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Pinfield J, Gaskin K, Bentley J, Rouse J. Recognition and management of asthma in children and young people. Nurs Stand 2017; 30:50-8; quiz 60. [PMID: 26373524 DOI: 10.7748/ns.30.3.50.e9987] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Asthma is a common childhood disorder that has global significance. Developing an understanding of the aetiology, effects, diagnosis and management of the disorder enables healthcare practitioners to reduce the physical, psychological and social effects of asthma on children, families and healthcare systems. This article refers to the Scottish Intercollegiate Guidelines Network and British Thoracic Society guideline on the management of asthma, and enables the reader to incorporate this guidance into their practice.
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Rai KK, Jordan RE, Siebert WS, Sadhra SS, Fitzmaurice DA, Sitch AJ, Ayres JG, Adab P. Birmingham COPD Cohort: a cross-sectional analysis of the factors associated with the likelihood of being in paid employment among people with COPD. Int J Chron Obstruct Pulmon Dis 2017; 12:233-242. [PMID: 28138233 PMCID: PMC5238806 DOI: 10.2147/copd.s119467] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Employment rates among those with chronic obstructive pulmonary disease (COPD) are lower than those without COPD, but little is known about the factors that affect COPD patients' ability to work. METHODS Multivariable analysis of the Birmingham COPD Cohort Study baseline data was used to assess the associations between lifestyle, clinical, and occupational characteristics and likelihood of being in paid employment among working-age COPD patients. RESULTS In total, 608 of 1,889 COPD participants were of working age, of whom 248 (40.8%) were in work. Older age (60-64 years vs 30-49 years: odds ratio [OR] =0.28; 95% confidence interval [CI] =0.12-0.65), lower educational level (no formal qualification vs degree/higher level: OR =0.43; 95% CI =0.19-0.97), poorer prognostic score (highest vs lowest quartile of modified body mass index, airflow obstruction, dyspnea, and exercise (BODE) score: OR =0.10; 95% CI =0.03-0.33), and history of high occupational exposure to vapors, gases, dusts, or fumes (VGDF; high VGDF vs no VGDF exposure: OR =0.32; 95% CI =0.12-0.85) were associated with a lower probability of being employed. Only the degree of breathlessness of BODE was significantly associated with employment. CONCLUSION This is the first study to comprehensively assess the characteristics associated with employment in a community sample of people with COPD. Future interventions should focus on managing breathlessness and reducing occupational exposures to VGDF to improve the work capability among those with COPD.
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Abstract
Chronic heart failure is a common and complex clinical syndrome that results from impaired cardiac relaxation or contraction. There have been considerable advances in the management of chronic heart failure; however, the mortality rate remains high. Patients with chronic heart failure may experience multiple debilitating symptoms, such as fatigue, pain, and peripheral oedema. However, breathlessness may be considered the most debilitating symptom. The management of chronic heart failure aims to improve the patient's quality of life by reducing symptoms and supporting the patient to manage their condition. Treatment of patients with chronic heart failure may involve a combination of pharmacological therapy, device implantation and cardiac rehabilitation. This is the second of two articles on chronic heart failure. Part 1 discussed the pathophysiology of chronic heart failure, its causes, assessment, signs and symptoms. Part 2 outlines the treatment and management of patients with the condition, including pharmacological strategies, device implantation, lifestyle modification, cardiac rehabilitation and palliative care.
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Abstract
Chronic heart failure is a common and complex clinical syndrome that results from impaired cardiac relaxation or contraction. Patients with chronic heart failure may experience multiple debilitating symptoms, such as fatigue, pain, and peripheral oedema. However, breathlessness may be considered the most debilitating symptom. This is the first of two articles on chronic heart failure, and outlines the pathophysiology of the condition, its causes, assessment, and signs and symptoms. Part 2 will discuss the treatment and management of the condition, including pharmacological strategies, device implantation, lifestyle modification, cardiac rehabilitation and palliative care.
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Abstract
Chronic obstructive pulmonary disease (COPD) is a common, progressive and disabling disease that causes significant burden to patients, their families, and the NHS. Research suggests that the complexity of factors contributing to the disease requires a deeper understanding of the patient experience and a more holistic approach to care provision. This, the second of two articles, discusses the non-pharmacological therapies for managing patients with COPD and explores the concept of mindfulness as a therapy in the management of breathlessness.
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Collier A, Breaden K, Phillips JL, Agar M, Litster C, Currow DC. Caregivers' Perspectives on the Use of Long-Term Oxygen Therapy for the Treatment of Refractory Breathlessness: A Qualitative Study. J Pain Symptom Manage 2017; 53:33-39. [PMID: 27840229 DOI: 10.1016/j.jpainsymman.2016.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 06/06/2016] [Accepted: 06/23/2016] [Indexed: 11/26/2022]
Abstract
CONTEXT Despite limited clinical evidence, long-term oxygen therapy (LTOT) is used for the management of refractory breathlessness in people with life-limiting illnesses who are not necessarily hypoxemic. OBJECTIVES The aim of this study was to understand caregiver factors associated with caring for someone with LTOT from the perspectives and experiences of caregivers themselves. METHODS The qualitative study used semistructured interviews. The study was conducted in two states in Australia. Participants (n = 20) were self-nominated caregivers of people receiving LTOT for refractory breathlessness in the palliative setting. RESULTS Data analyses established one overarching theme titled: "Oxygen giveth (something to help caregivers relieve breathlessness) and oxygen taketh away (from patients who lose some autonomy)." The theme captured caregivers' feelings of extreme distress in response to witnessing refractory breathlessness, and oxygen fulfilling several critical and beneficial roles in this context. In parallel, caregivers also explicitly and implicitly articulated several downsides to the use of LTOT. CONCLUSION Caregivers find caring for someone with refractory breathlessness extremely distressing. The benefits of LTOT are often overestimated, whereas its potential harms are underestimated. As significant stakeholders of people receiving LTOT, caregivers should be provided with opportunities to collaborate with clinicians in evidence-based decision making, efforts should be made to provide them with information and education about the most effective pharmacological and nonpharmacological strategies to manage refractory breathlessness in a palliative care setting including the appropriate use of LTOT to enable them to do so.
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Watts GJ, Clark K, Agar M, Davidson PM, McDonald C, Lam LT, Sajkov D, McCaffrey N, Doogue M, Abernethy AP, Currow DC. Study protocol: a phase III randomised, double-blind, parallel arm, stratified, block randomised, placebo-controlled trial investigating the clinical effect and cost-effectiveness of sertraline for the palliative relief of breathlessness in people with chronic breathlessness. BMJ Open 2016; 6:e013177. [PMID: 27899400 PMCID: PMC5168508 DOI: 10.1136/bmjopen-2016-013177] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Breathlessness remains a highly prevalent and distressing symptom for many patients with progressive life-limiting illnesses. Evidence-based interventions for chronic breathlessness are limited, and there is an ongoing need for high-quality research into developing management strategies for optimal palliation of this complex symptom. Previous studies have suggested that selective serotonin reuptake inhibitors such as sertraline may have a role in reducing breathlessness. This paper presents the protocol for a large, adequately powered randomised study evaluating the use of sertraline for chronic breathlessness in people with progressive life-limiting illnesses. METHODS AND ANALYSIS A total of 240 participants with modified Medical Research Council Dyspnoea Scale breathlessness of level 2 or higher will be randomised to receive either sertraline or placebo for 28 days in this multisite, double-blind study. The dose will be titrated up every 3 days to a maximum of 100 mg daily. The primary outcome will be to compare the efficacy of sertraline with placebo in relieving the intensity of worst breathlessness as assessed by a 0-100 mm Visual Analogue Scale. A number of other outcome measures and descriptors of breathlessness as well as caregiver assessments will also be recorded to ensure adequate analysis of participant breathlessness and to allow an economic analysis to be performed. Participants will also be given the option of continuing blinded treatment until either study data collection is complete or net benefit ceases. Appropriate statistical analysis of primary and secondary outcomes will be used to describe the wealth of data obtained. ETHICS AND DISSEMINATION Ethics approval was obtained at all participating sites. Results of the study will be submitted for publication in peer-reviewed journals and the key findings presented at national and international conferences. TRIAL REGISTRATION NUMBER ACTRN12610000464066.
