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Chua KY, Paranchothy M, Ng SF, Lee CC. Short-term Non-invasive Ventilation for Children with Palliative Care Needs. Indian J Palliat Care 2024; 30:182-186. [PMID: 38846132 PMCID: PMC11152513 DOI: 10.25259/ijpc_304_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/28/2024] [Indexed: 06/09/2024] Open
Abstract
Objectives Non-invasive ventilation (NIV), namely continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP), delivers mechanical ventilation without endotracheal intubation. Short-term NIV (planned for <21 days during initiation) can be used for the management of acute respiratory distress (ARD) among paediatric palliative patients with "Do Not Resuscitate or Intubate" (DNI) as the ceiling of care. This study aimed to describe the usage of short-term NIV among paediatric palliative patients in a woman and child hospital with a paediatric palliative subspecialty. Materials and Methods A retrospective and observational study was conducted on all paediatric palliative patients who received short-term NIV in Tunku Azizah Hospital Kuala Lumpur, Malaysia, from March 2020 to May 2022. Results During the study period, short-term NIV was offered on 23 occasions for 20 different children. Indications for short-term NIV include 16 (69.6%) occasions of potentially reversible ARD (NIV Category 1) and 7 (30.4%) occasions of comfort care at the end of life (NIV Category 2). The main cause of ARD was pneumonia (90.3%) due to either aspiration or infection. The modality of NIV used was BiPAP only (14 occasions, 60.9%), CPAP only (three occasions, 13%) and both BiPAP and CPAP (six occasions, 26.1%). The median duration of NIV usage was four days (minimum one day and maximum 15 days). NIV was initiated as an escalation from nasal prong, Ventimask or high-flow mask oxygen on 22 occasions and as weaning down post-extubation on one occasion. For the 22 occasions of escalating therapy, there was significant improvement at six hours compared to pre-NIV in the median heart rate (136 to 121, P=0.002), respiratory rate (40 to 31, P=0.002) and oxygen saturation (96% to 99%, P=0.025). All 17 documented parental impressions of the child's condition post six hours of NIV were that the child had improved. Adverse events during short-term NIV include five episodes (21.7%) of stomach distension, four episodes (17.4%) of skin sores on the face and one episode (4.3%) of excessive drooling. Three patients passed away while on NIV in the hospital. For the other 20 (87%) occasions, patients were able to wean off NIV. Post-weaning off NIV, three patients passed away during the same admission. On 17 occasions, patients were discharged home after weaning off NIV. Conclusion Usage of short-term NIV in paediatric palliative care, where children have an advanced directive in place indicating DNI, as seen in our study, can be a valuable modality of management for distressing symptoms, in addition to the pharmacological management of breathlessness. This is shown through our study to be of benefit in potentially reversible ARD as well as comfort care at the end of life. Further rigorous studies will need to be conducted for a clearer understanding of short-term NIV that would enable the formulation of guidelines to improve the quality of life and death in children.
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Affiliation(s)
- Ker Yang Chua
- Department of Paediatrics, Hospital Tunku Azizah, Ministry of Health, Malaysia
| | - Malini Paranchothy
- Department of Paediatrics, Hospital Tunku Azizah, Ministry of Health, Malaysia
| | - Su Fang Ng
- Department of Paediatrics, Hospital Likas, Ministry of Health, Malaysia
| | - Chee Chan Lee
- Department of Paediatrics, Hospital Tunku Azizah, Ministry of Health, Malaysia
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Leivo-Korpela S, Rantala HA, Piili RP, Lehtimäki L, Lehto JT. Palliation of Dyspnea With Mouthpiece Ventilation in Patients With Chronic Obstructive Pulmonary Disease: A Pilot Feasibility Study. J Palliat Med 2023; 26:1261-1265. [PMID: 37155710 DOI: 10.1089/jpm.2023.0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
Background: Mouthpiece ventilation (MPV) reduces hypoventilation, but its efficacy in relieving dyspnea in patients with acute chronic obstructive pulmonary disease exacerbation (AECOPD) is unclear. Objective: To assess the feasibility of MPV in relieving dyspnea among patients with AECOPD. Methods: In this prospective single-arm pilot study, the change in dyspnea on numeric rating scale (NRS) after using MPV and side effects of the treatment were studied in 18 patients with AECOPD. Results: The median decrease in dyspnea was 1.5 (95% confidence interval = 0.0-2.5, p = 0.006) on NRS after the intervention lasting a median of 16.9 minutes. Of the patients, 61% found MPV beneficial. The use of MPV did not increase the sense of anxiety or pain. Conclusions: MPV is feasible and may relieve dyspnea in patients with AECOPD, but the intervention needs further evaluation. clinicaltrials.gov study number: NCT03025425.
