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Lu-Song J, Bakal JA, Younus S, Moran-Mendoza O, Harle I, Morales M, Rippon N, Barratt SL, Adamali H, Kalluri M. The Impact of Integrated Palliative Care on Survival in Idiopathic Pulmonary Fibrosis: A Retrospective Multicenter Comparison. Am J Hosp Palliat Care 2024; 41:610-618. [PMID: 37553275 PMCID: PMC11032628 DOI: 10.1177/10499091231194722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023] Open
Abstract
Background: Early and integrated palliative care is recommended for patients with idiopathic pulmonary fibrosis. Unfortunately, palliative care delivery remains poor due to various barriers in practice. This study describes various palliative care delivery models in a real-world cohort of patients with idiopathic pulmonary fibrosis, examines the predictors of survival in this cohort of patients, and explores the impact of palliative care on survival. Design: Charts were reviewed retrospectively and analyzed. The primary outcome was survival during a 4-year follow-up period. Two multivariable models were created to examine the impact of therapeutic strategies including palliative intervention on survival. Results: 298 patients with idiopathic pulmonary fibrosis were enrolled from 3 interstitial lung disease clinics with different palliative care models in Edmonton, Canada; Bristol, UK; and Kingston, Canada. 200 (67%) patients received palliative care and 119 (40%) died during follow up. Primary palliative care models (Edmonton and Bristol) delivered palliative care to 96% and 100% respectively compared 21% in the referral model (Queens). Palliative care [adjusted hazard ratio (aHR) .28 (.12-.65)] along with the use of antifibrotics [aHR .56 (.37-.84)], and body mass index >30 [aHR .47 (.37-.85)] reduced the risk of death in our idiopathic pulmonary fibrosis cohort. Opioid use was associated with worse survival [aHR 2.11 (1.30-23.43)]. Conclusions: Both palliative care and antifibrotic use were associated with survival benefit in this cohort of patients with idiopathic pulmonary fibrosis after adjusting for covariates. The benefit was seen despite differences in disease severity and different palliative care delivery models.
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Affiliation(s)
- Jenny Lu-Song
- Division of Pulmonary Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Jeffrey A. Bakal
- Provincial Research Data Services, Alberta Health Services, Edmonton, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
| | | | - Onofre Moran-Mendoza
- Division of Respirology and Sleep Medicine, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | - Ingrid Harle
- Department of Medicine, Division of Palliative Care, Queen’s University, Kingston, ON, Canada (Retired)
| | - Michelle Morales
- Bristol Interstitial Lung Disease, North Bristol Trust, Southmead Hospital, Bristol, UK
| | - Naomi Rippon
- Bristol Interstitial Lung Disease, North Bristol Trust, Southmead Hospital, Bristol, UK
| | - Shaney L. Barratt
- Bristol Interstitial Lung Disease, North Bristol Trust, Southmead Hospital, Bristol, UK
| | - Huzaifa Adamali
- Bristol Interstitial Lung Disease, North Bristol Trust, Southmead Hospital, Bristol, UK
| | - Meena Kalluri
- Division of Pulmonary Medicine, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
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Demoule A, Baptiste A, Thille AW, Similowski T, Ragot S, Prat G, Mercat A, Girault C, Carteaux G, Boulain T, Perbet S, Decavèle M, Belin L, Frat JP. Dyspnea is severe and associated with a higher intubation rate in de novo acute hypoxemic respiratory failure. Crit Care 2024; 28:174. [PMID: 38783367 PMCID: PMC11118550 DOI: 10.1186/s13054-024-04903-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 04/05/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Dyspnea is a key symptom of de novo acute hypoxemic respiratory failure. This study explores dyspnea and its association with intubation and mortality in this population. METHODS This was a secondary analysis of a multicenter, randomized, controlled trial. Dyspnea was quantified by a visual analog scale (dyspnea-VAS) from zero to 100 mm. Dyspnea was measured in 259 of the 310 patients included. Factors associated with intubation were assessed with a competing risks model taking into account ICU discharge. The Cox model was used to evaluate factors associated with 90-day mortality. RESULTS At baseline (randomization in the parent trial), median dyspnea-VAS was 46 (interquartile range, 16-65) mm and was ≥ 40 mm in 146 patients (56%). The intubation rate was 45%. Baseline variables independently associated with intubation were moderate (dyspnea-VAS 40-64 mm) and severe (dyspnea-VAS ≥ 65 mm) dyspnea at baseline (sHR 1.96 and 2.61, p = 0.023), systolic arterial pressure (sHR 2.56, p < 0.001), heart rate (sHR 1.94, p = 0.02) and PaO2/FiO2 (sHR 0.34, p = 0.028). 90-day mortality was 20%. The cumulative probability of survival was lower in patients with baseline dyspnea-VAS ≥ 40 mm (logrank test, p = 0.049). Variables independently associated with mortality were SAPS 2 ≥ 25 (p < 0.001), moderate-to-severe dyspnea at baseline (p = 0.073), PaO2/FiO2 (p = 0.118), and treatment arm (p = 0.046). CONCLUSIONS In patients admitted to the ICU for de novo acute hypoxemic respiratory failure, dyspnea is associated with a higher risk of intubation and with a higher mortality. TRIAL REGISTRATION clinicaltrials.gov Identifier # NCT01320384.
