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Higginson IJ, Reilly CC, Maddocks M. Breathlessness. Respir Med 2021. [DOI: 10.1007/978-3-030-81788-6_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Iyer AS, Curtis JR, Meier DE. Proactive Integration of Geriatrics and Palliative Care Principles Into Practice for Chronic Obstructive Pulmonary Disease. JAMA Intern Med 2020; 180:815-816. [PMID: 32338726 DOI: 10.1001/jamainternmed.2020.1088] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Anand S Iyer
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham.,Center for Palliative and Supportive Care, Division of Gerontology, Geriatrics, and Palliative Care, Department of Medicine, University of Alabama at Birmingham
| | - J Randall Curtis
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Seattle.,Cambia Palliative Care Center of Excellence, University of Washington, Seattle
| | - Diane E Meier
- Brookdale Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai, New York, New York.,Center to Advance Palliative Care, New York, New York
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Viglino D, Daoust R, Bailly S, Faivre-Pierret C, Charif I, Roustit M, Paquet J, Debaty G, Pépin JL, Maignan M, Chauny JM. Opioid drug use in emergency and adverse outcomes among patients with chronic obstructive pulmonary disease: a multicenter observational study. Sci Rep 2020; 10:5038. [PMID: 32193505 PMCID: PMC7081336 DOI: 10.1038/s41598-020-61887-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 03/03/2020] [Indexed: 11/09/2022] Open
Abstract
There is still debate as to the safety of non-palliative opioid administration to chronic obstructive pulmonary disease (COPD) patients punctually treated for an acute complaint. All patients over 40 presenting at two university hospital emergency departments (Montréal Qc, Grenoble Fr) from March 2008 to September 2014 with dyspnea, abdominal pain or trauma were retrieved, and COPD patients were selected. Our primary endpoint was a composite criterion including invasive ventilation and death. Comparisons between visits in which opioid drugs were prescribed and those without opioids were performed using an inverse probability of treatment and censoring weight (IPTCW) estimator to adjust for baseline confounders. A survival weighted Cox model was used. 7799 visits by COPD patients were identified, corresponding to 4173 unique patients. Opioid drug prescription was reported in 1317 (16.9%) visits. After applying IPCTW weighting, opioid prescription was found to be associated with the composite criterion of poor clinical outcomes (HR = 4.73 (2.94; 7.61), p < 0.01). When taken separately, this association remained significant for invasive ventilation and death, but not for NIV. All sensitivity analyses confirmed the association, except for patients with trauma or abdominal pain as the main complaint. This excess risk is observed whatever the route of administration.
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Affiliation(s)
- Damien Viglino
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France. .,INSERM U1042, HP2 Laboratory, Grenoble-Alpes University, Grenoble, France.
| | - Raoul Daoust
- Department of Emergency Medicine, Research Centre, Sacré-Coeur Hospital of Montreal, Montreal, Quebec, Canada
| | - Sebastien Bailly
- INSERM U1042, HP2 Laboratory, Grenoble-Alpes University, Grenoble, France.,Department of Physiology and Sleep, Grenoble Alpes University Hospital, Grenoble, France
| | - Caroline Faivre-Pierret
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Isma Charif
- INSERM U1042, HP2 Laboratory, Grenoble-Alpes University, Grenoble, France
| | - Matthieu Roustit
- INSERM U1042, HP2 Laboratory, Grenoble-Alpes University, Grenoble, France.,Clinical Pharmacology Department, INSERM CIC1406, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean Paquet
- Department of Emergency Medicine, Research Centre, Sacré-Coeur Hospital of Montreal, Montreal, Quebec, Canada
| | - Guillaume Debaty
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean-Louis Pépin
- INSERM U1042, HP2 Laboratory, Grenoble-Alpes University, Grenoble, France.,Department of Physiology and Sleep, Grenoble Alpes University Hospital, Grenoble, France
| | - Maxime Maignan
- Emergency Department and Mobile Intensive Care Unit, Grenoble Alpes University Hospital, Grenoble, France.,INSERM U1042, HP2 Laboratory, Grenoble-Alpes University, Grenoble, France
| | - Jean-Marc Chauny
- Department of Emergency Medicine, Research Centre, Sacré-Coeur Hospital of Montreal, Montreal, Quebec, Canada
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Maddocks M, Brighton LJ, Farquhar M, Booth S, Miller S, Klass L, Tunnard I, Yi D, Gao W, Bajwah S, Man WDC, Higginson IJ. Holistic services for people with advanced disease and chronic or refractory breathlessness: a mixed-methods evidence synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07220] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Background
Breathlessness is a common and distressing symptom of many advanced diseases, affecting around 2 million people in the UK. Breathlessness increases with disease progression and often becomes chronic or refractory. Breathlessness-triggered services that integrate holistic assessment and specialist palliative care input as part of a multiprofessional approach have been developed for this group, offering tailored interventions to support self-management and reduce distress.