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Affiliation(s)
- Sirpa Leivo-Korpela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Palliative Care Centre and Department of Geriatrics, Tampere University Hospital, Tampere, Finland
| | - Heidi A Rantala
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland
| | - Reetta P Piili
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Palliative Care Centre and Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Allergy Centre, Tampere University Hospital, Tampere, Finland
| | - Juho T Lehto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
- Palliative Care Centre and Department of Oncology, Tampere University Hospital, Tampere, Finland
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3
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Rajan SK, Cottin V, Dhar R, Danoff S, Flaherty KR, Brown KK, Mohan A, Renzoni E, Mohan M, Udwadia Z, Shenoy P, Currow D, Devraj A, Jankharia B, Kulshrestha R, Jones S, Ravaglia C, Quadrelli S, Iyer R, Dhooria S, Kolb M, Wells AU. Progressive pulmonary fibrosis: an expert group consensus statement. Eur Respir J 2023; 61:2103187. [PMID: 36517177 PMCID: PMC10060665 DOI: 10.1183/13993003.03187-2021] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 11/17/2022] [Indexed: 12/23/2022]
Abstract
This expert group consensus statement emphasises the need for standardising the definition of progressive fibrosing interstitial lung diseases (F-ILDs), with an accurate initial diagnosis being of paramount importance in ensuring appropriate initial management. Equally, case-by-case decisions on monitoring and management are essential, given the varying presentations of F-ILDs and the varying rates of progression. The value of diagnostic tests in risk stratification at presentation and, separately, the importance of a logical monitoring strategy, tailored to manage the risk of progression, are also stressed. The term "progressive pulmonary fibrosis" (PPF) exactly describes the entity that clinicians often face in practice. The importance of using antifibrotic therapy early in PPF (once initial management has failed to prevent progression) is increasingly supported by evidence. Artificial intelligence software for high-resolution computed tomography analysis, although an exciting tool for the future, awaits validation. Guidance is provided on pulmonary rehabilitation, oxygen and the use of non-invasive ventilation focused specifically on the needs of ILD patients with progressive disease. PPF should be differentiated from acute deterioration due to drug-induced lung toxicity or other forms of acute exacerbations. Referral criteria for a lung transplant are discussed and applied to patient needs in severe diseases where transplantation is not realistic, either due to access limitations or transplantation contraindications. In conclusion, expert group consensus guidance is provided on the diagnosis, treatment and monitoring of F-ILDs with specific focus on the recognition of PPF and the management of pulmonary fibrosis progressing despite initial management.