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Affiliation(s)
- Alexandre Demoule
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75005, Paris, France.
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Hôpital Universitaire Pitié-Salpêtrière, AP-HP, 47-83 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France.
| | - Amandine Baptiste
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Unité de Recherche Clinique, AP-HP, Paris, France
| | - Arnaud W Thille
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Thomas Similowski
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75005, Paris, France
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Département R3S, AP-HP, 75013, Paris, France
| | - Stephanie Ragot
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
| | - Gwénael Prat
- Service de Médecine Intensive et Réanimation, CHU de Brest, Brest, France
| | - Alain Mercat
- Service de Réanimation médicale et Médecine Hyperbare, Centre Hospitalier Régional Universitaire, Angers, France
| | - Christophe Girault
- UNIROUEN, UR 3830, Medical Intensive Care Unit, Rouen University Hospital, Normandie University, Rouen, France
| | - Guillaume Carteaux
- Hôpitaux Universitaires Henri Mondor, Service de Médecine Intensive Réanimation, Université Paris Est Créteil, Groupe de Recherche Clinique CARMAS, AP-HP, Créteil, France
| | - Thierry Boulain
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire d'Orléans, Orléans, France
| | - Sébastien Perbet
- Réanimation Médico-Chirurgicale, CHU de Clermont-Ferrand, Clermont-Ferrand, France
- GReD, UMR/CNRS 6293, INSERM U1103, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Maxens Decavèle
- INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, 75005, Paris, France
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), Hôpital Universitaire Pitié-Salpêtrière, AP-HP, 47-83 Boulevard de L'Hôpital, 75651, Paris Cedex 13, France
| | - Lisa Belin
- Site Pitié-Salpêtrière, Département de Santé Publique, INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, AP-HP, APHP-Sorbonne Université, Paris, France
| | - Jean-Pierre Frat
- Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Poitiers, Poitiers, France
- Centre d'Investigation Clinique 1402 ALIVE, Université de Poitiers, Poitiers, France
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3
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Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Eur Respir J 2024; 63:2300347. [PMID: 38387998 DOI: 10.1183/13993003.00347-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
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Affiliation(s)
- Alexandre Demoule
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Maxens Decavele
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation, Département R3S, F-75013 Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behaviorial Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Department of Anesthesia, Critical Care and Emergency, Milan, Italy
- University of Milan, Department of Pathophysiology and Transplantation, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
- L. Heunks and T. Similowski contributed equally to the manuscript
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, F-75005 Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, F-75013 Paris, France
- L. Heunks and T. Similowski contributed equally to the manuscript
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4
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Demoule A, Decavele M, Antonelli M, Camporota L, Abroug F, Adler D, Azoulay E, Basoglu M, Campbell M, Grasselli G, Herridge M, Johnson MJ, Naccache L, Navalesi P, Pelosi P, Schwartzstein R, Williams C, Windisch W, Heunks L, Similowski T. Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement. Intensive Care Med 2024; 50:159-180. [PMID: 38388984 DOI: 10.1007/s00134-023-07246-x] [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] [Received: 04/14/2023] [Accepted: 09/16/2023] [Indexed: 02/24/2024]
Abstract
This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society (ERS) and the European Society of Intensive Care Medicine (ESICM). Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.