Objectives
The aim was to synthesise evidence on holistic breathlessness services for people with advanced disease and chronic or refractory breathlessness. The objectives were to describe the structure, organisation and delivery of services, determine clinical effectiveness, cost-effectiveness and acceptability, identify predictors of treatment response, and elicit stakeholders’ evidence-based priorities for clinical practice, policy and research.
Design
The mixed-methods evidence synthesis comprised three components: (1) a systematic review to determine the clinical effectiveness, cost-effectiveness and acceptability of holistic breathlessness services; (2) a secondary analysis of pooled individual data from three trials to determine predictors of clinical response; and (3) a transparent expert consultation (TEC), comprising a stakeholder workshop and an online consensus survey, to identify stakeholders’ priorities.
Results
Thirty-seven papers reporting on 18 holistic breathlessness services were included in the systematic review. Most studies enrolled people with thoracic cancer, were delivered over 4–6 weeks, and included breathing training, relaxation techniques and psychological support. Meta-analysis demonstrated significant reductions in the Numeric Rating Scale (NRS) distress due to breathlessness, significant reductions in the Hospital Anxiety and Depressions Scale (HADS) depression scores, and non-significant reductions in the Chronic Respiratory Disease Questionnaire (CRQ) mastery and HADS anxiety, favouring the intervention. Recipients valued education, self-management interventions, and expertise of the staff in breathlessness and person-centred care. Evidence for cost-effectiveness was limited and inconclusive. The responder analysis (n = 259) revealed baseline CRQ mastery and NRS distress to be strong predictors of the response to breathlessness services assessed by these same measures, and no significant influence from baseline breathlessness intensity, patient diagnosis, lung function, health status, anxiety or depression. The TEC elicited 34 priorities from stakeholders. Seven priorities received high agreement and consensus, reflecting stakeholders’ (n = 74) views that services should be person-centred and multiprofessional, share their breathlessness management skills with others, and recognise the roles and support needs of informal carers.
Limitations
The evidence synthesis draws predominantly from UK services and may not be generalisable to other settings. Some meta-analyses were restricted by reporting biases and statistical heterogeneity.
Conclusions
Despite heterogeneity in composition and delivery, holistic breathlessness services are highly valued by recipients and can lead to significant improvements in the distress caused by breathlessness and depression. Outcomes of improved mastery and reduced distress caused by breathlessness are not influenced by patient diagnosis, lung function or health status. Stakeholders highlighted the need for improved access to person-centred, multiprofessional breathlessness services and support for informal carers.
Future work
Our research suggests that key therapeutic components of holistic breathlessness services be considered in clinical practice and models of delivery and educational strategies to address stakeholders’ priorities tested.
Study registration
This study is registered as PROSPERO CRD42017057508.