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Affiliation(s)
- Sujeet K Rajan
- Bombay Hospital Institute of Medical Sciences and Bhatia Hospital, Mumbai, India
| | - Vincent Cottin
- National French Reference Coordinating Center for Rare Pulmonary Diseases, Louis Pradel Hospital Hospices Civils de Lyon, Université Claude Bernard Lyon 1, INRAE, Member of ERN-LUNG, Lyon, France
| | | | - Sonye Danoff
- Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | - Kevin K Brown
- Department of Medicine, National Jewish Health, Denver, CO, USA
| | - Anant Mohan
- All India Institute of Medical Sciences, New Delhi, India
| | | | | | | | - Padmanabha Shenoy
- Department of Rheumatology, Centre for Arthritis and Rheumatism Excellence, Kochi, India
| | | | - Anand Devraj
- Department of Radiology, Royal Brompton Hospital, London, UK
| | | | - Ritu Kulshrestha
- Department of Pathology, Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India
| | - Steve Jones
- European Idiopathic Pulmonary Fibrosis Federation (EU-IPFF), Peterborough, UK
| | - Claudia Ravaglia
- Pulmonology Unit, GB Morgagni Hospital/University of Bologna, Forlì, Italy
| | | | - Rajam Iyer
- Bhatia Hospital and PD Hinduja Hospital, Mumbai, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Martin Kolb
- Firestone Institute for Respiratory Heath, St Joseph's Healthcare and McMaster University, Hamilton, ON, Canada
- Co-senior authors
| | - Athol U Wells
- Interstitial Lung Disease Unit, Royal Brompton and Harefield NHS Foundation Trust, London, UK
- Co-senior authors
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4
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Chaaban S, McCormick J, Gleason D, McFarlin JM. Palliative Care for the Interstitial Lung Disease Patient a Must and Not Just a Need. Am J Hosp Palliat Care 2021; 39:710-715. [PMID: 34409885 DOI: 10.1177/10499091211040232] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Patients with interstitial lung disease (ILD) have many unmet palliative care needs. The majority of patients with chronic ILD have poor access to a specialist in palliative medicine and that is due to several barriers. The mortality for the ILD patient is high and reaches up to 80% if admitted to the ICU with respiratory failure. Palliative care addresses symptoms in diseases where cure is unlikely or impossible. Palliative care consultation also ensures communication among patients, caregivers and providers regarding treatments, prognosis, and end of life planning. Methods: We performed a literature review on palliative care and ILD, accessing articles published since 2002. We found 71 articles related to the topic. We chose 37 that were most relevant and with no redundancy of information to include in this review. Objectives: Summarize the palliative care needs of patients with ILD, discuss the barriers to receiving palliative care, and summarize clinical practice for providing palliative care to this patient population.
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Chapman C, Bayes S, Sim M. Communication surrounding initiation and withdrawal of non-invasive ventilation in adults with Motor Neuron(e) Disease: clinicians’ and family members’ perspectives. INTERNATIONAL JOURNAL OF CARE COORDINATION 2021. [DOI: 10.1177/20534345211010132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Introduction International guidelines recommend that health care clinicians communicate with people with MND and their family members about non-invasive ventilation (NIV) and percutaneous gastrostomy tube (PEG) prior to or at the onset of respiratory symptoms. This study sought to discover the degree to which these recommendations are followed in practice. Methods Interpretive Description methodology was employed. Nineteen clinicians experienced in caring for people with MND, six relatives of recently deceased people with MND and one person with MND participated in semi-structured in-depth interviews. Clinicians’ accounts of NIV and PEG related communications were compared to family member participants’ recollections of their own discussions with clinicians. Data were analysed thematically. Results Six major themes emerged that together capture the factors that impact practitioner-patient-family communications about NIV and PEG. Some clinicians were unaware of MND guidelines particularly communicating the burdens or possible withdrawal of NIV or found them challenging to implement. Consequently, family participants reported that they and their relatives with MND found clinicians’ communication on these topics inadequate. This led to them ‘topping up’ their knowledge from less authoritative sources, predominantly the internet. Discussion Clinicians’ lack of awareness of the international guidelines and discomfort about discussing the benefits and burdens of NIV and PEGs means some people with MND and their families may be unprepared for the consequences of using and ceasing NIV.