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Affiliation(s)
- Alexandre Demoule
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France.
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France.
| | - Maxens Decavele
- Service de Médecine Intensive-Réanimation, Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
| | - Massimo Antonelli
- Department of Anesthesiology and Intensive Care Medicine, Catholic University of the Sacred Heart, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luigi Camporota
- Department of Adult Critical Care, Health Centre for Human and Applied Physiological Sciences, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Fekri Abroug
- ICU and Research Lab (LR12SP15), Fattouma Bourguiba Teaching Hospital, Monastir, Tunisia
| | - Dan Adler
- Division of Pulmonary Diseases, Hôpital de la Tour, Geneva, Switzerland
- Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elie Azoulay
- Medical Intensive Care Unit, APHP Hôpital Saint-Louis, Paris, France
| | - Metin Basoglu
- Istanbul Center for Behavioral Sciences (DABATEM), Istanbul, Turkey
| | | | - Giacomo Grasselli
- Department of Anesthesia, Critical Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Margaret Herridge
- Toronto General Research Institute, University Health Network, Toronto, ON, Canada
| | - Miriam J Johnson
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Lionel Naccache
- Département de Neurophysiologie, Sorbonne Université, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Paris, France
- Institut du Cerveau et de la Moelle Épinière, ICM, PICNIC Lab, Paris, France
| | - Paolo Navalesi
- Department of Medicine, University of Padua, Padua, Italy
- Institute of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Paolo Pelosi
- Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Richard Schwartzstein
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | | | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Witten/Herdecke University, Cologne, Germany
| | - Leo Heunks
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, 75005, Paris, France
- Département R3S, AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
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5
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Kochovska S, Ekström M, Hansen-Flaschen J, Ferreira D, Similowski T, Johnson MJ, Currow DC. Hiding in plain sight: the evolving definition of chronic breathlessness and new ICD-11 wording. Eur Respir J 2023; 61:61/3/2300252. [PMID: 36997231 DOI: 10.1183/13993003.00252-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 03/31/2023]
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6
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Baker KM, Phelan AM, Reilly JB, Lansing RW, Schwartzstein RM, Banzett RB. Rating Dyspnea and Pain: "No" is Not Always "Zero". Clin Nurs Res 2023; 32:15-21. [PMID: 36367118 PMCID: PMC10989776 DOI: 10.1177/10547738221134564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Nurses routinely assess pain in hospitalized patients; similar assessment of dyspnea is increasing. Most nurses start with a yes-no question when assessing pain or dyspnea; many record "no" as a zero rating, skipping the rating scale. We tested the hypothesis that recording "no" answers as "zero" fails to detect the symptoms that would have been detected with a rating scale. Nurses asked 60 patients yes-no questions about the presence of dyspnea and pain, then asked patients to rate the symptoms using a 0-10 scale. All "yes" answers were followed by a concordant rating (i.e., greater than zero). More than 25% of "no" answers were followed by a discordant rating (> zero). Documenting "no" as "zero" missed information potentially useful in care planning; patients who rate dyspnea above zero are at greater risk of adverse outcomes. This information can also provide opportunity to start a discussion with patients who may benefit from symptom management.