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Yorke J, Adair P, Doyle AM, Dubrow-Marshall L, Fleming S, Holmes L, Menzies-Gow A, Niven R, Pilling M, Shuldham C. A randomised controlled feasibility trial of Group Cognitive Behavioural Therapy for people with severe asthma. J Asthma 2016; 54:543-554. [PMID: 27880064 DOI: 10.1080/02770903.2016.1229335] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Evidence for the efficacy of Cognitive Behavioural Therapy (CBT) in asthma is developing but it is not known if this translates to benefits in severe asthma or if a group approach is acceptable to this patient group. This study aimed to assess the feasibility and acceptability of Group-CBT in severe asthma. METHOD This was a two-centre, randomised controlled parallel group feasibility study. Eligible participants (patients with severe asthma and a clinically significant diagnosis of anxiety and/or depression - Hospital Anxiety and Depression Scale (HAD) score greater than 8 for the anxiety or depression sub-scale) received Group-CBT in weekly sessions for eight consecutive weeks and usual care or usual care only. Follow-up was for 16 weeks and end points were: Asthma Quality of Life Questionnaire, Asthma Control Questionnaire, HAD, Dyspnoea-12, EuroQual-5D and EuroQuol-VAS. RESULTS 51 patients were randomised: 36% (51 out of 140) consent rate and attrition at week 16 was 12. Screening logs indicated that study take-up was influenced by patients living long distances from the treatment centre and inability to commit to the weekly demands of the programme. Drop-out was higher in Group-CBT compared due to inability to commit to the weekly programme because of poor health. Participants who contributed to focus group discussions reported that Group-CBT contributed to a better understanding of their illness and related approaches to anxiety management and acceptance of their asthma condition. Although weekly face-to-face sessions were challenging, this was the preferred method of delivery for these participants. CONCLUSIONS This feasibility study shows that Group-CBT warrants further investigation as a potentially promising treatment option for patients with severe asthma. It has been possible but not easy to recruit and retain the sample. Options for a less demanding intervention schedule, such as less frequent face-to-face visits and the use of web-based interventions, require careful consideration.
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Wiffen PJ. Systematic Reviews Published in the July 2016 Issue of the Cochrane Library. J Pain Palliat Care Pharmacother 2016; 30:324-325. [PMID: 27849411 DOI: 10.1080/15360288.2016.1246505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online ( http://www.thecochranelibrary.com ). The July 2016 issue (third DVD for 2016) contains 6963 complete reviews, 2457 protocols for reviews in production. In addition, there are citations of 945,000 randomized controlled trials, and 15,700 cited papers in the Cochrane Methodology Register. The Health Technology Assessment database contains some 16,000 citations. One hundred and twenty-one new reviews have been published in the previous three months, of which four have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 6.1. Readers are encouraged to access the full report for any articles of interest, as only a brief commentary is provided.
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Sundh J, Ekström M. Persistent disabling breathlessness in chronic obstructive pulmonary disease. Int J Chron Obstruct Pulmon Dis 2016; 11:2805-2812. [PMID: 27877034 PMCID: PMC5108478 DOI: 10.2147/copd.s119992] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Objective To determine the prevalence, change in breathlessness status over time, and risk factors for disabling and persistent disabling breathlessness in relation to treatments in chronic obstructive pulmonary disease (COPD). Materials and methods Longitudinal analysis of data from the Swedish National Register of COPD with breathlessness measured using modified Medical Research Council (mMRC) scores at two subsequent visits. Prevalence of disabling breathlessness (mMRC ≥2 at baseline) and persistent disabling breathlessness (disabling breathlessness at baseline and follow-up) was investigated in relation to COPD treatment. Risk factors for disabling breathlessness, change from non-disabling to disabling breathlessness, and persistent disabling breathlessness were analyzed using multiple logistic regression. Results A total of 1,689 patients were included in the study with a median follow-up of 12 months (interquartile range: 4 months). Prevalence of disabling breathlessness was 54% at baseline. Persistent disabling breathlessness was present in 43% of patients despite treatment and in 74% of patients despite combined inhaled triple therapy and physiotherapy. Risk factors for disabling breathlessness or change to disabling breathlessness were higher age, lower lung function, frequent exacerbations, obesity, heart failure, depression, and hypoxic respiratory failure (all P<0.05). Persistent disabling breathlessness was associated with lower lung function and ischemic heart disease (all P<0.05). Conclusion Disabling breathlessness is common in COPD despite treatment, which calls for improved symptomatic treatments and consideration of factors influencing disabling breathlessness. Factors influencing disabling breathlessness should be considered for COPD management.
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Ekström M, Sundh J. Swedish translation and linguistic validation of the multidimensional dyspnoea profile. Eur Clin Respir J 2016; 3:32665. [PMID: 27834177 PMCID: PMC5103669 DOI: 10.3402/ecrj.v3.32665] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 10/18/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Dyspnoea, the feeling of breathing discomfort, consists of multiple dimensions that can vary in intensity, including the level of unpleasantness, qualities or descriptors of the sensation, emotional responses, and impact on function. No validated instrument for multidimensional measurement of dyspnoea is available in Swedish. The Multidimensional Dyspnea Profile (MDP) was recently developed to measure the unpleasantness, sensory qualities, and emotional responses of dyspnoea across diseases and settings. We aimed to take forward a Swedish version of the MDP. METHODS Translation and linguistic validation of the MDP was conducted in collaboration with a specialised company in the field (Mapi, Lyon, France). The structured process involved forward and backward translations by two independent certified translators, input from an in-country linguistic consultant, the developers, and three respiratory physicians. Understandability and acceptability were evaluated through in-depth interviews with five patients with dyspnoea in accordance with international guidelines. RESULTS AND CONCLUSION A Swedish version of the MDP was obtained and linguistically validated. The MDP includes 11 rated items: the immediate unpleasantness of the sensation, the presence and intensity of five sensory qualities, and the intensity of five emotional responses to dyspnoea. The time period of measurement is specified by the user. The MDP is copyrighted by the developers but can be used free of charge in the context of non-funded academic research. CONCLUSION The MDP is the first instrument for measuring multiple dimensions of dyspnoea available in Swedish and should be validated across diseases and settings. Multidimensional measurement is essential for improved assessment and management of dyspnoea in research and clinical care.
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O'Donnell DE, Neder JA, Harle I, Moran-Mendoza O. Chronic breathlessness in patients with idiopathic pulmonary fibrosis: a major challenge for caregivers. Expert Rev Respir Med 2016; 10:1295-1303. [PMID: 27766905 DOI: 10.1080/17476348.2016.1251843] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Idiopathic pulmonary fibrosis (IPF) is one of the most common forms of interstitial lung disease, with a median survival time of two to five years. Most patients with IPF experience chronic breathlessness, which is closely linked to poor perceived quality of life and significant restriction of daily activities; therefore, effective management of this distressing symptom is a major goal of patient care. Areas covered: This report summarizes the physiology of IPF during rest and exercise, outlines current concepts of the mechanisms of breathlessness, and provides a physiological rationale for optimal management of individual patients. It also examines the evidence for efficacy of a number of therapeutic interventions currently at our disposal for the management of breathlessness in IPF, which aim to reduce respiratory neural drive, reduce worsening of mechanical load, and alter central perception. Expert commentary: The current evidence supporting general measures in relieving chronic breathlessness is weak; hence, more carefully designed prospective studies are required.