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Hui D, Bohlke K, Bao T, Campbell TC, Coyne PJ, Currow DC, Gupta A, Leiser AL, Mori M, Nava S, Reinke LF, Roeland EJ, Seigel C, Walsh D, Campbell ML. Management of Dyspnea in Advanced Cancer: ASCO Guideline. J Clin Oncol 2021; 39:1389-1411. [DOI: 10.1200/jco.20.03465] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
PURPOSE To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer. METHODS ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020. RESULTS The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea. RECOMMENDATIONS A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed. Additional information is available at www.asco.org/supportive-care-guidelines .
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Affiliation(s)
- David Hui
- MD Anderson Cancer Center, Houston, TX
| | - Kari Bohlke
- American Society of Clinical Oncology, Alexandria, VA
| | - Ting Bao
- Memorial Sloan Kettering Cancer Center, New York, NY
| | | | | | | | - Arjun Gupta
- Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, MD
| | - Aliza L. Leiser
- Rutgers RWJ Cancer Institute of New Jersey, New Brunswick, NJ
| | - Masanori Mori
- Seirei Mikatahara General Hospital, Hamamatsu, Shizuoka, Japan
| | - Stefano Nava
- IRCCS Azienda Ospedaliera University of Bologna, S. Orsola-Malpighi Hospital, Alma Mater University, Bologna, Italy
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7
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Lehto JT, Leivo-Korpela S, Korhonen T, Rantala HA, Raunio H, Lyly-Yrjänäinen T, Lehtimäki L. Mouthpiece ventilation in the management of dyspnea: A single-arm pilot study. Palliat Med 2020; 34:1274-1278. [PMID: 32579086 PMCID: PMC7495670 DOI: 10.1177/0269216320935003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Noninvasive ventilation may relieve dyspnea in advanced diseases, but noninvasive ventilation through mouthpiece has not been tested in palliative care. AIM To assess the feasibility of mouthpiece ventilation in relieving dyspnea among patients with advanced disease. DESIGN In this prospective single-arm pilot study, the change in dyspnea by mouthpiece ventilation was measured with numeric rating scale (0-10) and 100-mm visual analogue scale. Overall, benefit and adverse events of the therapy were also assessed. SETTING/PARTICIPANTS Twenty-two patients with an advanced disease and dyspnea from the Tampere University Hospital or Pirkanmaa Hospice were treated with mouthpiece ventilation. The patients used mouthpiece ventilation as long as they preferred, but for a minimum of 5 min. RESULTS After the treatment period lasting a median of 13.5 min, mean decrease in dyspnea was -1.1 (95 % confidence interval = -2.2 to -0.1, p = 0.034) on numeric rating scale and -11.8 mm (95 % confidence interval = -19.9 to -3.7, p = 0.006) on visual analogue scale. Nonetheless, there was a high variability in this effect between individual patients. About half of the patients found mouthpiece ventilation beneficial. No serious adverse events occurred, but dry mouth was the most common adverse event. Anxiety did not increase with mouthpiece ventilation. CONCLUSION Mouthpiece ventilation is feasible and may relieve dyspnea in some patients with an advanced disease. Further studies are needed, and these might concentrate on stable patients in early palliative care. Before initiation, this study was registered at clinicaltrials.gov (study no. NCT03012737).
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Affiliation(s)
- Juho T Lehto
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Palliative Care Centre and Tays Cancer Centre, Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Sirpa Leivo-Korpela
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland
| | - Tarja Korhonen
- Pirkanmaa Hospice, Palliative Care Centre, Tampere University Hospital, Tampere, Finland
| | - Heidi A Rantala
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland
| | - Hanna Raunio
- Palliative Care Centre and Tays Cancer Centre, Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Tiina Lyly-Yrjänäinen
- Palliative Care Centre and Tays Cancer Centre, Department of Oncology, Tampere University Hospital, Tampere, Finland
| | - Lauri Lehtimäki
- Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland.,Department of Respiratory Medicine, Tampere University Hospital, Tampere, Finland
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Mendlik MT, McFarlin J, Kluger BM, Vaughan CL, Phillips JN, Jones CA. Top Ten Tips Palliative Care Clinicians Should Know About Caring for Patients with Neurologic Illnesses. J Palliat Med 2020; 22:193-198. [PMID: 30707071 DOI: 10.1089/jpm.2018.0617] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with neurologic illnesses are commonly encountered by palliative care (PC) clinicians though many clinicians feel uncomfortable caring for these patients. Understanding how to diagnose, treat, communicate with, and prognosticate for neurology patients will improve the confidence and competence of PC providers in the neurology setting. This article offers PC providers 10 useful tips that neurologists with PC training think all PC providers should know to improve care for patients with neurologic illness.