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Affiliation(s)
- Kathy M. Baker
- Lois E. Silverman Dept of Nursing, Beth Israel Deaconess
Medical Center, Boston, MA, 02115 USA
| | | | - Jennifer B Reilly
- Lois E. Silverman Dept of Nursing, Beth Israel Deaconess
Medical Center, Boston, MA, 02115 USA
| | - Robert W. Lansing
- Department of Medicine, Division of Pulmonary, Critical
Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02115
USA
| | - Richard M Schwartzstein
- Department of Medicine, Division of Pulmonary, Critical
Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02115
USA
- Harvard Medical School, Boston, MA, 02115 USA
| | - Robert B. Banzett
- Department of Medicine, Division of Pulmonary, Critical
Care, and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, 02115
USA
- Harvard Medical School, Boston, MA, 02115 USA
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7
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Sandau C, Hansen EF, Pedersen L, Jensen JUS. Hypoxemia and not hyperoxemia predicts worse outcome in severe COPD exacerbations - an observational study. Eur Clin Respir J 2022; 10:2153644. [PMID: 36505897 PMCID: PMC9731582 DOI: 10.1080/20018525.2022.2153644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Objectives For patients admitted with an acute exacerbation of COPD (AECOPD) and a need for supplementary oxygen therapy, to determine if peripheral oxygen saturation < 88% (hypoxemia) or >92% (hyperoxemia), within first 24 hours of admission, is associated with 'treatment failure' or fewer days alive and out of hospital within 14 days after admission. Design A retrospective multicenter observational study, reviewing consecutive data on SpO2, oxygen, and drug administration at three predefined time points, on adverse events in patients admitted with COPD between December 2019 and June 2020. Multivariable logistic regression analysis, Mann Whitney U- and Chi-square-test were used. Setting Acute hospital setting, across four different hospitals in the capital region of Denmark. Participants Patients with a confirmed diagnosis of COPD admitted with an acute exacerbation and an oxygen need within the first 24 hours admission. Results In total 289 COPD patients were included. The median age was 74.8 years [interquartile range (IQR):69.6 to 81.8], 191 were female and 132 patients experienced 'treatment failure'. A minimum of one episode of hypoxemia (SpO2 < 88%) within first 24 hours was associated with having a low number (≤4) of days alive and out of hospital within 14 days after admission: OR 2.4 (95%CI 1.2 to 4.8), p = 0.02, absolute risk 44% vs. 26% p = 0.01, Chi-square. Comparable results were observed after 30 days of follow-up: OR 2.6 (95% CI 1.0 to7.1), p = 0.05. A minimum of one measurement of hyperoxemia (SpO2 > 92%), within first 24 hours of admission was not associated with low number of days alive and out of hospital within 14 days OR 1.0 (95% CI 0.5 to 2.1) nor at 30 days. Conclusion For admitted patients with AECOPD, being hypoxemic ever within the first 24 hours after admission is associated with a substantially increased risk of a poor prognosis.
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Affiliation(s)
- Charlotte Sandau
- Department of Respiratory Medicine and Endocrinology, Pulmonary Section, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark,CONTACT Charlotte Sandau Department of Respiratory Medicine and Endocrinology, Pulmonary Section, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Ejvind Frausing Hansen
- Department of Respiratory Medicine and Endocrinology, Pulmonary Section, Copenhagen University Hospital Hvidovre, Copenhagen, Denmark
| | - Lars Pedersen
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen Univervisity Hospital Bispebjerg Hospital, Copenhagen, Denmark
| | - Jens Ulrik Stæhr Jensen
- Department of Medicine, Respiratory Medicine Section, Copenhagen University Hospital Herlev Gentofte Hospital, Copenhagen, Denmark,Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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8
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Decavèle M, Serresse L, Gay F, Nion N, Lavault S, Freund Y, Niérat MC, Steichen O, Demoule A, Morélot-Panzini C, Similowski T. ' Involve me and I learn': an experiential teaching approach to improve dyspnea awareness in medical residents. MEDICAL EDUCATION ONLINE 2022; 27:2133588. [PMID: 36218180 PMCID: PMC9559048 DOI: 10.1080/10872981.2022.2133588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/30/2022] [Accepted: 10/05/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Dyspnea is a frightening and debilitating experience. It attracts less attention than pain ('dyspnea invisibility'), possibly because of its non-universal nature. We tested the impact of self-induced experimental dyspnea on medical residents. MATERIALS AND METHODS During a teaching session following the principles of experiential learning, emergency medicine residents were taught about dyspnea theoretically, observed experimental dyspnea in their teacher, and personally experienced self-induced dyspnea. The corresponding psychophysiological reactions were described. Immediate and 1-year evaluations were conducted to assess course satisfaction (overall 0-20 grade) and the effect on the understanding of what dyspnea represents for patients. RESULTS Overall, 55 emergency medicine residents participated in the study (26 men, median age 26 years). They were moderately satisfied with previous dyspnea teaching (6 [5-7] on a 0-10 numerical rating scale [NRS]) and expressed a desire for an improvement in the teaching (8 [7-9]). Immediately after the course they reported improved understanding of patients' experience (7 [6-8]), which persisted at 1 year (8 [7-9], 28 respondents). Overall course grade was 17/20 [15-18], and there were significant correlations with experimental dyspnea ratings (intensity: r = 0.318 [0.001-0.576], p = 0.043; unpleasantness: r = 0.492 [0.208-0.699], p = 0.001). In multivariate analysis, the only factor independently associated with the overall course grade was 'experiential understanding' (the experimental dyspnea-related improvement in the understanding of dyspneic patients' experience). A separate similar experiment conducted in 50 respiratory medicine residents yielded identical results. CONCLUSIONS This study suggests that, in advanced medical residents, the personal discovery of dyspnea can have a positive impact on the understanding of what dyspnea represents for patients. This could help fight dyspnea invisibility.