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Ahmadi Z, Bernelid E, Currow DC, Ekström M. Prescription of opioids for breathlessness in end-stage COPD: a national population-based study. Int J Chron Obstruct Pulmon Dis 2016; 11:2651-2657. [PMID: 27799763 PMCID: PMC5085299 DOI: 10.2147/copd.s112484] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Low-dose opioids can relieve breathlessness but may be underused in late-stage COPD due to fear of complications, contributing to poor symptom control. OBJECTIVES We aimed to study the period prevalence and indications of opioids actually prescribed in people with end-stage COPD. METHODS The study was a longitudinal, population-based study of patients starting long-term oxygen therapy (LTOT) for COPD between October 1, 2005 and June 30, 2009 in Sweden. A random sample (n=2,000) of their dispensed opioid prescriptions was obtained from the national Prescribed Drugs Register from 91 days before starting LTOT until the first of LTOT withdrawal, death, or study end (December 31, 2009). We analyzed medication type, dispensed quantity, date of dispensing, and indications categorized as pain, breathlessness, other, or unknown. RESULTS In total, 2,249 COPD patients (59% women) were included. During a median follow-up of 1.1 (interquartile range 0.6-2.0) years, 1,034 patients (46%) were dispensed ≥1 opioid prescription (N=13,722 prescriptions). The most frequently prescribed opioids were tramadol (23%), oxycodone (23%), morphine (16%), and codeine (16%). Average dispensed quantity was 9.3 (interquartile range 3.7-16.7) defined daily doses per prescription. In the random sample, the most commonly stated indication was pain (97%), with only 2% for breathlessness and 1% for other reasons. CONCLUSION Despite evidence that supported the use of opioids for the relief of breathlessness predating this study, opioids are rarely prescribed to relieve breathlessness in oxygen-dependent COPD, potentially contributing to less-than-optimal symptom control. This study creates a baseline against which to compare future changes in morphine prescribing in this setting.
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Smith AK, Currow DC, Abernethy AP, Johnson MJ, Miao Y, Boscardin WJ, Ritchie CS. Prevalence and Outcomes of Breathlessness in Older Adults: A National Population Study. J Am Geriatr Soc 2016; 64:2035-2041. [PMID: 27603500 DOI: 10.1111/jgs.14313] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVES To determine the prevalence and outcomes of breathlessness in older Americans. SETTING Community-dwelling older adults. PARTICIPANTS Individuals aged 70 and older in the nationally representative Health and Retirement Study (2008, follow-up through 2012) (N = 3,671; mean age 78). MEASUREMENTS Breathlessness was assessed by asking the question, "How often do you become short of breath while awake?" Responses of often or sometimes were considered to represent a level of breathlessness sufficient to warrant clinical attention. The prevalence of breathlessness is described overall and in subpopulations, then rates of associated symptoms, well-being, and health services use of participants who were breathless are compared with rates of those who were not. The risk of decline in activities of daily living (ADLs) and death through 2012 was estimated by creating a multivariable Cox proportional hazards model, adjusting for age, sex, race and ethnicity, and education. RESULTS Twenty-five percent of participants reported breathlessness. The prevalence of breathlessness was higher in certain subpopulations: chronic lung disease (63%), multimorbidity (≥2 chronic conditions) (45%), current smokers (38%), heart disease (36%), obesity (body mass index ≥30.0 kg/m2 ) (33%), and education less than high school (32%). Breathlessness was associated with higher rates of depression, anxiety, and severe fatigue; lower ratings of well-being; and higher rates of clinic and emergency department visits and hospitalizations (all P < .001). Breathlessness predicted ADL decline over 5 years (adjusted hazard ratio (aHR) = 1.43, 95% confidence interval (CI) = 1.22-1.68) and death (aHR 1.62, 95% CI = 1.32-2.02). CONCLUSION One in four adults aged 70 and older in the United States experiences breathlessness, which is associated with lack of well-being, greater health services use, and a 40% greater risk of worsened function and 60% greater risk of death over the next 5 years.
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Oxley R, Macnaughton J. Inspiring change: humanities and social science insights into the experience and management of breathlessness. Curr Opin Support Palliat Care 2016; 10:256-61. [PMID: 27490147 PMCID: PMC4974063 DOI: 10.1097/spc.0000000000000221] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
PURPOSE OF REVIEW Breathlessness can be debilitating for those with chronic conditions, requiring continual management. Yet, the meaning of breathlessness for those who live with it is poorly understood in respect of its subjective, cultural, and experiential significance. This article discusses a number of current issues in understanding the experience of breathlessness. RECENT FINDINGS Effective communication concerning the experience of breathlessness is crucial for diagnosis, to identify appropriate treatment, and to provide patients with the capacity to self-manage their condition. However, there is an evident disconnect between the way breathlessness is understood between clinical and lay perspectives, in terms of awareness of breathlessness, the way symptoms are expressed, and acknowledgement of how it affects the daily lives of patients. SUMMARY The review highlights the need for integrated multidisciplinary work on breathlessness, and suggests that effective understanding and management of breathlessness considers its wider subjective and social significance.
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Wiffen PJ. Systematic Reviews Published in the April 2016 Issue of the Cochrane Library. J Pain Palliat Care Pharmacother 2016; 30:231-2. [PMID: 27541203 DOI: 10.1080/15360288.2016.1208708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
The Cochrane Library of Systematic Reviews is published quarterly as a DVD and monthly online ( http://www.thecochranelibrary.com ). The April 2016 issue (2nd DVD for 2016) contains 6875 complete reviews, 2417 protocols for reviews in production, and 36,600 short summaries of systematic reviews published in the general medical literature (this short summary database is no longer being updated). In addition, there are citations of 934,000 randomized controlled trials, and 15,700 cited papers in the Cochrane Methodology Register. The Health Technology Assessment database contains some 16,000 citations. One hundred and twenty-nine new reviews have been published in the previous 3 months, of which three have potential relevance for practitioners in pain and palliative medicine. The impact factor of the Cochrane Library stands at 5.939. Readers are encouraged to access the full report for any articles of interest, as only a brief commentary is provided.
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Ekström M, Vergo MT, Ahmadi Z, Currow DC. Prevalence of Sudden Death in Palliative Care: Data From the Australian Palliative Care Outcomes Collaboration. J Pain Symptom Manage 2016; 52:221-7. [PMID: 27220950 DOI: 10.1016/j.jpainsymman.2016.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Revised: 01/20/2016] [Accepted: 02/13/2016] [Indexed: 10/21/2022]
Abstract
CONTEXT Advanced, life-limiting illnesses are likely to have a predictable functional decline through a terminal phase to death, but some patients may also die suddenly. To date, empirical evidence characterizing "sudden death" in hospice/palliative care is lacking. OBJECTIVES The aim of this study was to determine prevalence and clinicodemographic predictors of sudden death in hospice/palliative care. METHODS This is a longitudinal consecutive cohort study of prospectively collected national data in 104 specialist palliative care services from the Australian Palliative Care Outcomes Collaboration. Patients who died between July 1, 2013, and June 30, 2014, with one or more measurement of Australian-modified Karnofsky Performance Status (AKPS) in the last 30 days of life were included. "Sudden death" was defined as a lowest AKPS score of 50 or more in the last seven days of life and excluded anyone with "terminal phase" as their last phase before death. Predictors were defined using logistic regression. RESULTS In total, 13,966 patients were included, mean age 73.6 (SD 13.6) years, 46% women, and 77% had cancer. During the seven days before death, there were 20,992 AKPS measurements; median 1 (interquartile range 1-2) per patient. Four percent of deaths (one of 25) were sudden, predicted independently by having lung cancer (odds ratio [OR] 2.64), cardiovascular disease (OR 1.94), other cancers (OR 1.63), being male (OR 1.23), younger, worse fatigue, and worse breathlessness. Sudden death was associated with higher rates of death at home (OR 3.2; 95% CI 2.9 to 3.6). CONCLUSION This study quantifies rates of sudden death in hospice/palliative care and has implications for conversations about prognosis between clinicians, patients, and their families.