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Affiliation(s)
- Matthew T Mendlik
- 1 Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jessica McFarlin
- 2 Department of Neurology, University of Kentucky, Lexington, Kentucky
| | - Benzi M Kluger
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Christina L Vaughan
- 3 Department of Neurology, University of Colorado School of Medicine, Aurora, Colorado
| | - Joel N Phillips
- 4 Mercy Health Hauenstein Neurosciences, Grand Rapids, Michigan
| | - Christopher A Jones
- 5 Perelman School of Medicine and Palliative and Advanced Illness Research Center, University of Pennsylvania, Philadelphia, Pennsylvania
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Pan CX, Palathra BC, Leo-To WF. Management of Respiratory Symptoms in Those with Serious Illness. Med Clin North Am 2020; 104:455-470. [PMID: 32312409 DOI: 10.1016/j.mcna.2019.12.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.
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Affiliation(s)
- Cynthia X Pan
- Division of Palliative Medicine and Geriatrics, Designated Institution Official of Graduate Medical Education, NewYork-Presbyterian Queens, 56-45 Main Street, Flushing, NY 11355, USA; Weill Cornell Medical College, New York, NY, USA.
| | - Brigit C Palathra
- Weill Cornell Medical College, New York, NY, USA; Hospice and Palliative Medicine Fellowship, Division of Palliative Medicine and Geriatrics, NewYork-Presbyterian Queens, 56-45 Main Street, Flushing, NY 11355, USA. https://twitter.com/bpalathra
| | - Wing Fun Leo-To
- NewYork-Presbyterian Queens, 56-45 Main Street, Flushing, NY 11355, USA; Affiliate Clinical Faculty, College of Pharmacy and Health Science, St John's University, Jamaica, NY, USA
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10
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Gäbler M, Ohrenberger G, Funk GC. Treatment decisions in end-stage COPD: who decides how? A cross-sectional survey of different medical specialties. ERJ Open Res 2019; 5:00163-2018. [PMID: 31544110 PMCID: PMC6745412 DOI: 10.1183/23120541.00163-2018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 06/20/2019] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION End-stage chronic obstructive pulmonary disease (COPD) patients with acute respiratory failure are often treated by representatives from different medical specialties. This study investigates if the choice of treatment is influenced by the medical specialty. METHODS An online cross-sectional survey among four Austrian medical societies was performed, accompanied by a case vignette of a geriatric end-stage COPD patient with acute respiratory failure. Respondents had to choose between noninvasive ventilation (NIV), a conservative treatment attempt (without NIV) and a palliative approach. Ethical considerations and their impact on decision making were also assessed. RESULTS Responses of 162 physicians (67 from intensive care units (ICUs), 51 from pulmonology or internal departments and 44 from geriatric or palliative care) were included. The decision for NIV (instead of a conservative or palliative approach) was associated with working in an ICU (OR 14.9, 95% CI 1.87-118.8) and in a pulmonology or internal department (OR 9.4, 95% CI 1.14-78.42) compared with working in geriatric or palliative care (Model 1). The decision for palliative care was negatively associated with working in a pulmonology or internal department (OR 0.16, 95% CI 0.05-0.47) and (nonsignificantly) in an ICU (OR 0.41, 95% CI 0.15-1.12) (Model 2). CONCLUSIONS Department association was shown to be an independent predictor for treatment decisions in end-stage COPD with acute respiratory failure. Further research on these differences and influential factors is necessary.
