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Hackner K, Heim M, Masel EK, Riedl G, Weber M, Strieder M, Danninger S, Pecherstorfer M, Kreye G. Evaluation of diagnostic and treatment approaches to acute dyspnea in a palliative care setting among medical doctors with different educational levels. Support Care Cancer 2022; 30:5759-5768. [PMID: 35338391 PMCID: PMC9135814 DOI: 10.1007/s00520-022-06996-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/17/2022] [Indexed: 11/24/2022]
Abstract
Background Dyspnea is common in patients with advanced cancer. Diagnostic procedures in patients with dyspnea are mandatory but often time-consuming and hamper rapid treatment of the underlying refractory symptoms. Opioids are the first-line drugs for the treatment of refractory dyspnea in palliative care patients with advanced lung cancer. Methods To evaluate the knowledge levels of medical doctors with different educational levels on the diagnosis of and treatment options for dyspnea in patients with advanced lung cancer in a palliative care setting, a case report and survey were distributed to physicians at the University Hospital Krems, describing acute dyspnea in a 64-year-old stage IV lung cancer patient. A total of 18 diagnostic and 22 therapeutic options were included in the survey. The physicians were asked to suggest and rank in order of preference their diagnosis and treatment options. Statistical analyses of the data were performed, including comparison of the responses of the senior doctors and the physicians in training. Results A total of 106 surveys were completed. The respondents were 82 senior physicians and 24 physicians in training (response rates of 86% and 80%, respectively). Regarding diagnostic investigations, inspection and reading the patient’s chart were the most important diagnostic tools chosen by the respondents. The choices of performing blood gas analysis (p = 0.01) and measurement of oxygen saturation (p = 0.048) revealed a significant difference between the groups, both investigations performed more frequently by the physicians in training. As for non-pharmacological treatment options, providing psychological support was one of the most relevant options selected. A significant difference was seen in choosing the option of improving a patient’s position in relation to level of training (65.9% senior physicians vs. 30.4% physicians in training, p = 0.04). Regarding pharmacological treatment options, oxygen application was the most chosen approach. The second most frequent drug chosen was a ß-2 agonist. Only 9.8% of the senior physicians and 8.7% of the physicians in training suggested oral opioids as a treatment option, whereas intravenous opioids were suggested by 43.9% of the senior physicians and 21.7% of the physicians in training (p = 0.089). For subcutaneous application of opioids, the percentage of usage was significantly higher for the physicians in training than for the senior physicians (78.3% vs. 48.8%, p = 0.017, respectively). Conclusion The gold standard treatment for treating refractory dyspnea in patients with advanced lung cancer is opioids. Nevertheless, this pharmacological treatment option was not ranked as the most important. Discussing hypothetical cases of patients with advanced lung cancer and refractory dyspnea with experienced doctors as well as doctors at the beginning of their training may help improve symptom control for these patients. Supplementary Information The online version contains supplementary material available at 10.1007/s00520-022-06996-6.
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Affiliation(s)
- Klaus Hackner
- Karl Landsteiner University of Health Sciences, Krems, Austria.,Department of Pneumology, University Hospital Krems, Krems, Austria
| | - Magdalena Heim
- Karl Landsteiner University of Health Sciences, Krems, Austria
| | - Eva Katharina Masel
- Clinical Division of Palliative Medicine, Department of Internal Medicine I, Medical University Vienna, Vienna, Austria
| | - Gunther Riedl
- Department for Anesthesia and Intensive Care, Landesklinikum Baden-Mödling, Baden, Austria
| | - Michael Weber
- Karl Landsteiner University of Health Sciences, Krems, Austria
| | | | - Sandra Danninger
- Clinical Division of Palliative Medicine, Department of Internal Medicine II, University Hospital Krems, Mitterweg 10, 3500, Krems, Austria
| | - Martin Pecherstorfer
- Karl Landsteiner University of Health Sciences, Krems, Austria.,Clinical Division of Palliative Medicine, Department of Internal Medicine II, University Hospital Krems, Mitterweg 10, 3500, Krems, Austria
| | - Gudrun Kreye
- Karl Landsteiner University of Health Sciences, Krems, Austria. .,Clinical Division of Palliative Medicine, Department of Internal Medicine II, University Hospital Krems, Mitterweg 10, 3500, Krems, Austria.