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Chowienczyk S, Javadzadeh S, Booth S, Farquhar M. Association of Descriptors of Breathlessness With Diagnosis and Self-Reported Severity of Breathlessness in Patients With Advanced Chronic Obstructive Pulmonary Disease or Cancer. J Pain Symptom Manage 2016; 52:259-64. [PMID: 27233139 DOI: 10.1016/j.jpainsymman.2016.01.014] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 01/15/2016] [Accepted: 02/13/2016] [Indexed: 11/30/2022]
Abstract
CONTEXT Verbal descriptors are important in understanding patients' experience of breathlessness. OBJECTIVES The aim of this study was to examine the association between selection of breathlessness descriptors, diagnosis, self-reported severity of breathlessness and self-reported distress due to breathlessness. METHODS We studied 132 patients grouped according to their diagnosis of advanced chronic obstructive pulmonary disease (n = 69) or advanced cancer (n = 63), self-reported severity of breathlessness as mild breathlessness (Numerical Rating Scale [NRS] ≤ 3, n = 53), moderate breathlessness (4 ≤ NRS ≥ 6, n = 59) or severe breathlessness (NRS ≥ 7, n = 20), and distress due to breathlessness as mild distress (NRS ≤ 3, n = 31), moderate distress (4 ≤ NRS ≥ 6, n = 44), or severe distress (NRS ≥ 7, n = 57). Patients selected three breathlessness descriptors. The relationship between descriptors selected and patient groups was evaluated by cluster analysis. RESULTS Different combinations of clusters were associated with each diagnostic group; the cluster chest tightness was associated with cancer patients. The association of clusters with patient groups differed depending on their severity of breathlessness and their distress due to breathlessness. The air hunger cluster was associated with patients with moderate or severe breathlessness, and the chest tightness cluster was associated with patients with mild breathlessness. The air hunger cluster was associated with patients with severe distress due to breathlessness. CONCLUSION The relationship between clusters and diagnosis is not robust enough to use the descriptors to identify the primary cause of breathlessness. Further work exploring how use of breathlessness descriptors reflects the severity of breathlessness and distress due to breathlessness could enable the descriptors to evaluate patient status and target interventions.
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Smallwood N, Le B, Currow D, Irving L, Philip J. Management of refractory breathlessness with morphine in patients with chronic obstructive pulmonary disease. Intern Med J 2016; 45:898-904. [PMID: 26332621 DOI: 10.1111/imj.12857] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 06/15/2015] [Indexed: 11/30/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive, incurable illness, which leads to significant morbidity over long periods of time and mortality. Treatment aims to reduce symptoms, improve exercise capacity and quality of life, reduce exacerbations, slow disease progression and reduce mortality. However, breathlessness is common in patients with advanced COPD and remains undertreated. As all reversible causes of breathlessness are being optimally managed, consideration should be given to specific non-pharmacological and pharmacological treatment strategies for breathlessness. Low dose morphine has been shown to reduce safely and effectively breathlessness in patients with severe COPD and refractory dyspnoea. However, despite numerous guidelines recommending opioids in this clinical setting, many barriers limit their uptake by clinicians. Integration of palliative care earlier in the disease course can help to improve symptom control for people with severe COPD and refractory breathlessness. A multidisciplinary approach involving both respiratory and palliative care teams offers a new model of care for these patients.
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Hodson M, Sherrington R. Treating patients with chronic obstructive pulmonary disease. Nurs Stand 2016; 29:50-8. [PMID: 25351094 DOI: 10.7748/ns.29.9.50.e9061] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a long-term lung disease characterised by breathlessness, cough and sputum production. Progressively worsening breathlessness for the patient with COPD limits everyday activity, reduces quality of life and increases the risk of premature death. Beyond reducing symptoms and the rate and severity of exacerbations, the aim of treatment is to increase exercise capacity and improve overall health and wellbeing. Nurses have an important role in ensuring advance care planning is implemented for every patient. This article describes the diagnosis, assessment and management of COPD, and includes practical points for patient care.
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Abstract
BACKGROUND While many patients hope to die at home, many die in hospitals. Patients die with unrecognized and untreated symptoms including dyspnea. OBJECTIVE We sought to determine prevalence of dyspnea at end of life in patients dying in acute hospital care and examine treatment patterns. DESIGN/PARTICIPANTS A retrospective chart review of deaths at tertiary care hospital over a 3-month period evaluated dyspnea in last 24 hours of life, opioid orders and administration as well as presence of palliative care consultation. RESULTS Of 106 decedents, 88 experienced dyspnea or tachypnea in last 24 hours of life. Health care providers noted only 50% as dyspneic, even those undergoing terminal comfort extubation. Almost all patients with dyspnea documented by staff had orders and received opioids; however, few orders described treatment specifically for dyspnea. Patients with palliative care consultations more often received opioids ( P = .0007), and opioid orders more often specified treatment of dyspnea ( P = .013). CONCLUSION These findings support that previous work noting many patients experience dyspnea at end of life. Despite national guidelines, health care providers may still be underrecognizing and likely not optimally treating dyspnea at the end of life in the hospital. Collaboration with palliative medicine providers may improve assessments and treatments for quality end-of-life care for hospitalized patients.
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Faull OK, Cox PJ, Pattinson KTS. Psychophysical Differences in Ventilatory Awareness and Breathlessness between Athletes and Sedentary Individuals. Front Physiol 2016; 7:231. [PMID: 27378940 PMCID: PMC4910254 DOI: 10.3389/fphys.2016.00231] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Accepted: 05/30/2016] [Indexed: 12/14/2022] Open
Abstract
Purpose: Breathlessness is a complex set of symptoms that are comprised of both sensory and affective (emotional) dimensions. While ventilation is now understood to be a potential limiter to performance in highly-trained individuals, the contribution of breathlessness-anxiety in those nearing maximal ventilation during intense exercise has not yet been considered as a limiter to performance. Methods: In this study, we compared the physiology and psychology of breathlessness in 20 endurance athletes with 20 untrained age- and sex-matched sedentary controls. Subjects completed baseline spirometry and anxiety questionnaires, an incremental exercise test to exhaustion and a steady-state hypercapnic ventilatory response test, with concurrent measures of breathlessness intensity and breathlessness-anxiety. Results: Compared with sedentary subjects, athletes reported equivalent breathlessness intensity but greater breathlessness-anxiety at maximal exercise (athletes vs. sedentary (mean ± SD): breathlessness intensity (0–100%) 80.7 (22.7) vs. 72.5 (17.2), p = 0.21; breathlessness-anxiety (0–100%), 45.3 (36.3) vs. 22.3 (20.0), p = 0.02). Athletes operated at higher proportions of their maximal ventilatory capacity (MVV) (athletes vs. sedentary (mean ventilation ± SD; % MVV): 101.6 (27.2) vs. 73.7 (30.1), p = 0.003). In the athletes there was a positive linear correlation between ventilation and breathlessness score during the hypercapnic challenge that was not observed in the sedentary controls. Conclusion: The results of this study indicate that whilst operating at high proportions of maximal ventilation, breathlessness-anxiety becomes increasingly prominent in athletes. Our results suggest that ventilatory perception pathways may be a target for improved athletic performance in some individuals.