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Affiliation(s)
- Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive, Réanimation, Département R3S, Paris, France
| | - Laure Serresse
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Unité Mobile de Soins Palliatifs, Paris, France
| | - Frédérick Gay
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Laboratoire de parasitologie-mycologie, Paris, France
| | - Nathalie Nion
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, Paris, France
| | - Sophie Lavault
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, Paris, France
| | - Yonathan Freund
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service d’accueil des urgences, Paris, France
- Sorbonne Université, INSERM, UMRS 1166, IHU ICAN, Paris, France
| | - Marie-Cécile Niérat
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Olivier Steichen
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Tenon, Service de médecine interne, Paris, France
- Sorbonne Université, INSERM, UMRS 1142 LIMICS, Paris, France
| | - Alexandre Demoule
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive, Réanimation, Département R3S, Paris, France
| | - Capucine Morélot-Panzini
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Département R3S, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, Paris, France
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9
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Andrews P, Shiber J, Madden M, Nieman GF, Camporota L, Habashi NM. Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal. Front Physiol 2022; 13:928562. [PMID: 35957991 PMCID: PMC9358044 DOI: 10.3389/fphys.2022.928562] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 06/21/2022] [Indexed: 12/16/2022] Open
Abstract
In the pursuit of science, competitive ideas and debate are necessary means to attain knowledge and expose our ignorance. To quote Murray Gell-Mann (1969 Nobel Prize laureate in Physics): “Scientific orthodoxy kills truth”. In mechanical ventilation, the goal is to provide the best approach to support patients with respiratory failure until the underlying disease resolves, while minimizing iatrogenic damage. This compromise characterizes the philosophy behind the concept of “lung protective” ventilation. Unfortunately, inadequacies of the current conceptual model–that focuses exclusively on a nominal value of low tidal volume and promotes shrinking of the “baby lung” - is reflected in the high mortality rate of patients with moderate and severe acute respiratory distress syndrome. These data call for exploration and investigation of competitive models evaluated thoroughly through a scientific process. Airway Pressure Release Ventilation (APRV) is one of the most studied yet controversial modes of mechanical ventilation that shows promise in experimental and clinical data. Over the last 3 decades APRV has evolved from a rescue strategy to a preemptive lung injury prevention approach with potential to stabilize the lung and restore alveolar homogeneity. However, several obstacles have so far impeded the evaluation of APRV’s clinical efficacy in large, randomized trials. For instance, there is no universally accepted standardized method of setting APRV and thus, it is not established whether its effects on clinical outcomes are due to the ventilator mode per se or the method applied. In addition, one distinctive issue that hinders proper scientific evaluation of APRV is the ubiquitous presence of myths and misconceptions repeatedly presented in the literature. In this review we discuss some of these misleading notions and present data to advance scientific discourse around the uses and misuses of APRV in the current literature.