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Affiliation(s)
- Martin Gäbler
- Institute of Preventive and Applied Sports Medicine, Krems University Hospital, Karl Landsteiner University of Health Sciences, Krems, Austria
- Dept of Respiratory and Critical Care Medicine, Otto-Wagner-Hospital, Vienna, Austria
| | | | - Georg-Christian Funk
- Medical Dept II and Karl-Landsteiner Institute für Lungenforschung und Pneumologische Onkologie Wilheminenspital, Vienna, Austria
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Faverio P, De Giacomi F, Bonaiti G, Stainer A, Sardella L, Pellegrino G, Sferrazza Papa GF, Bini F, Bodini BD, Carone M, Annoni S, Messinesi G, Pesci A. Management of Chronic Respiratory Failure in Interstitial Lung Diseases: Overview and Clinical Insights. Int J Med Sci 2019; 16:967-980. [PMID: 31341410 PMCID: PMC6643124 DOI: 10.7150/ijms.32752] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 05/05/2019] [Indexed: 01/11/2023] Open
Abstract
Interstitial lung diseases (ILDs) may be complicated by chronic respiratory failure (CRF), especially in the advanced stages. Aim of this narrative review is to evaluate the current evidence in management of CRF in ILDs. Many physiological mechanisms underlie CRF in ILDs, including lung restriction, ventilation/perfusion mismatch, impaired diffusion capacity and pulmonary vascular damage. Intermittent exertional hypoxemia is often the initial sign of CRF, evolving, as ILD progresses, into continuous hypoxemia. In the majority of the cases, the development of CRF is secondary to the worsening of the underlying disease; however, associated comorbidities may also play a role. When managing CRF in ILDs, the need for pulmonary rehabilitation, the referral to lung transplant centers and palliative care should be assessed and, if necessary, promptly offered. Long-term oxygen therapy is commonly prescribed in case of resting or exertional hypoxemia with the purpose to decrease dyspnea and improve exercise tolerance. High-Flow Nasal Cannula oxygen therapy may be used as an alternative to conventional oxygen therapy for ILD patients with severe hypoxemia requiring both high flows and high oxygen concentrations. Non-Invasive Ventilation may be used in the chronic setting for palliation of end-stage ILD patients, although the evidence to support this application is very limited.
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Affiliation(s)
- Paola Faverio
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Federica De Giacomi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Giulia Bonaiti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Anna Stainer
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Luca Sardella
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Giulia Pellegrino
- Casa di Cura del Policlinico, Dipartimento di Scienze Neuroriabilitative, Milan, Italy
| | | | - Francesco Bini
- UOC Pulmonology, Department of Internal Medicine, Ospedale ASST-Rhodense, Garbagnate Milanese, Italy
| | - Bruno Dino Bodini
- Pulmonology Unit, Ospedale Maggiore della Carità, University of Piemonte Orientale, Novara, Italy
| | - Mauro Carone
- UOC Pulmonology and Pulmonary Rehabilitation, Istituti Clinici Scientifici Maugeri, IRCCS di Cassano Murge (BA), Italy
| | - Sara Annoni
- Physical therapy and Rehabilitation Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Grazia Messinesi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
| | - Alberto Pesci
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Respiratory Unit, San Gerardo Hospital, ASST di Monza, Monza, Italy
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Abstract
Patients with cancer continue to have unmet palliative care needs. Concurrent palliative care is tailored to the needs of patients as well as their families to relieve suffering. Specialty palliative care referral is associated with improved symptom management, improved end-of-life quality, and higher family-rated satisfaction. Optimal timing for palliative care referral has not been determined. Barriers to palliative care referral include workforce limitations, provider attitudes and perceptions, and potential ethnic and racial disparities in access to palliative care. Future work should focus on novel, patient-centered approaches to identify and address unmet palliative care needs for patients living with cancer.