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2
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Krooupa AM, Vivat B, McKeever S, Marcus E, Sawyer J, Stone P. Identification and evaluation of observational measures for the assessment and/or monitoring of level of consciousness in adult palliative care patients: A systematic review for I-CAN-CARE. Palliat Med 2020; 34:83-113. [PMID: 31434526 PMCID: PMC6952953 DOI: 10.1177/0269216319871666] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [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 The use of observational measures to assess palliative care patients' level of consciousness may improve patient care and comfort. However, there is limited knowledge regarding the validity and reliability of these measures in palliative care settings. AIM To identify and evaluate the psychometric performance of observational level of consciousness measures used in palliative care. DESIGN Systematic review; PROSPERO registration: CRD42017073080. DATA SOURCES We searched six databases until November 2018, using search terms combining subject headings and free-text terms. Psychometric performance for each identified tool was appraised independently by two reviewers following established criteria for developing and evaluating health outcome measures. RESULTS We found 35 different levels of consciousness tools used in 65 studies. Only seven studies reported information about psychometric performance of just eight tools. All other studies used either ad hoc measures for which no formal validation had been undertaken (n = 21) or established tools mainly developed and validated in non-palliative care settings (n = 37). The Consciousness Scale for Palliative Care and a modified version of the Richmond Agitation-Sedation Scale received the highest ratings in our appraisal, but, since psychometric evidence was limited, no tool could be assessed for all psychometric properties. CONCLUSION An increasing number of studies in palliative care are using observational measures of level of consciousness. However, only a few of these tools have been tested for their psychometric performance in that context. Future research in this area should validate and/or refine the existing measures, rather than developing new tools.
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Affiliation(s)
- Anna-Maria Krooupa
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Bella Vivat
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Stephen McKeever
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK.,school of Nursing, Faculty of Health, Social Care and Education, Kingston Hill, UK
| | - Elena Marcus
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Joseph Sawyer
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
| | - Paddy Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, Faculty of Brain Sciences, University College London, UK
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3
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Coyle S, Elverson J, Harlow T, Jordan A, McNamara P, O'Neill C, Quibell R, Regnard C, Spiller J, Stephenson J. The myth that shames us all. Lancet 2018; 392:1196. [PMID: 30319108 DOI: 10.1016/s0140-6736(18)31876-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/07/2018] [Indexed: 11/23/2022]
Affiliation(s)
- Séamus Coyle
- Palliative Care Institute, University of Liverpool and Saint Helens and Knowsley Hospitals Trust, Liverpool, UK
| | - Jo Elverson
- Saint Oswald's Hospice, Newcastle upon Tyne NE31EE, UK
| | - Tim Harlow
- Saint Oswald's Hospice, Newcastle upon Tyne NE31EE, UK
| | | | - Paul McNamara
- Saint Oswald's Hospice, Newcastle upon Tyne NE31EE, UK
| | - Catherine O'Neill
- Saint Oswald's Hospice, Newcastle upon Tyne NE31EE, UK; Hospiscare, Exeter, UK
| | - Rachel Quibell
- Newcastle Upon Tyne NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Claud Regnard
- Saint Oswald's Hospice, Newcastle upon Tyne NE31EE, UK.
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4
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Verberkt CA, van den Beuken-van Everdingen MHJ, Schols JMGA, Datla S, Dirksen CD, Johnson MJ, van Kuijk SMJ, Wouters EFM, Janssen DJA. Respiratory adverse effects of opioids for breathlessness: a systematic review and meta-analysis. Eur Respir J 2017; 50:50/5/1701153. [PMID: 29167300 DOI: 10.1183/13993003.01153-2017] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/18/2017] [Indexed: 01/19/2023]
Abstract
Previous studies have shown that opioids can reduce chronic breathlessness in advanced disease. However, physicians remain reluctant to prescribe opioids for these patients, commonly due to fear of respiratory adverse effects. The aim of this study was to systematically review reported respiratory adverse effects of opioids in patients with advanced disease and chronic breathlessness.PubMed, Embase, the Cochrane Central Register of Controlled Trials, CINAHL, ClinicalTrials.gov and the reference lists of relevant systematic reviews were searched. Two independent researchers screened against predefined inclusion criteria and extracted data. Meta-analysis was conducted where possible.We included 63 out of 1990 articles, describing 67 studies. Meta-analysis showed an increase in carbon dioxide tension (0.27 kPa, 95% CI 0.08-0.45 kPa,) and no significant change in oxygen tension and oxygen saturation (both p>0.05). Nonserious respiratory depression (definition variable/not stated) was described in four out of 1064 patients. One cancer patient pretreated with morphine for pain needed temporary respiratory support following nebulised morphine for breathlessness (single case study).We found no evidence of significant or clinically relevant respiratory adverse effects of opioids for chronic breathlessness. Heterogeneity of design and study population, and low study quality are limitations. Larger studies designed to detect respiratory adverse effects are needed.