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Quon BS, Wilkie SS, Ramsook AH, Schaeffer MR, Puyat JH, Wilcox PG, Guenette JA. Qualitative dimensions of exertional dyspnea in adults with cystic fibrosis. J Appl Physiol (1985) 2016; 121:449-56. [PMID: 27311438 DOI: 10.1152/japplphysiol.00391.2016] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 06/15/2016] [Indexed: 11/22/2022] Open
Abstract
No studies of cystic fibrosis (CF) have systematically characterized the evolution of the qualitative dimensions of exertional dyspnea. Adults with CF (n = 25) and control individuals matched for sex, age, and body mass index (n = 25) underwent cardiopulmonary cycle exercise testing with a detailed evaluation of ventilatory and dyspnea responses. The qualitative dimensions of dyspnea were examined during each exercise stage by having subjects select phrases that best described their breathing (i.e., "work/effort," "unsatisfied inspiration," and "unsatisfied expiration"). Subjects also selected phrases that described the quality of their breathing at peak exercise using an established 15-item questionnaire, which was then clustered into different categories. Subjects with CF had greater ventilatory requirements, higher end-inspiratory and end-expiratory lung volumes (% total lung capacity), and an earlier inflection/plateau in tidal volume during exercise compared with control subjects. Increased work/effort was the dominant qualitative descriptor in both groups throughout exercise. Unsatisfied inspiration was selected by 48% of subjects with CF and 40% of controls at some point during exercise. The onset of unsatisfied inspiration in these subjects occurred at a significantly lower relative exercise intensity in subjects with CF vs. controls (72 ± 21 vs. 94 ± 11% Wmax, P < 0.01). Chest tightness was the only qualitative descriptor cluster that was selected more frequently by subjects with CF vs. controls (36 vs. 0%, respectively, P < 0.05) at peak exercise. Therapeutic interventions that reduce ventilatory requirements and improve lung volumes may delay the onset of distressing sensations such as unsatisfied inspiration and chest tightness in adults with CF.
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Booth S, Galbraith S, Ryan R, Parker RA, Johnson M. The importance of the feasibility study: Lessons from a study of the hand-held fan used to relieve dyspnea in people who are breathless at rest. Palliat Med 2016; 30:504-9. [PMID: 26494368 DOI: 10.1177/0269216315607180] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The dyspnea accompanying advanced cardiorespiratory disease is often refractory to palliation. It is disabling, distressing and associated with the diseases most common everywhere in the world. The hand-held fan, used to generate a draught across the face, is a simple, cost-effective, safe, and universally applicable palliative breathlessness intervention, consistently described as valuable in qualitative research. A previous crossover trial confirmed its benefit in patients breathless at rest, but the washout period was uncertain. AIM To determine the washout period after use of the hand-held fan to inform accurate randomized controlled trial design. DESIGN An observational methodological study. Breathlessness intensity was measured using 100 mm visual analog scale and numerical rating scale, and "relief of breathlessness" was measured on a 5-point scale. Those benefitting from the fan provided visual analog scale/numerical rating scale scores until (1) scores returned to baseline values or (2) until response had plateaued. The primary outcome measure was the time (in minutes) to reach either component of the primary study endpoint. SETTINGS/PARTICIPANTS Four in-/out-patient hospice/hospital units; participants had chronic refractory breathlessness using the fan. RESULTS Overall, 31 patients participated (mean age: 74.8 years; range: 49-98 years, standard deviation = 11.5 years); 64% were males. Approximately, half of the sample experienced benefit of moderate effect size. The relative reduction in breathlessness relative to the mean baseline score for the sample was 27% for the visual analog scale and 19% for the numerical rating scale. CONCLUSION Feasibility work is essential, even for simple widely employed interventions.
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Chan WL, Ng CW, Lee C, Cheng P, Cheung KW, Siu WKS, Yuen KK, Leung TW. Effective Management of Breathlessness in Advanced Cancer Patients With a Program-Based, Multidisciplinary Approach: The "SOB Program" in Hong Kong. J Pain Symptom Manage 2016; 51:623-7.e2. [PMID: 26774405 DOI: 10.1016/j.jpainsymman.2015.10.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/16/2015] [Accepted: 10/23/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Breathlessness is common in patients with advanced cancer. Using a multidisciplinary approach for relieving this challenging symptom was believed to be just a theory. The "SOB Program" was implemented in our institution in March 2013. MEASURES An audit of medical records before and after implementation of the "SOB Program" was performed to identify any changes in practice after implementation, specifically in the use of nonpharmacologic interventions. INTERVENTION The "SOB Program" is a multidisciplinary service in our department, using both pharmacologic and nonpharmacologic interventions for all patients with advanced cancer who have dyspnea. OUTCOMES There was a marked increase in the use of nonpharmacologic interventions after the "SOB Program" (26.86% preimplementation vs. 89.35% postimplementation). Patients joining the program also had satisfactory improvement in breathlessness. CONCLUSIONS/LESSONS LEARNED A multidisciplinary approach for breathlessness control is both feasible and practical. Similar services can be promoted in other palliative care centers.
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Reilly CC, Bausewein C, Pannell C, Moxham J, Jolley CJ, Higginson IJ. Patients' experiences of a new integrated breathlessness support service for patients with refractory breathlessness: Results of a postal survey. Palliat Med 2016; 30:313-22. [PMID: 26311570 PMCID: PMC4778380 DOI: 10.1177/0269216315600103] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND We developed a new single point of access to integrated palliative care, respiratory medicine and physiotherapy: the breathlessness support service for patients with advanced disease and refractory breathlessness. This study aimed to describe patients' experiences of the service and identify the aspects valued. DESIGN We attempted to survey all patients who had attended and completed the 6-week breathlessness support service intervention by sending them a postal questionnaire to self-complete covering experience, composition, effectiveness of the BSS and about participation in research. Data were analysed using descriptive statistics and thematic analysis of free text comments. RESULTS Of the 70 postal questionnaires sent out, 25 (36%) returned. A total of 21 (84% (95% confidence interval: 69%-98%)) responding patients reported that they definitely found the breathlessness support service helpful and 13 (52% (95% confidence interval: 32%-72%)) rated the breathlessness support service as excellent. A total of 21 (84% (95% confidence interval: 69%-98%)) patients reported that the breathlessness support service helped with their management of their breathlessness along with additional symptoms and activities (e.g. mood and mobility). Four key themes were identified: (1) personalised care, (2) caring nature of the staff, (3) importance of patient education to empower patients and (4) effectiveness of context-specific breathlessness interventions. These were specific aspects that patients valued. CONCLUSION Patients' satisfaction with the breathlessness support service was high, and identified as important to this was a combination of personalised care, nature of staff, education and empowerment, and use of specific interventions. These components would be important in any future breathlessness service.