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Affiliation(s)
- Penny Andrews
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
- *Correspondence: Penny Andrews,
| | - Joseph Shiber
- University of Florida College of Medicine, Jacksonville, FL, United States
| | - Maria Madden
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Gary F. Nieman
- Department of Surgery, SUNY Upstate Medical University, Syracuse, NY, United States
| | - Luigi Camporota
- Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences, London, United Kingdom
| | - Nader M. Habashi
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, United States
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10
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Neutrophile-to-Lymphocyte Ratio (NLR) Identifies Patients with Coronavirus Infectious Disease 2019 (COVID-19) at High Risk for Deterioration and Mortality—A Retrospective, Monocentric Cohort Study. Diagnostics (Basel) 2022; 12:diagnostics12051109. [PMID: 35626265 PMCID: PMC9139590 DOI: 10.3390/diagnostics12051109] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/25/2022] [Accepted: 04/27/2022] [Indexed: 01/31/2023] Open
Abstract
Among people infected with SARS-CoV-2, the determination of clinical features associated with poor outcome is essential to identify those at high risk of deterioration. Here, we aimed to investigate clinical phenotypes of patients hospitalized due to COVID-19 and to examine the predictive value of the neutrophil-to-lymphocyte ratio (NLR) in a representative patient collective of the Swiss population. We conducted a retrospective monocentriccohort study with patients hospitalized due to COVID-19 between 27 February and 31 December 2020. Data were analyzed descriptively, using the binary logistic regression model, proportional odds logistic regression model, competing risk analysis, and summary measure analysis. A total of 454 patients were included in our study. Dyspnea, elevated respiratory rate, low oxygen saturation at baseline, age, and presence of multiple comorbidities were associated with a more severe course of the disease. A high NLR at baseline was significantly associated with disease severity, unfavorable outcome, and mortality. In non-survivors, NLR further increased during hospital stay, whereas in survivors, NLR decreased. In conclusion, our data emphasize the importance of accurate history taking and clinical examination upon admission and confirm the role of baseline NLR as a surrogate marker for increased disease severity, unfavorable outcome, and mortality in patients hospitalized due to infection with SARS-CoV-2.
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11
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Schwartzstein RM, Campbell ML. Dyspnea and Mechanical Ventilation: The Emperor Has No Clothes. Am J Respir Crit Care Med 2022; 205:864-865. [PMID: 35134318 PMCID: PMC9838635 DOI: 10.1164/rccm.202201-0078ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Affiliation(s)
- Richard M. Schwartzstein
- Division of Pulmonary, Critical Care and Sleep MedicineBeth Israel Deaconess Medical CenterBoston, Massachusetts
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12
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Demoule A, Hajage D, Messika J, Jaber S, Diallo H, Coutrot M, Kouatchet A, Azoulay E, Fartoukh M, Hraiech S, Beuret P, Darmon M, Decavèle M, Ricard JD, Chanques G, Mercat A, Schmidt M, Similowski T. Prevalence, Intensity and Clinical Impact of Dyspnea in Critically Ill Patients Receiving Invasive Ventilation. Am J Respir Crit Care Med 2022; 205:917-926. [DOI: 10.1164/rccm.202108-1857oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Alexandre Demoule
- Groupe Hospitalier Pitié Salpêtrière, Assistance Publique Hopitaux de Paris, Service de Pneumologie et Réanimation Médicale, Paris, France
| | | | - Jonathan Messika
- Hôpital Louis-Mourier, 26931, Service de Médecine Intensive - Réanimation, Colombes, France
| | - Samir Jaber
- University hospital. CHU de MONTPELLIER HOPITAL SAINT ELOI, Intensive Care Unit and transplantation-Departement of Anesthesiology DAR B, Montpellier Cedex 5, France
| | - Hassimiou Diallo
- University Hospital Pitié Salpêtrière, 26933, Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Maxime Coutrot
- Hopital Universitaire Pitie Salpetriere, 26933, Service de Medecine Intensive Réanimation - Institut de Cardiologie, Paris, France
| | - Achille Kouatchet
- Service de Reanimation Médicale et Médecine Hyperbare, Angers, France
| | | | - Muriel Fartoukh
- Assistance Publique Hopitaux de Paris. Sorbonne Université, Hôpital Tenon, Médecine intensive Réanimatio, Paris, France
| | - Sami Hraiech
- Aix-Marseille Univ, APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Marseille, France
| | - Pascal Beuret
- CENTRE HOSPITALIER, SERVICE DE REANIMATION POLYVALENTE, ROANNE, France
| | | | - Maxens Decavèle
- Groupe Hospitalier La Pitié Salpêtrière-Charles Foix, 55577, Médecine Intensive Réanimation, Paris, France
| | | | - Gerald Chanques
- University of Montpellier Hospitals, Anesthesiology & Critical Care, Montpellier, France
| | - Alain Mercat
- Angers University Hospital, Departement de Reanimation medicale et medecine hyperbare, Angers, France
| | - Matthieu Schmidt
- Groupe Hospitalier Pitié-Salpêtrière, Service de réanimation médicale, Paris, France
| | - Thomas Similowski