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Affiliation(s)
- Kathleen M Akgün
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, VA Connecticut Healthcare System, Yale University School of Medicine, 950 Campbell Avenue, MS11 ACSLG, West Haven, CT 06516, USA.
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Tiirola A, Korhonen T, Surakka T, Lehto JT. End-of-Life Care of Patients With Amyotrophic Lateral Sclerosis and Other Nonmalignant Diseases. Am J Hosp Palliat Care 2016; 34:154-159. [DOI: 10.1177/1049909115610078] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background: Palliative care services extend to meet the needs of patients with nonmalignant diseases. Aim: To explore the diagnoses, symptoms, and treatment of patients dying in hospice due to nonmalignant diseases, with special emphasis on amyotrophic lateral sclerosis (ALS). Design: A retrospective study based on a detailed analysis of patient records. Setting/Participants: All patients with nonmalignant diseases who died in Pirkanmaa Hospice during the period 2004 to 2013 were included. Results: Of the 67 patients studied, 48% had ALS, and the remaining had pulmonary (18%), cardiovascular (13%), neurologic (10%), and other (10%) diseases. Dyspnea, followed by pain and fatigue, was the most common symptom reported, increasing in frequency from admission to the last day of life (31% vs 48%; P < .05). Compared with ALS, patients with other diseases had more comorbidities (3.8% vs 1.4%, P < .001) and were more likely to have very short (≤3 days) final care periods (31% vs 9%; P < .05). During the last day of life, patients with ALS were more frequently unable to swallow (87% vs 31%, P < .001) and received significantly more antidepressants, antibiotics, and laxatives but less corticosteroids and oxygen compared to other patients. Noninvasive ventilation was used in 31% of all patients. Conclusion: Respiratory symptoms are important in the management of nonmalignant diseases in hospice. Especially, units taking care of ALS should be prepared to meet the special needs involved in ventilation support. In contrast to ALS, late referrals to hospice are common in patients with other nonmalignant diseases.
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Affiliation(s)
- Anna Tiirola
- Department of Palliative Medicine, University of Tampere, Tampere, Finland
| | | | | | - Juho T. Lehto
- Department of Palliative Medicine, University of Tampere, Tampere, Finland
- Department of Oncology, Tampere University Hospital, Tampere, Finland
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Piroddi IMG, Barlascini C, Esquinas A, Braido F, Banfi P, Nicolini A. Non-invasive mechanical ventilation in elderly patients: A narrative review. Geriatr Gerontol Int 2016; 17:689-696. [PMID: 27215767 DOI: 10.1111/ggi.12810] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2016] [Revised: 03/17/2016] [Accepted: 03/25/2016] [Indexed: 10/21/2022]
Abstract
The treatment of acute respiratory failure with non-invasive ventilation (NIV) as a first-line therapy is increasingly common in intensive care units. The reduced invasiveness of NIV leads to better outcomes than endotracheal intubation in carefully selected groups of patients. Furthermore, the use of NIV as a palliative treatment for respiratory failure and dyspnea has become increasingly common. NIV also has an impact on the use of "do not intubate" orders. In the present narrative review, we explore the use and outcome of NIV in elderly patients. To accomplish this, we reviewed the most recent available medical literature. Geriatr Gerontol Int 2017; 17: 689-696.