Funding
The National Institute for Health Research (NIHR) Health Services and Delivery programme. Matthew Maddocks, Wei Gao and Irene J Higginson are supported by the NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South London; Matthew Maddocks is supported by a NIHR Career Development Fellowship (CDF-2017-009), William D-C Man is supported by the NIHR CLAHRC Northwest London and Irene J Higginson holds a NIHR Emeritus Senior Investigator Award.
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Affiliation(s)
- Matthew Maddocks
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Lisa Jane Brighton
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Morag Farquhar
- School of Health Sciences, University of East Anglia, Norwich, UK
| | - Sara Booth
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
- Department of Oncology, University of Cambridge, Cambridge, UK
| | - Sophie Miller
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Lara Klass
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - India Tunnard
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Deokhee Yi
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Wei Gao
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - Sabrina Bajwah
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
| | - William D-C Man
- National Heart and Lung Institute, Imperial College London, London, UK
- Harefield Pulmonary Rehabilitation and Muscle Research Laboratory, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - Irene J Higginson
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King’s College London, London, UK
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Senderovich H, Yendamuri A. Management of Breathlessness in Palliative Care: Inhalers and Dyspnea-A Literature Review. Rambam Maimonides Med J 2019; 10:RMMJ.10357. [PMID: 30332384 PMCID: PMC6363369 DOI: 10.5041/rmmj.10357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Dyspnea is prominently observed in palliative care (PC). Dyspnea can be multifactorial, primarily caused by obstructive or restrictive lung diseases or secondarily induced by various comorbidities. Numerous interventions exist, with route of administration and efficacy requiring further discussion. Despite opioids being the first line of treatment, their adverse effects lead to reluctance on the side of patients to take them, creating limitations in patient management planning. OBJECTIVES This paper reviews and highlights the role of inhalers for dyspnea management in PC. METHODS The CINAHL, CENTRAL, and OVID databases were searched for scholarly articles on the role of inhalers in dyspnea management from 1998 to the present. A grey literature Internet search was also performed via Google, the World Health Organization, and CareSearch. Twenty-five articles relevant to the subject at hand were located and summarized. The Cochrane Systematic Reviews of Health Promotion and Public Health Interventions Handbook was consulted for structuring. RESULT Isolated bronchodilators can be effective in dyspnea management. However, combination with opioids leads to a 52% reduction of dyspnea, demonstrating efficacy of their combined use. There is a role for conventional inhalers not only in patients afflicted with chronic obstructive pulmonary disease, but also in those where obstruction is reversible, and in cases of dyspnea not yet diagnosed. CONCLUSION Inhalers can be utilized as adjuvant therapy to opioids, to limit opioid use, augment responses to dyspnea, and/or minimize opioid side effects, especially in opioid-naïve patients. Correct administration can increase the efficacy of short-acting beta-agonists, long-acting beta-agonists, short- and long-acting anticholinergic agents, and inhaled corticosteroids, achieving reduction and alleviation of dyspnea.
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Affiliation(s)
- Helen Senderovich
- Geriatrics & Pain Medicine & Palliative Care Physician, Baycrest Health Sciences, Toronto, ON, Canada
- Assistant Professor at the Department of Family and Community Medicine, Division of Palliative Care, University of Toronto, Toronto, ON, Canada
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Lewthwaite H, Williams G, Baldock KL, Williams MT. Systematic Review of Pain in Clinical Practice Guidelines for Management of COPD: A Case for Including Chronic Pain? Healthcare (Basel) 2019; 7:healthcare7010015. [PMID: 30678205 PMCID: PMC6473434 DOI: 10.3390/healthcare7010015] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 01/10/2019] [Accepted: 01/19/2019] [Indexed: 12/11/2022] Open
Abstract
Chronic pain is highly prevalent and more common in people with chronic obstructive pulmonary disease (COPD) than people of similar age/sex in the general population. This systematic review aimed to describe how frequently and in which contexts pain is considered in the clinical practice guidelines (CPGs) for the broad management of COPD. Databases (Medline, Scopus, CiNAHL, EMbase, and clinical guideline) and websites were searched to identify current versions of COPD CPGs published in any language since 2006. Data on the frequency, context, and specific recommendations or strategies for the assessment or management of pain were extracted, collated, and reported descriptively. Of the 41 CPGs (English n = 20) reviewed, 16 (39%) did not mention pain. Within the remaining 25 CPGs, pain was mentioned 67 times (ranging from 1 to 10 mentions in a single CPG). The most frequent contexts for mentioning pain were as a potential side effect of specific pharmacotherapies (22 mentions in 13 CPGs), as part of differential diagnosis (14 mentions in 10 CPGs), and end of life or palliative care management (7 mentions in 6 CPGs). In people with COPD, chronic pain is common; adversely impacts quality of life, mood, breathlessness, and participation in activities of daily living; and warrants consideration within CPGs for COPD.