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Affiliation(s)
- Cindy A Verberkt
- Dept of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | | | - Jos M G A Schols
- Dept of Health Services Research, Maastricht University, Maastricht, The Netherlands.,Dept of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Sushma Datla
- Hull York Medical School, University of Hull, Hull, UK
| | - Carmen D Dirksen
- Dept of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | | | - Sander M J van Kuijk
- Dept of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Emiel F M Wouters
- CIRO, Centre of expertise for chronic organ failure, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Daisy J A Janssen
- Centre of Expertise for Palliative Care, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,CIRO, Centre of expertise for chronic organ failure, Horn, The Netherlands
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5
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Maeda T, Hayakawa T. Combined Effect of Opioids and Corticosteroids for Alleviating Dyspnea in Terminal Cancer Patients: A Retrospective Review. J Pain Palliat Care Pharmacother 2016; 30:106-10. [PMID: 27093633 DOI: 10.3109/15360288.2016.1167803] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Dyspnea is a prognostic factor that affects the quality of life of terminal cancer patients, and many reports have described opioid treatment for dyspnea alleviation. Here, we retrospectively evaluated differences in the effects of various opioids administered concomitantly with corticosteroids on dyspnea in 20 terminal-stage cancer patients (13 men, 7 women; mean age [range]: 71 [49-94] years) who received opioids concomitantly with corticosteroids. Effectiveness was assessed throughout administration using the Support Team Assessment Schedule, Japanese version (STAS-J), particularly the subscale indicating how strongly a patient is affected by symptoms. The effectiveness of combined opioid and corticosteroid therapy against dyspnea and the opioid dose comprised the primary and secondary foci, respectively. Among concomitantly treated patients, STAS-J scores at initiation (mean ± SD: 3.1 ± 0.24) and lowest recorded STAS-J scores (1.4 ± 0.22) differed significantly (P = .0034) among those receiving morphine, but not among those receiving oxycodone (P = .068) or fentanyl (P = .18). Concomitant opioid and corticosteroid treatment was associated with a ≥2-point STAS-J score improvement in 14/20 patients (effectiveness: 70%). The opioid dose did not significantly affect dyspnea alleviation. We conclude that concomitant opioid and corticosteroid treatment can effectively alleviate dyspnea in terminal cancer patients.
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6
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Gott M, Gardiner C, Small N, Payne S, Seamark D, Halpin D, Ruse C, Barnes S. The effect of the Shipman murders on clinician attitudes to prescribing opiates for dyspnoea in end-stage chronic obstructive pulmonary disease in England. PROGRESS IN PALLIATIVE CARE 2015. [DOI: 10.1179/096992610x12624290276700] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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7
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Beyea A, Winzelberg G, Stafford RE. To drain or not to drain: an evidence-based approach to palliative procedures for the management of malignant pleural effusions. J Pain Symptom Manage 2012; 44:301-6. [PMID: 22871511 DOI: 10.1016/j.jpainsymman.2012.05.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 05/07/2012] [Accepted: 05/09/2012] [Indexed: 10/28/2022]
Abstract
Malignant pleural effusions are often symptomatic and diagnosed late in the course of cancer. The optimal management strategy is controversial and includes both invasive and non-invasive strategies. Practitioners have the option of invasive procedures such as intermittent drainage or more permanent catheter drainage to confirm malignancy and to palliate symptoms. Because these effusions are often detected late in the course of disease in patients who may have limited life expectancy, procedural management may be associated with harms that outweigh benefits. We performed a literature review to examine the available evidence for catheter drainage of malignant pleural effusions in advanced cancer and reviewed alternative management strategies for the management of dyspnea. We provide a clinical case within the context of the research evidence for invasive and non-invasive management strategies. Our intent is to help inform decision making of patients and families in collaboration with their health care practitioners and interventionists by weighing the risks and benefits of catheter drainage versus alternative medical management strategies for malignant pleural effusions.