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Faull OK, Jenkinson M, Ezra M, Pattinson KT. Conditioned respiratory threat in the subdivisions of the human periaqueductal gray. eLife 2016; 5. [PMID: 26920223 PMCID: PMC4821794 DOI: 10.7554/elife.12047] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Accepted: 02/26/2016] [Indexed: 11/25/2022] Open
Abstract
The sensation of breathlessness is the most threatening symptom of respiratory disease. The different subdivisions of the midbrain periaqueductal gray (PAG) are intricately (and differentially) involved in integrating behavioural responses to threat in animals, while the PAG has previously only been considered as a single entity in human research. Here we investigate how these individual PAG columns are differently involved with respiratory threat. Eighteen healthy subjects were conditioned to associate shapes with certain or uncertain impending respiratory load, and scanned the following day during anticipation and application of inspiratory loading using 7 T functional MRI. We showed activity in the ventrolateral PAG (vlPAG) during anticipation of resistive loading, with activity in the lateral PAG (lPAG) during resistive loading, revealing spatially and temporally distinct functions within this structure. We propose that lPAG is involved with sensorimotor responses to breathlessness, while the vlPAG operates within the threat perception network for impending breathlessness. DOI:http://dx.doi.org/10.7554/eLife.12047.001 Many people find feeling breathless one of the most upsetting symptoms of respiratory diseases, and breathlessness often causes anxiety that makes the condition seem more threatening than it is. Studies in animals suggest that a small cluster of neurons called the periaqueductal gray is important for responding to threats. This cluster, located at the top of the brainstem, is divided into parallel columns running from top to bottom. In animals, these columns are known to have distinct roles, but human research has tended to consider the periaqueductal gray as a single, uniform entity. Faull et al. wanted to find out whether different columns of the human periaqueductal gray have distinct roles in the perception of respiratory threat. During the study, participants breathed through a tube while watching shapes appear on a screen. This tube could be altered to make breathing more or less difficult – much like breathing through a narrow drinking straw. A conditioning session was first conducted so that participants learned that certain shapes on the screen signalled that their breathing was about to become difficult, while other shapes signalled normal breathing. A second session was then conducted in a brain scanner, using a technique called functional magnetic resonance imaging. This allowed Faull et al. to compare brain activity during the anticipation of difficult breathing with the brain activity during the breathing challenge itself. The results show that the column at the front of the periaqueductal gray (the ventrolateral column) was more active when participants saw the shape that signaled upcoming breathing difficulty. In contrast, difficult breathing was associated with activity in the lateral column (at the side of the periaqueductal gray). Thus, the different columns of the human periaqueductal gray have different roles in the response to respiratory threat. Future studies could investigate how these columns interact with each other and with other brain regions. Such understanding is important for a range of conditions that may be influenced by the activity of the periaqueductal gray, including disruptions in bladder control, hypertension, chronic pain, and asthma. DOI:http://dx.doi.org/10.7554/eLife.12047.002
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Russell AM, Maher TM. Detecting anxiety and depression in patients diagnosed with an interstitial lung disease. Can we do better? Respirology 2016; 19:1095-6. [PMID: 25302755 DOI: 10.1111/resp.12407] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Ferreira DH, Silva JP, Quinn S, Abernethy AP, Johnson MJ, Oxberry SG, Currow DC. Blinded Patient Preference for Morphine Compared to Placebo in the Setting of Chronic Refractory Breathlessness--An Exploratory Study. J Pain Symptom Manage 2016; 51:247-54. [PMID: 26598037 DOI: 10.1016/j.jpainsymman.2015.10.005] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 09/28/2015] [Accepted: 10/06/2015] [Indexed: 12/14/2022]
Abstract
CONTEXT Patients' preference for morphine therapy has received little attention in the setting of chronic refractory breathlessness. However, this is one important factor in considering longer term therapy. OBJECTIVES The aim of this secondary analysis was to explore blinded patient preference of morphine compared to placebo for this indication and to define any predictors of preference. METHODS Data were pooled from three randomized, double-blind, crossover, placebo-controlled studies of morphine (four days each) in chronic refractory breathlessness. Blinded patient preferences were chosen at the end of each study. A multivariable regression model was used to establish patient predictors of preference. RESULTS Sixty-five participants provided sufficient data (60 men; median age 74 years; heart failure 55%, chronic obstructive pulmonary disease 45%; median Eastern Cooperative Oncology Group performance status 2). Forty-three percent of participants preferred morphine (32% placebo and 25% no preference). Morphine preference and younger age were strongly associated: odds ratio = 0.85, 95% confidence interval 0.78-0.93; P < 0.001). There was also an inverse association between morphine preference and sedation (odds ratio = 0.77, 95% confidence interval 0.60-0.99; P < 0.05). An inverse association was also seen between nausea and morphine preference in the univariate model only (P < 0.05). No association was seen between morphine preference and breathlessness intensity, either at baseline or change from baseline. CONCLUSION Participants preferred morphine over placebo for the relief of chronic refractory breathlessness. Morphine offers clinically important improvement, but net benefit can be easily outweighed by side effects, reducing net benefits. Side effects require aggressive management to allow more patients to realize benefits.
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Karloh M, Fleig Mayer A, Maurici R, Pizzichini MMM, Jones PW, Pizzichini E. The COPD Assessment Test: What Do We Know So Far?: A Systematic Review and Meta-Analysis About Clinical Outcomes Prediction and Classification of Patients Into GOLD Stages. Chest 2016; 149:413-425. [PMID: 26513112 DOI: 10.1378/chest.15-1752] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2015] [Revised: 09/09/2015] [Accepted: 10/01/2015] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND The COPD Assessment Test (CAT) was developed as a simple instrument to assess health status in patients with COPD. This study aimed to systematically review the determinants of the CAT score, its ability to predict clinical outcomes, and the agreement between CAT (≥ 10) and the modified Medical Research Council scale (mMRC ≥ 2) to categorize patients into the new Global Initiative for Chronic Obstructive Lung Disease classification system. METHODS From January 1, 2009, to June 30, 2015, databases were searched for studies using CAT in adults with COPD and in general populations aiming to detect COPD. Two investigators independently screened, selected, and extracted data by using a standardized form. Where appropriate, the results were combined in a random effects meta-analysis. RESULTS Of 453 studies, 17 were included, and eight were used in the meta-analysis. The models to predict the CAT score were able to explain < 50% of its variance. CAT scores can indicate risk of exacerbation, depression, acute deterioration in health status, and mortality. All studies found a different proportion of patients in each Global Initiative for Chronic Obstructive Lung Disease category using CAT ≥ 10 or mMRC ≥ 2. On average, the distribution was 13% different according to the instrument used. The κ agreement between CAT and mMRC ranged from 0.13 to 0.77. CONCLUSIONS CAT may be used as a complementary tool in a patient's clinical assessment to predict COPD exacerbation, health status deterioration, depression, and mortality. The interpretation of this meta-analysis does not support the use of the recommended cutoff points of ≥10 for CAT and ≥2 for mMRC as equivalents for the purpose of assessing patient symptoms.
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Pralong A, Bausewein C, Magnussen H, Radbruch L, Meißner W, Becker G, Holtmann M, Perrar KM, Fegg M, Voltz R, Simon ST. [Assessment and management of breathlessness, cancer pain, constipation and depression in patients with incurable cancer]. MMW Fortschr Med 2016; 158:35-39. [PMID: 28924768 DOI: 10.1007/s15006-016-7698-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
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Johnson MJ, Bland JM, Gahbauer EA, Ekström M, Sinnarajah A, Gill TM, Currow DC. Breathlessness in Elderly Adults During the Last Year of Life Sufficient to Restrict Activity: Prevalence, Pattern, and Associated Factors. J Am Geriatr Soc 2016; 64:73-80. [PMID: 26782854 PMCID: PMC4719155 DOI: 10.1111/jgs.13865] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To investigate relationships between age, clinical characteristics, and breathlessness sufficient to have people spend at least half a day a month in bed or to cut down on their usual activities (restricting breathlessness) during the last year of life. DESIGN Secondary data analysis. SETTING General community. PARTICIPANTS Nondisabled persons aged 70 and older (N=754). MEASUREMENTS Monthly telephone interviews were conducted to determine the occurrence of restricting breathlessness. The primary outcome was percentage of months with restricting breathlessness reported during the last year of life. RESULTS Data regarding breathlessness were available for 548 of 589 (93.0%) participants who died (mean age 86.7, range 71-106; 38.8% male) between enrollment (March 1998 to October 1999) and June 2013; 311 of these (56.8%) reported restricting breathlessness at some point during the last year of life, but none reported it every month. Frequency increased in the months closer to death, irrespective of cause. Restricting breathlessness was associated with anxiety (0.25 percentage points greater in months with breathlessness per percentage point months reported anxiety, 95% confidence interval (CI)=0.16-0.34, P<.001), depression (0.14, 95% CI=0.05-0.24, P=.003), and mobility problems (0.07, 0.03-0.1, P<.001). Percentage months of restricting breathlessness was greater if chronic lung disease was noted at the most-recent comprehensive assessment (6.62 percentage points, 95% CI=4.31-8.94, P<.001), heart failure (3.34 percentage points, 95% CI=0.71-5.97, P=.01), and ex-smoker status (3.01 percentage points, 95% CI=0.94-5.07, P=.004) but decreased with older age (-0.19 percentage points, 95% CI=-0.37 to -0.02, P=.03). CONCLUSION Restricting breathlessness increased in this elderly population in the months preceding death from any cause. Breathlessness should be assessed and managed in the context of poor prognosis.
