life (HRQoL) are common in people following lung resection for non-small cell lung cancer (NSCLC). Exercise training has been demonstrated to confer gains in exercise capacity and HRQoL for people with a range of chronic conditions, including chronic obstructive pulmonary disease and heart failure, as well as in people with cancers such as prostate and breast cancer. A programme of exercise training for people following lung resection for NSCLC may confer important gains in these outcomes. To date, evidence of its efficacy in this population is unclear. OBJECTIVES The primary aim of this study was to determine the effects of exercise training on exercise capacity in people following lung resection(with or without chemotherapy) for NSCLC. The secondary aims were to determine the effects on other outcomes such as HRQoL,lung function (forced expiratory volume in one second (FEV1)), peripheral muscle force, dyspnoea and fatigue as well as feelings of anxiety and depression. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 2 of 12), MEDLINE(via PubMed) (1966 to February 2013), EMBASE (via Ovid) (1974 to February 2013), SciELO (The Scientific Electronic Library Online) (1978 to February 2013) as well as PEDro (Physiotherapy Evidence Database) (1980 to February 2013). SELECTION CRITERIA We included randomised controlled trials (RCTs) in which study participants withNSCLC, who had recently undergone lung resection,were allocated to receive either exercise training or no exercise training. DATA COLLECTION AND ANALYSIS Two review authors screened the studies and identified those for inclusion. Meta-analyses were performed using post-intervention datafor those studies in which no differences were reported between the exercise and control group either: (i) prior to lung resection, or(ii) following lung resection but prior to the commencement of the intervention period. Although two studies reported measures of quadriceps force on completion of the intervention period, meta-analysis was not performed on this outcome as one of the two studies demonstrated significant differences between the exercise and control group at baseline (following lung resection). MAIN RESULTS We identified three RCTs involving 178 participants. Three out of the seven domains included in the Cochrane Collaboration' s 'seven evidence-based domains' table were identical in their assessment across the three studies (random sequence generation, allocation concealment and blinding of participants and personnel). The domain which had the greatest variation was 'blinding of outcome assessment' where one study was rated at low risk of bias, one at unclear risk of bias and the remaining one at high risk of bias. On completion of the intervention period, exercise capacity as measured by the six-minute walk distance was statistically greater in the intervention group compared to the control group (mean difference (MD) 50.4 m; 95% confidence interval (CI) 15.4 to 85.2 m). No between-group differences were observed in HRQoL (standardised mean difference (SMD) 0.17; 95% CI -0.16 to 0.49) or FEV1 (MD-0.13 L; 95% CI -0.36 to 0.11 L). Differences in quadriceps force were not demonstrated on completion of the intervention period. AUTHORS' CONCLUSIONS The evidence summarised in our review suggests that exercise training may potentially increase the exercise capacity of people following lung resection for NSCLC. The findings of our systematic review should be interpreted with caution due to disparities between the studies, methodological limitations, some significant risks of bias and small sample sizes. This systematic review emphasises the need for larger RCTs..
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