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Affiliation(s)
- Annette Beyea
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
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8
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Pohl G, Marosi C, Dieckmann K, Goldner G, Elandt K, Hassler M, Schemper M, Strasser-Weippl K, Nauck F, Gaertner J, Watzke H. Evaluation of diagnostic and treatment approaches towards acute dyspnea in a palliative care setting among medical students at the University of Vienna. Wien Med Wochenschr 2012; 162:18-28. [DOI: 10.1007/s10354-011-0046-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Accepted: 12/16/2011] [Indexed: 12/01/2022]
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9
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Scientific Opinion on the risks for public health related to the presence of opium alkaloids in poppy seeds. EFSA J 2011. [DOI: 10.2903/j.efsa.2011.2405] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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10
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Rezk Y, Timmins PF, Smith HS. Review article: palliative care in gynecologic oncology. Am J Hosp Palliat Care 2010; 28:356-74. [PMID: 21187291 DOI: 10.1177/1049909110392204] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patients with advanced gynecologic malignancies have a multitude of symptoms; pain, nausea, and vomiting, constipation, anorexia, diarrhea, dyspnea, as well as symptoms resulting from intestinal obstruction, hypercalcemia, ascites, and/or ureteral obstruction. Pain is best addressed through a multimodal approach. The optimum palliative management of end-stage malignant intestinal obstruction remains controversial, with no clear guidelines governing the choice of surgical versus medical management. Patient selection for palliative surgery, therefore, should be highly individualized because only carefully selected candidates may derive real benefit from such surgeries. There remains a real need for more emphasis on palliative care education in training programs.
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Affiliation(s)
- Youssef Rezk
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Albany Medical College, Albany, NY 12208, USA
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11
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Clemens KE, Klaschik E. Dyspnoea associated with anxiety—symptomatic therapy with opioids in combination with lorazepam and its effect on ventilation in palliative care patients. Support Care Cancer 2010; 19:2027-33. [DOI: 10.1007/s00520-010-1058-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2010] [Accepted: 11/25/2010] [Indexed: 11/29/2022]
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12
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Oral Transmucosal Fentanyl Citrate for Dyspnea in Terminally Ill Patients: An Observational Case Series. J Palliat Med 2008; 11:643-8. [DOI: 10.1089/jpm.2007.0161] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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13
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The Care of the Terminal Patient. Oncology 2007. [DOI: 10.1007/0-387-31056-8_91] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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14
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Kvale PA, Selecky PA, Prakash UBS. Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest 2007; 132:368S-403S. [PMID: 17873181 DOI: 10.1378/chest.07-1391] [Citation(s) in RCA: 133] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
UNLABELLED GOALS/OBJECTIVES: To review the scientific evidence on symptoms and specific complications that are associated with lung cancer, and the methods available to palliate those symptoms and complications. METHODS MEDLINE literature review (through March 2006) for all studies published in the English language, including case series and case reports, since 1966 using the following medical subject heading terms: bone metastases; brain metastases; cough; dyspnea; electrocautery; hemoptysis; interventional bronchoscopy; laser; pain management; pleural effusions; spinal cord metastases; superior vena cava syndrome; and tracheoesophageal fistula. RESULTS Pulmonary symptoms that may require palliation in patients who have lung cancer include those caused by the primary cancer itself (dyspnea, wheezing, cough, hemoptysis, chest pain), or locoregional metastases within the thorax (superior vena cava syndrome, tracheoesophageal fistula, pleural effusions, ribs, and pleura). Respiratory symptoms can also result from complications of lung cancer treatment or from comorbid conditions. Constitutional symptoms are common and require attention and care. Symptoms referable to distant extrathoracic metastases to bone, brain, spinal cord, and liver pose additional problems that require a specific response for optimal symptom control. There are excellent scientific data regarding the management of many of these issues, with lesser evidence from case series or expert opinion on other aspects of providing palliative care for lung cancer patients. CONCLUSIONS Palliation of symptoms and complications in lung cancer patients is possible, and physicians who provide such care must be knowledgeable about these issues.