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Charalambous A, Molassiotis A. Preliminary validation and reliability of the Short Form Chronic Respiratory Disease Questionnaire in a lung cancer population. Eur J Cancer Care (Engl) 2015; 26. [PMID: 26586282 DOI: 10.1111/ecc.12418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 11/30/2022]
Abstract
The Short Form Chronic Respiratory Questionnaire (SF-CRQ) is frequently used in patients with obstructive pulmonary disease and it has demonstrated excellent psychometric properties. Since there is no psychometric information for its use with lung cancer patients, this study explored its validity and reliability in this population. Forty-six patients were assessed at two time points (with a 4-week interval) using the SF-CRQ, the modified Borg Scale, five numerical rating scales related to Perceived Severity of Breathlessness, and the Hospital Anxiety and Depression Scale. Internal consistency reliability was investigated by Cronbach's alpha reliability coefficient, test-retest reliability by Spearman-Brown reliability coefficient (P), content validity as well as convergent validity by Pearson's correlation coefficient between the SF-CRQ, and the conceptual similar scales mentioned above were explored. A principal component factor analysis was performed. The internal consistency was high [α = 0.88 (baseline) and 0.91 (after 1 month)]. The SF-CRQ had good stability with test-retest reliability ranging from r = 0.64 to 0.78, P < 0.001. Factor analysis suggests a single construct in this population. The preliminary data analyses supported the convergent, content, and construct validity of the SF-CRQ providing promising evidence that this can be a valid and reliable instrument for the assessment of quality of life related to breathlessness in lung cancer patients.
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Vargas-Bermúdez A, Cardenal F, Porta-Sales J. Opioids for the Management of Dyspnea in Cancer Patients: Evidence of the Last 15 Years--A Systematic Review. J Pain Palliat Care Pharmacother 2015; 29:341-52. [PMID: 26523974 DOI: 10.3109/15360288.2015.1082005] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The objective of this study was to review the evidence on the use of opioids for treatment of the dyspnea in adult cancer patients. A systematic literature review was conducted in the databases MEDLINE, CINAHL (EBSCO), ScienceDirect, and Cochrane Library of trials testing the effect of opioids in relieving dyspnea in cancer patients. Fourteen trials met the criteria for inclusion in the review. Eight randomized trials and six nonrandomized trials. All randomized clinical trials analyzed present risks of bias. Morphine has been the most studied strong opioid showing efficacy in alleviating dyspnea when administered, either orally or subcutaneously, in cancer patients. The potential benefit of the strong opioids in the alleviation of dyspnea in cancer patients is modest and limited to some opioids. More studies are needed to sufficiently support the role of opioids in dyspnea at rest, at exertion, and for breakthrough dyspnea and to clarify the safety issues.
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Johnson MJ, Kanaan M, Richardson G, Nabb S, Torgerson D, English A, Barton R, Booth S. A randomised controlled trial of three or one breathing technique training sessions for breathlessness in people with malignant lung disease. BMC Med 2015; 13:213. [PMID: 26345362 PMCID: PMC4562360 DOI: 10.1186/s12916-015-0453-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Accepted: 08/14/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND About 90 % of patients with intra-thoracic malignancy experience breathlessness. Breathing training is helpful, but it is unknown whether repeated sessions are needed. The present study aims to test whether three sessions are better than one for breathlessness in this population. METHODS This is a multi-centre randomised controlled non-blinded parallel arm trial. Participants were allocated to three sessions or single (1:2 ratio) using central computer-generated block randomisation by an independent Trials Unit and stratified for centre. The setting was respiratory, oncology or palliative care clinics at eight UK centres. Inclusion criteria were people with intrathoracic cancer and refractory breathlessness, expected prognosis ≥3 months, and no prior experience of breathing training. The trial intervention was a complex breathlessness intervention (breathing training, anxiety management, relaxation, pacing, and prioritisation) delivered over three hour-long sessions at weekly intervals, or during a single hour-long session. The main primary outcome was worst breathlessness over the previous 24 hours ('worst'), by numerical rating scale (0 = none; 10 = worst imaginable). Our primary analysis was area under the curve (AUC) 'worst' from baseline to 4 weeks. All analyses were by intention to treat. RESULTS Between April 2011 and October 2013, 156 consenting participants were randomised (52 three; 104 single). Overall, the 'worst' score reduced from 6.81 (SD, 1.89) to 5.84 (2.39). Primary analysis [n = 124 (79 %)], showed no between-arm difference in the AUC: three sessions 22.86 (7.12) vs single session 22.58 (7.10); P value = 0.83); mean difference 0.2, 95 % CIs (-2.31 to 2.97). Complete case analysis showed a non-significant reduction in QALYs with three sessions (mean difference -0.006, 95 % CIs -0.018 to 0.006). Sensitivity analyses found similar results. The probability of the single session being cost-effective (threshold value of £20,000 per QALY) was over 80 %. CONCLUSIONS There was no evidence that three sessions conferred additional benefits, including cost-effectiveness, over one. A single session of breathing training seems appropriate and minimises patient burden. TRIAL REGISTRATION Registry: ISRCTN; TRIAL REGISTRATION NUMBER ISRCTN49387307; http://www.isrctn.com/ISRCTN49387307 ; registration date: 25/01/2011.
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Stoeckel MC, Esser RW, Gamer M, Büchel C, von Leupoldt A. Brain mechanisms of short-term habituation and sensitization toward dyspnea. Front Psychol 2015; 6:748. [PMID: 26082746 PMCID: PMC4451234 DOI: 10.3389/fpsyg.2015.00748] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Accepted: 05/19/2015] [Indexed: 01/27/2023] Open
Abstract
Dyspnea is a prevalent and threatening cardinal symptom in many diseases including asthma. Whether patients suffering from dyspnea show habituation or sensitization toward repeated experiences of dyspnea is relevant for both quality of life and treatment success. Understanding the mechanisms, including the underlying brain activation patterns, that determine the dynamics of dyspnea perception seems crucial for the improvement of treatment and rehabilitation. Toward this aim, we investigated the interplay between short-term changes of dyspnea perception and changes of related brain activation. Healthy individuals underwent repeated blocks of resistive load induced dyspnea with parallel acquisition of functional magnetic resonance imaging data. Late vs. early ratings on dyspnea intensity and unpleasantness were correlated with late vs. early brain activation for both, dyspnea anticipation and dyspnea perception. Individual trait and state anxiety were determined using questionnaire data. Our results indicate an involvement of the orbitofrontal cortex (OFC), midbrain/periaqueductal gray (PAG) and anterior insular cortex in habituation/sensitization toward dyspnea. Changes in the anterior insular cortex were particularly linked to changes in dyspnea unpleasantness. Changes of both dyspnea intensity and unpleasantness were positively correlated with state and trait anxiety. Our findings are in line with the suggested relationship between the anterior insular cortex and dyspnea unpleasantness. They further support the notion that habituation/sensitization toward dyspnea is influenced by anxiety. Our study extends the known role of the midbrain/PAG in anti-nociception to an additional involvement in habituation/sensitization toward dyspnea and suggests an interplay with the OFC.