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Affiliation(s)
- Hayley Lewthwaite
- Alliance for Research in Exercise, Nutrition and Activity, School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide 5001, Australia.
| | - Georgia Williams
- Alliance for Research in Exercise, Nutrition and Activity, School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide 5001, Australia.
| | - Katherine L Baldock
- Australian Centre for Precision Health, School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide 5001, Australia.
| | - Marie T Williams
- Alliance for Research in Exercise, Nutrition and Activity, School of Health Sciences, Division of Health Sciences, University of South Australia, Adelaide 5001, Australia.
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Lovell N, Wilcock A, Bajwah S, Etkind SN, Jolley CJ, Maddocks M, Higginson IJ. Mirtazapine for chronic breathlessness? A review of mechanistic insights and therapeutic potential. Expert Rev Respir Med 2019; 13:173-180. [PMID: 30596298 DOI: 10.1080/17476348.2019.1563486] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Chronic breathlessness is a common and distressing symptom of advanced disease with few effective treatments. Central nervous system mechanisms are important in respiratory sensation and control. Consequently, drugs which may modify processing and perception of afferent information in the brain may have a role. Antidepressants have been proposed; however, current evidence is limited. Of potentially suitable antidepressants, mirtazapine is an attractive option given its tolerability profile, low cost, and wide availability, along with additional potential benefits. Areas covered: The paper provides an overview of the physiology of breathlessness, with an emphasis on central mechanisms, particularly the role of fear circuits and the associated neurotransmitters. It provides a potential rationale for how mirtazapine may improve chronic breathlessness and quality of life in patients with advanced disease. The evidence was identified by a literature search performed in PubMed through to October 2018. Expert opinion: Currently, there is insufficient evidence to support the routine use of antidepressants for chronic breathlessness in advanced disease. Mirtazapine is a promising candidate to pursue, with definitive randomized controlled trials required to determine its efficacy and safety in this setting.
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Affiliation(s)
- N Lovell
- a Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
| | - A Wilcock
- b University of Nottingham, Palliative Medicine, Hayward House Specialist Palliative Care Unit , Nottingham University Hospitals NHS Trust , Nottingham , UK
| | - S Bajwah
- a Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
| | - S N Etkind
- a Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
| | - C J Jolley
- c Centre for Human & Applied Physiological Sciences, School of Basic & Medical Biosciences, Faculty of Life Sciences & Medicine , King's College London , UK
| | - M Maddocks
- a Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
| | - I J Higginson
- a Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation , King's College London , London , UK
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Vozoris NT. Opioids, Chronic Obstructive Pulmonary Disease, and Hyperbole. J Palliat Med 2018; 21:745. [PMID: 29889015 DOI: 10.1089/jpm.2018.0090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nicholas T Vozoris
- 1 Division of Respirology, Department of Medicine, St. Michael's Hospital , Toronto, Ontario, Canada .,2 Keenan Research Centre in the Li Ka Shing Knowledge Institute , St Michael's Hospital, Toronto, Ontario, Canada .,3 Department of Medicine, University of Toronto , Toronto, Ontario, Canada
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