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Affiliation(s)
- Paul A Kvale
- Division of Pulmonary, Critical Care, Allergy, Immunology, and Sleep Disorders Medicine, Henry Ford Health System, 2799 W Grand Blvd, Detroit, MI 48202, USA.
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15
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Gartner V, Watzke H. [Palliative treatment. Basic principles and symptom control]. Wien Klin Wochenschr 2007; 118:123-33; quiz 134. [PMID: 17598319 DOI: 10.1007/s11812-006-0011-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Verena Gartner
- Universitätsklinik für Innere Medizin I, Medizinische Universität Wien, Wien, Osterreich.
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16
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Clemens KE, Klaschik E. Symptomatic therapy of dyspnea with strong opioids and its effect on ventilation in palliative care patients. J Pain Symptom Manage 2007; 33:473-81. [PMID: 17397708 DOI: 10.1016/j.jpainsymman.2006.09.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Revised: 09/04/2006] [Accepted: 09/06/2006] [Indexed: 11/30/2022]
Abstract
This study assessed the effect of opioid treatment on ventilation in dyspneic palliative care patients who received symptomatic treatment with strong opioids. The assessments measured changes in peripheral arterial oxygen saturation (SaO(2)), transcutaneous arterial pressure of carbon dioxide (tcPCO(2)), respiratory rate (f), and pulse rate (PF) during the titration phase with morphine or hydromorphone. The aims of the study were to verify the efficacy of opioids for the management of dyspnea, assess the effect on ventilation, and show whether nasal O(2) insufflation before opioid application leads to a decrease in the intensity of dyspnea. Eleven patients admitted to our palliative care unit were included in this prospective, nonrandomized trial. At admission, all patients suffered from dyspnea. tcPCO(2), SaO(2), and PF were measured transcutaneously by means of a SenTec Digital Monitor (SenTec AG, Switzerland). During O(2) insufflation, the intensity of dyspnea did not change. In contrast, the opioid produced a significant improvement in the intensity of dyspnea (P=0.003). Mean f decreased as early as 30 minutes after the first opioid administration, declining from 41.8+/-4.7 (35.0-50.0) to 35.5+/-4.2 (30.0-40.0), and after 90 minutes, to 25.7+/-4.5 (20.0-32.0) breaths/min. Other monitored respiratory parameters, however, showed no significant changes. There was no opioid-induced respiratory depression.
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Affiliation(s)
- Katri Elina Clemens
- Department of Science and Research in Palliative Medicine, University of Bonn, and Center for Palliative Medicine, Malteser Hospital Bonn/Rhein-Sieg Bonn, Germany.
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18
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Jantarakupt P, Porock D. Dyspnea Management in Lung Cancer: Applying the Evidence From Chronic Obstructive Pulmonary Disease. Oncol Nurs Forum 2007; 32:785-97. [PMID: 15990908 DOI: 10.1188/05.onf.785-797] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE/OBJECTIVES To provide an overview of mechanisms of dyspnea and causes of dyspnea in chronic obstructive pulmonary disease (COPD) and lung cancer and to critically review current pharmacologic and nonpharmacologic management of dyspnea for COPD and lung cancer. DATA SOURCES Published articles, abstracts, textbooks, and the authors' personal experiences with dyspnea management in COPD and lung cancer. DATA SYNTHESIS The causes of dyspnea in cancer are more varied than the causes of dyspnea in COPD; however, many are similar, thus providing the justification for recommending best practice from COPD research to be used in lung cancer. Dyspnea in both diseases is treated by corticosteroids, bronchodilators, antianxiety drugs, local anesthetics, and oxygen. However, when dyspnea is severe, morphine is the first choice. Using specific breathing techniques, positioning, energy conservation, exercise, and some dietary modifications and nutrient supplements can help with dyspnea management. CONCLUSIONS Pharmacologic and nonpharmacologic management of dyspnea in COPD can be applied to dyspnea related to lung cancer. Further research in the management of dyspnea in lung cancer is required, particularly controlled studies with larger sample sizes, to determine the effectiveness of the application of COPD dyspnea management in lung cancer. IMPLICATIONS FOR NURSING Previous studies provide a guideline for applying dyspnea management for COPD to cancer. The theoretical frameworks used in previous studies can be modified for conducting further study.