- groupe hospitalier pitié-salpêtrière, Service de Pneumologie, PARIS, France
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13
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Clarke SY, Williams MT, Johnston KN, Lee AL. The prevalence and assessment of pain and dyspnoea in acute exacerbations of COPD: A systematic review. Chron Respir Dis 2022; 19:14799731221105518. [PMID: 35698999 PMCID: PMC9201350 DOI: 10.1177/14799731221105518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 04/12/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Dyspnoea and pain are symptoms of chronic obstructive pulmonary disease (COPD). This review focused upon pain and dyspnoea during hospital admissions for acute exacerbations of COPD (AECOPD), with the aim of examining prevalence, assessment, clinical associations, and researcher-reported implications of these symptoms. METHODS Four electronic databases were searched from inception to 31 May 2021. Full text versions of studies were assessed for methodological quality and data were extracted independently by two reviewers. Where data permitted, pooled prevalence of pain and dyspnoea were calculated by meta-analysis. RESULTS Four studies were included. The pooled prevalence of pain and dyspnoea was 44% (95% confidence interval (CI) 35%-52%) and 91% (95% CI 87%-94%) respectively. An array of instruments with varying focal periods were reported (pain: six tools, dyspnoea: four tools). Associations and clinical implications between the two symptoms at the time of hospital admission were rarely reported. CONCLUSIONS Few studies reported prevalence of pain and dyspnoea during an AECOPD. A greater understanding into the prevalence, intensity and associations of these symptoms during AECOPD could be furthered by use of standardised assessment tools with clearly defined focal periods.
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Affiliation(s)
- Stephanie Y Clarke
- Department of Physiotherapy, School
of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health
Sciences, Monash University, Frankston, Victoria, Australia
- Physiotherapy Department, Eastern Health, Victoria, Australia
| | - Marie T Williams
- IMPlementation And Clinical
Translation in Health (IIMPACT), Allied Health and Human Performance, University of South
Australia, Adelaide, South Australia, Australia
| | - Kylie N Johnston
- IMPlementation And Clinical
Translation in Health (IIMPACT), Allied Health and Human Performance, University of South
Australia, Adelaide, South Australia, Australia
| | - Annemarie L Lee
- Department of Physiotherapy, School
of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health
Sciences, Monash University, Frankston, Victoria, Australia
- Centre for Allied Health Research
and Education, Cabrini Health, Victoria, Australia
- Institute for Breathing and
Sleep, Victoria, Australia
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14
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Abstract
The clinical term dyspnea (a.k.a. breathlessness or shortness of breath) encompasses at least three qualitatively distinct sensations that warn of threats to breathing: air hunger, effort to breathe, and chest tightness. Air hunger is a primal homeostatic warning signal of insufficient alveolar ventilation that can produce fear and anxiety and severely impacts the lives of patients with cardiopulmonary, neuromuscular, psychological, and end-stage disease. The sense of effort to breathe informs of increased respiratory muscle activity and warns of potential impediments to breathing. Most frequently associated with bronchoconstriction, chest tightness may warn of airway inflammation and constriction through activation of airway sensory nerves. This chapter reviews human and functional brain imaging studies with comparison to pertinent neurorespiratory studies in animals to propose the interoceptive networks underlying each sensation. The neural origins of their distinct sensory and affective dimensions are discussed, and areas for future research are proposed. Despite dyspnea's clinical prevalence and impact, management of dyspnea languishes decades behind the treatment of pain. The neurophysiological bases of current therapeutic approaches are reviewed; however, a better understanding of the neural mechanisms of dyspnea may lead to development of novel therapies and improved patient care.
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Affiliation(s)
- Andrew P Binks
- Department of Basic Science Education, Virginia Tech Carilion School of Medicine, Roanoke, VA, United States; Faculty of Health Sciences, Virginia Tech, Blacksburg, VA, United States.
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15
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Decavèle M, Similowski T. Dyspnoea upon hospital admission: listen to the bird of ill omen! Eur Respir J 2021; 58:58/3/2100988. [PMID: 34475114 DOI: 10.1183/13993003.00988-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Accepted: 04/06/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Maxens Decavèle
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,Service de Médecine Intensive et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France .,Département R3S (Respiration, Réanimation, Réhabilitation respiratoire, Sommeil), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Paris, France
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