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Affiliation(s)
| | - Cornelius Barlascini
- Hygiene and Health Medicine Unit Hospital of Sestri Levante, Sestri Levante, Italy
| | | | - Fulvio Braido
- Allergy and Respiratory Diseases Unit Department IRCSS AOU San Martino- IST, Genova, Italy
| | - Paolo Banfi
- Pulmonary Rehabilitation Fondazione Don Carlo Gnocchi, Milan, Italy
| | - Antonello Nicolini
- Respiratory Diseases Unit Hospital of Sestri Levante, Sestri Levante, Italy
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Vilaça M, Aragão I, Cardoso T, Dias C, Cabral-Campello G. The Role of Noninvasive Ventilation in Patients with "Do Not Intubate" Order in the Emergency Setting. PLoS One 2016; 11:e0149649. [PMID: 26901060 PMCID: PMC4763309 DOI: 10.1371/journal.pone.0149649] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Accepted: 02/03/2016] [Indexed: 12/15/2022] Open
Abstract
Background Noninvasive ventilation (NIV) is being used increasingly in patients who have a “do not intubate” (DNI) order. However, the impact of NIV on the clinical and health-related quality of life (HRQOL) in the emergency setting is not known, nor is its effectiveness for relieving symptoms in end-of-life care. Objective The aim of this prospective study was to determine the outcome and HRQOL impact of regular use of NIV outcomes on patients with a DNI order who were admitted to the emergency room department (ED). Methods: Eligible for participation were DNI-status patients who receive NIV for acute or acute-on-chronic respiratory failure when admitted to the ED of a tertiary care, university-affiliated, 600-bed hospital between January 2014 and December 2014. Patients were divided into 2 groups: (1) those whose DNI order related to a decision to withhold therapy and (2) those for whom any treatment, including NIV, was provided for symptom relief only. HRQOL was evaluated only in group 1, using the 12-item Short Form Health Survey (SF-12). Long-term outcome was evaluated 90 days after hospital discharge by means of a telephone interview. Results During the study period 1727 patients were admitted to the ED, 243 were submitted to NIV and 70 (29%) were included in the study. Twenty-nine (41%) of the 70 enrollees received NIV for symptom relief only (group2). Active cancer [7% vs 35%, p = 0,004] and neuromuscular diseases [0% vs. 17%] were more prevalent in this group. NIV was stopped in 59% of the patients in group 2 due to lake of clinical benefit. The in-hospital mortality rate was 37% for group 1 and 86% for group 2 0,001). Among patients who were discharged from hospital, 23% of the group 1 and all patients in group 2 died within 90 days. Relative to baseline, no significant decline in HRQOL occurred in group 1 by 90 days postdischarge. Conclusion The survival rate was 49% among DNI-status patients for whom NIV was used as a treatment in ED, and these patients did not experience a decline in HRQOL throughout the study. NIV did not provide significant relief of symptoms in more than half the patients who receive it for that purpose.
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Affiliation(s)
- Marta Vilaça
- Medicine Integrated Master (MIM), Instituto de Ciências Biomédicas Abel Salazar (ICBAS), Oporto University (UP), Porto, Portugal
- * E-mail:
| | - Irene Aragão
- Intensive Care Unit (UCIP), Oporto Hospital Center, Porto, Portugal
| | - Teresa Cardoso
- Intensive Care Unit (UCIP), Oporto Hospital Center, Porto, Portugal
| | - Cláudia Dias
- Center for Health Technology and Services Research (CINTESIS) and Information Sciences and Decision on Health Department (CIDES), Faculty of Medicine, Oporto University (UP), Porto, Portugal
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Affiliation(s)
- Salvador Díaz Lobato
- Department of Pneumology, Ramon y Cajal Teaching Hospital, The Ramon's y Cajal Health Research Institute (IRYCIS), Alcala de Henares University, Madrid, Spain. E-mail:
| | - Sagrario Mayoralas Alises
- Department of Pneumology, Ramon y Cajal Teaching Hospital, The Ramon's y Cajal Health Research Institute (IRYCIS), Alcala de Henares University, Madrid, Spain. E-mail:
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Abstract
Over the course of the last half-century, intensive care units have been the setting for many ethical and legal debates in medicine. This article outlines 3 important domains that lie at the intersection of critical care, palliative care, ethics, and the law: withholding and withdrawal of potentially life-sustaining therapies, making decisions for critically ill patients who lack decision-making capacity, and approaching cases of perceived futility when patients and families still request everything that is medically possible. Important principles and precedents that underlie our understanding of how nurses should approach critically ill patients are reviewed.
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