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Abstract
Progressive respiratory failure is a common modality of death in children with a terminal illness. The management of respiratory failure, and in particular symptoms of dyspnoea and musculoskeletal chest pain in children receiving palliative care, remains challenging. The emergence of palliative care paediatricians and the application of non-invasive ventilation to children with progressive respiratory failure are the two major advances in the care of children with respiratory complaints in the palliative care setting. This article outlines current approaches to palliative care in children with progressive respiratory symptoms.
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Abstract
Dyspnea, defined as uncomfortable or labored breathing, is a common and often devastating cause of distress for patients and their caregivers with advanced cancer and other life-threatening illnesses. The mechanism by which dyspnea develops is not fully understood, but it involves integration of the central respiratory complex with the sensory (perceptual) cortex. The gold standard of diagnosis is patient self-report. Careful assessment should be undertaken to identify reversible existing causes. Systemic opioids are the first-line therapy for symptomatic management, along with other general comfort measures (positioning, cool air, calming environment). Medical or surgical management can be directed toward underlying causes. Advanced care planning should include discussions concerning the burdens and benefits of medical/surgical management of underlying causes of dyspnea to more effectively direct goals of care. This article reviews current literature on dyspnea, with a focus on items published since 2000.
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Abstract
Lung cancer often is associated with significant morbidity, which has a detrimental effect on quality of life. Supportive care plays a central role in the multimodal treatment of lung cancer. Palliation of symptoms often improves quality of life and compliance with therapy. New developments in supportive care, reviewed here, include management of symptoms of the disease, such as respiratory problems, pain, and cachexia, as well as effects of treatment, including chemotherapy-induced nausea and vomiting, neutropenia, anemia, and mucositis. In the past few years, significant advances have been made in this field; however, palliation of the symptoms of lung cancer remains an area of active investigation.
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Affiliation(s)
- Michelle Boyar
- Department of Medicine, Columbia University Medical Center, 177 Fort Washington Avenue, MHB6-435, New York, NY 10032, USA
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23
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24
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LeGrand SB, Khawam EA, Walsh D, Rivera NI. Opioids, respiratory function, and dyspnea. Am J Hosp Palliat Care 2003; 20:57-61. [PMID: 12568438 DOI: 10.1177/104990910302000113] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Dyspnea, the sensation of difficult breathing, is a common debilitating symptom in advanced cancer and chronic progressive cardiopulmonary disease. Primary treatment is correction of the underlying etiology. In incurable illness wherein the cause is irreversible and the goal is palliation, opioids are the drugs of choice for symptomatic relief. This article reviews current knowledge in the pathophysiology of dyspnea, proposed opioid mechanism of action, and evidence of efficacy.
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Affiliation(s)
- Susan B LeGrand
- The Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Taussig Cancer Center, Cleveland, Ohio, USA
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25
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Abstract
The majority of patients who acquire lung cancer will have troublesome symptoms at some time during the course of their disease. Some of the symptoms are common to many types of cancers, while others are more often encountered with lung cancer than other primary sites. The most common symptoms are pain, dyspnea, and cough. This document will address the management of these symptoms, and it will also address the palliation of specific problems that are commonly seen in lung cancer: metastases to the brain, spinal cord, and bones; hemoptysis; tracheoesophageal fistula; and obstruction of the superior vena cava.
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Affiliation(s)
- Paul A Kvale
- Division of Pulmonary, Critical Care, Allergy, Immunology, and Sleep Disorders Medicine, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
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Silvestri GA, Sherman C, Williams T, Leong SS, Flume P, Turrisi A. Caring for the dying patient with lung cancer. Chest 2002; 122:1028-36. [PMID: 12226050 DOI: 10.1378/chest.122.3.1028] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Affiliation(s)
- Gerard A Silvestri
- Divisions of Pulmonary and Critical Care Medicine, Medical University of South Carolina, Charleston 29425, USA.
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Affiliation(s)
- Rita Wickham
- Rush-Presbyterian-St. Luke's Medical Center and Rush College of Nursing, Chicago, IL, USA.
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28
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Abstract
Dyspnea, like pain, is a subjective experience that incorporates physical elements and affective components. Management of breathlessness in patients with cancer requires expertise that includes an understanding and assessment of the multidimensional components of the symptom, knowledge of the pathophysiologic mechanisms and clinical syndromes that are common in cancer, and familiarity with the indications and limitations of the available therapeutic approaches. Relief of breathlessness should be the goal of treatment at all stages of cancer. Good control of dyspnea will improve the patient's quality of life.
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Affiliation(s)
- Deborah J Dudgeon
- Palliative Care Medicine Program, Queen's University, Room 2025, Etherington Hall, 94 Stuart Street, Kingston, Ontario, Canada K7L 3N6.
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29
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Abstract
Dyspnoea, defined as a sensation of an uncomfortable awareness of breathing, is one of the most frightening and distressing symptoms for patients with cancer. It is very common in cancer patients with and without direct lung involvement. The gold standard of diagnosis and assessment is the patient's self-report. Measurements of respiratory rate, oxygen saturation, and arterial blood gases do not measure dyspnoea. Fast, safe, and effective relief of the symptom is possible whether or not identifiable reversible causes exist. Opioids are the first line of therapy for such relief. Medical management can be directed at the underlying cause when the potential benefits outweigh the burdens of such treatment. In rare cases for which symptomatic treatment does not control dyspnoea to the patient's satisfaction, sedation is an effective, ethical option.
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Affiliation(s)
- Jay R Thomas
- Center for Palliative Studies, San Diego Hospice, University of California, San Diego School of Medicine, San Diego, CA, USA.
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30
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Forum for Applied Cancer Education and Training. Eur J Cancer Care (Engl) 2001. [DOI: 10.1046/j.1365-2354.1999.00160.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Barnett M. Alternative opioids to morphine in palliative care: a review of current practice and evidence. Postgrad Med J 2001; 77:371-8. [PMID: 11375449 PMCID: PMC1742058 DOI: 10.1136/pmj.77.908.371] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- M Barnett
- Walsgrave Hospital, Coventry and University of Warwick, UK
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32
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Krishnasamy M, Corner J, Bredin M, Plant H, Bailey C. Cancer nursing practice development: understanding breathlessness. J Clin Nurs 2001; 10:103-8. [PMID: 11820227 DOI: 10.1046/j.1365-2702.2001.00451.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
This paper considers methodological and philosophical issues that arose during a multi-centre, randomized controlled trial of a new nursing intervention to manage breathlessness with patients with primary lung cancer. Despite including a diverse range of instruments to measure the effects of the intervention, the uniqueness of individuals' experiences of breathlessness were often hidden by a requirement to frame the study within a reductionist research approach. Evidence from the study suggests that breathlessness is only partly defined when understood and explored within a bio-medical framework, and that effective therapy can only be achieved once the nature and impact of breathlessness have been understood from the perspective of the individual experiencing it. We conclude that to work therapeutically we need to know how patients interpret their illness and its resultant problems and that this demands methodological creativity.
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Affiliation(s)
- M Krishnasamy
- Centre for Cancer and Palliative Care Studies, Institute of Cancer Research, Sutton, Surrey, UK.
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33
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Sarhill N, Walsh D, Khawam E, Tropiano P, Stahley MK. Nebulized hydromorphone for dyspnea in hospice care of advanced cancer. Am J Hosp Palliat Care 2000; 17:389-91. [PMID: 11886040 DOI: 10.1177/104990910001700609] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
This case report describes the use of nebulized hydromorphone for management of dyspnea in advanced cancer in home hospice care. The patient was intolerant of morphine; nebulized hydromorphone was used as an alternative to nebulized morphine for dyspnea and found to be both safe and effective.
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Affiliation(s)
- N Sarhill
- The Harry R. Horvitz Center for Palliative Medicine, The Cleveland Clinic Taussig Cancer Center, Ohio, USA
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34
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Abstract
Progression of chronic obstructive pulmonary disease (COPD) is frequently associated with increasing dyspnea; indeed, patients with severe COPD constitute the largest group of patients with chronic respiratory insufficiency. The sensation of dyspnea in these patients is mostly related to increased work of breathing, a consequence of an increased resistive load, of hyperinflation, and of the deleterious effect of intrinsic positive end-expiratory pressure (PEEP(i)). Once optimal medical treatment has been provided, pharmacological treatments of dyspnea exist (beta2-agonists, methylxanthines, opiates) but seldom suffice. Nonpharmacological complementary treatments must be envisioned. Patients with severe hyperinflation should be screened as possible candidates for lung reduction surgery. Pulmonary rehabilitation-including chest therapy, patient education, exercise training-has been established as effective on quality of life (QoL) and dyspnea. Noninvasive positive pressure devices may be effective for symptomatic treatment of severe dyspnea: continuous positive airway pressure (CPAP) counteracts the deleterious effect of PEEP(i) in patients with severe hyperinflation; intermittent positive pressure breathing (IPPB) may decrease dyspnea and discomfort during nebulized therapy; finally noninvasive positive pressure ventilation (NIPPV) has been shown to be effective on the sensation of dyspnea and QoL in COPD with severe hypercapnia.
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Affiliation(s)
- J P Janssens
- Center for Pulmonary Rehabilitation, Hôpital de Rolle, Vaud, Switzerland
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35
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Abstract
This study explores the similarities and differences between subjective assessments of dyspnoea and objective spirometric indices of respiratory function in advanced cancer. Of 155 patients investigated, 71 (46%) were dyspnoeic and 108 (70%) had spirometry (94 post-salbutamol). Of the 94, 84 had height and weight measured to calculate predicted spirometry. Average dyspnoea levels over 24 h were measured by patient visual analogue scales (VASMe 24). Forced expiratory volume after 1 s (FEV1) and forced vital capacity (FVC) were almost always lower than predicted, indicating frequent impaired respiratory function. Mean spirometric increase post-salbutamol was 21% for FEV1 and 12% for FVC. Correlations between VAS dyspnoea scores and spirometry were low; hence, the latter cannot be relied upon as a measure of the former. Respiratory impairment tended to be obstructive (mean FEV1/FVC = 65%).
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37
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Abstract
Dyspnea is a common and devastating symptom of life-threatening disease. Approximately 90% of non-small cell lung cancer patients experience moderate to severe dyspnea by death. Currently, the pathology is ill-defined and measurement of this subjective symptom is imprecise. The treatment is directed at the underlying cause when appropriate. When specific therapies no longer exist, palliative interventions are necessary. This article outlines the current state of knowledge and standards of care for palliative interventions in dyspnea. These include nonpharmacologic interventions, oxygen supplementation, and medications. Further research is needed to clarify the role of each and to develop better pathophysiologic understanding.
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Affiliation(s)
- S B LeGrand
- Department of Hematology/Oncology, Harry R. Horvitz Center for Palliative Medicine, Cleveland Clinic Foundation, Ohio 44195, USA.
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38
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Abstract
Breathlessness is a common problem in advanced cancer ranked amongst the 10 most common symptoms in patients admitted to palliative care units. Alongside coughing, it is the most commonly reported symptom in lung cancer. Despite the prevalence of breathlessness, little research has been undertaken on the experience of the symptom, or on the restrictions it imposes on daily life. The data reported in this paper were collected as part of a study piloting new non-pharmacological intervention for patients with breathlessness as a result of lung cancer. Data on the experience of breathlessness from assessment notes recorded by nurses during conversations with 52 patients with lung cancer, were analysed using content analysis. Both physical and emotional sensations were associated with descriptions of breathlessness, such as the feeling of being unable to get enough breath, or of panic or impending death. Breathlessness was only continuous in eight patients, the remainder (85%) had an intermittent pattern of the symptom, usually triggered by exertion or, less commonly, emotion. Numerous restrictions on activity were reported as a result of breathlessness, on functioning inside and outside the home, to social life, and its implications for feelings about oneself. Most patients had attempted to find ways of managing the problems for themselves since, prior to receiving nursing intervention, little or no help had been forthcoming from health professionals.
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Affiliation(s)
- M O'Driscoll
- Centre for Cancer and Palliative Care Studies, Royal Marsden NHS Trust, London, UK
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Abstract
Dyspnea is a complex subjective experience that is common in terminal illness. Patients may present at any time during the course of their illness, although prevalence increases with disease progression. Dyspnea has physical, psychological, social and spiritual components; without recognizing how each of these contributes to the total suffering of dyspnea, management is unlikely to be successful. The management of dyspnea involves both pharmacological and non-pharmacological treatment. The main pharmacological palliative treatments are oxygen, opioids, and benzodiazepines, but the evidence to support these treatments is limited. More research is urgently needed to establish the efficacy of current treatments and to identify new ones.
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