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Williams MT, Cafarella P, Paquet C, Frith P. Cognitive Behavioral Therapy for Management of Dyspnea: A Pilot Study. Respir Care 2015; 60:1303-13. [PMID: 25969515 DOI: 10.4187/respcare.03764] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND In patients with COPD, psychological interventions usually target generalized anxiety and depression rather than the sensation of breathlessness. The objectives of this pilot study were to develop and implement a cognitive behavioral therapy (CBT) program specific to the perceptual experience of breathlessness, identify practical issues in the study protocol, and estimate beneficial effects of combining the CBT program with comprehensive pulmonary rehabilitation. METHODS The CBT program for the sensation of breathlessness (Breathing: Recognize sensations, Explore thoughts and beliefs, Validate thoughts as useful or harmful, Evolve and change behavior [BREVE]) was developed as a sequential series of 8 modules enabling it to be embedded within an 8-week comprehensive pulmonary rehabilitation program. When appropriate, outcomes from the pilot group (comprehensive pulmonary rehabilitation program + BREVE) were compared with those from a retrospective control group (comprehensive pulmonary rehabilitation program only). Outcomes included feedback provided by pilot study subjects, sensation of breathlessness (volunteered and endorsed descriptors of breathlessness), 6-min walk distance (6MWD), and St George Respiratory Questionnaire (SGRQ) total score. Within-group analyses were undertaken for descriptors of breathlessness (the McNemar test), whereas between-group analyses (repeated-measures analysis of variance, effect-size comparison) were conducted for the 6MWD and SGRQ total score. RESULTS Pilot (n = 11) and control (n = 58) groups were not significantly different at baseline. Feedback indicated that the program structure and content were positively received. No significant changes were evident for the sensation of breathlessness or the SGRQ score (< 4 points). The 6MWD improved significantly in both groups, with the pilot group demonstrating greater gains compared with the control group (mean change of 57 m and effect size of 0.73 vs mean change of 27 m and effect size of 0.23; between groups, P = .03, effect size of 0.69). CONCLUSION The CBT program for the perceptual experience of breathlessness was feasible and well accepted by subjects, although the protocol raised a number of methodological limitations warranting modification. A larger randomized controlled trial is needed to determine the effectiveness and longer-term outcomes.
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Janssen DJA, de Hosson SM, bij de Vaate E, Mooren KJM, Baas AAF. Attitudes toward opioids for refractory dyspnea in COPD among Dutch chest physicians. Chron Respir Dis 2015; 12:85-92. [PMID: 25676931 DOI: 10.1177/1479972315571926] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Dyspnea is the most frequently reported symptom of outpatients with advanced chronic obstructive pulmonary disease (COPD). Opioids are an effective treatment for dyspnea. Nevertheless, the prescription of opioids to patients with advanced COPD seems limited. The aims of this study are to explore the attitudes of Dutch chest physicians toward prescription of opioids for refractory dyspnea to outpatients with advanced COPD and to investigate the barriers experienced by chest physicians toward opioid prescription in these patients. All chest physicians (n = 492) and residents in respiratory medicine (n = 158) in the Netherlands were invited by e-mail to complete an online survey. A total of 146 physicians (response rate 22.5%) completed the online survey. Fifty percent of the physicians reported to prescribe opioids for refractory dyspnea in 20% or less of their outpatients with advanced COPD and 18.5% reported never to prescribe opioids in these patients. The most frequently reported barriers toward prescription of opioids were resistance of the patient, fear of possible adverse effects, and fear of respiratory depression. To conclude, Dutch chest physicians and residents in respiratory medicine rarely prescribe opioids for refractory dyspnea to outpatients with advanced COPD. This reluctance is caused by perceived resistance of the patient and fear of adverse effects, including respiratory adverse effects.
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Kurmi OP, Semple S, Devereux GS, Gaihre S, Lam KBH, Sadhra S, Steiner MFC, Simkhada P, Smith WCS, Ayres JG. The effect of exposure to biomass smoke on respiratory symptoms in adult rural and urban Nepalese populations. Environ Health 2014; 13:92. [PMID: 25374400 PMCID: PMC4232609 DOI: 10.1186/1476-069x-13-92] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2014] [Accepted: 10/28/2014] [Indexed: 05/22/2023]
Abstract
BACKGROUND Half of the world's population is exposed to household air pollution from biomass burning. This study aimed to assess the relationship between respiratory symptoms and biomass smoke exposure in rural and urban Nepal. METHODS A cross-sectional study of adults (16+ years) in a rural population (n = 846) exposed to biomass smoke and a non-exposed urban population (n = 802) in Nepal. A validated questionnaire was used along with measures of indoor air quality (PM2.5 and CO) and outdoor PM2.5. RESULTS Both men and women exposed to biomass smoke reported more respiratory symptoms compared to those exposed to clean fuel. Women exposed to biomass were more likely to complain of ever wheeze (32.0 % vs. 23.5%; p = 0.004) and breathlessness (17.8% vs. 12.0%, p = 0.017) compared to males with tobacco smoking being a major risk factor. Chronic cough was similar in both the biomass and non-biomass smoke exposed groups whereas chronic phlegm was reported less frequently by participants exposed to biomass smoke. Higher PM2.5 levels (≥2 SDs of the 24-hour mean) were associated with breathlessness (OR = 2.10, 95% CI 1.47, 2.99) and wheeze (1.76, 1.37, 2.26). CONCLUSIONS The study suggests that while those exposed to biomass smoke had higher prevalence of respiratory symptoms, urban dwellers (who were exposed to higher ambient air pollution) were more at risk of having productive cough.
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Farquhar MC, Prevost AT, McCrone P, Brafman-Price B, Bentley A, Higginson IJ, Todd C, Booth S. Is a specialist breathlessness service more effective and cost-effective for patients with advanced cancer and their carers than standard care? Findings of a mixed-method randomised controlled trial. BMC Med 2014; 12:194. [PMID: 25358424 PMCID: PMC4222435 DOI: 10.1186/s12916-014-0194-2] [Citation(s) in RCA: 139] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Accepted: 09/29/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Breathlessness is common in advanced cancer. The Breathlessness Intervention Service (BIS) is a multi-disciplinary complex intervention theoretically underpinned by a palliative care approach, utilising evidence-based non-pharmacological and pharmacological interventions to support patients with advanced disease. We sought to establish whether BIS was more effective, and cost-effective, for patients with advanced cancer and their carers than standard care. METHODS A single-centre Phase III fast-track single-blind mixed-method randomised controlled trial (RCT) of BIS versus standard care was conducted. Participants were randomised to one of two groups (randomly permuted blocks). A total of 67 patients referred to BIS were randomised (intervention arm n = 35; control arm n = 32 received BIS after a two-week wait); 54 completed to the key outcome measurement. The primary outcome measure was a 0 to 10 numerical rating scale for patient distress due to breathlessness at two-weeks. Secondary outcomes were evaluated using the Chronic Respiratory Questionnaire, Hospital Anxiety and Depression Scale, Client Services Receipt Inventory, EQ-5D and topic-guided interviews. RESULTS BIS reduced patient distress due to breathlessness (primary outcome: -1.29; 95% CI -2.57 to -0.005; P = 0.049) significantly more than the control group; 94% of respondents reported a positive impact (51/53). BIS reduced fear and worry, and increased confidence in managing breathlessness. Patients and carers consistently identified specific and repeatable aspects of the BIS model and interventions that helped. How interventions were delivered was important. BIS legitimised breathlessness and increased knowledge whilst making patients and carers feel 'not alone'. BIS had a 66% likelihood of better outcomes in terms of reduced distress due to breathlessness at lower health/social care costs than standard care (81% with informal care costs included). CONCLUSIONS BIS appears to be more effective and cost-effective in advanced cancer than standard care. TRIAL REGISTRATION RCT registration at ClinicalTrials.gov NCT00678405 (May 2008) and Current Controlled Trials ISRCTN04119516 (December 2008).
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Lok CW. Management of Breathlessness in Patients With Advanced Cancer: A Narrative Review. Am J Hosp Palliat Care 2014; 33:286-90. [PMID: 25318928 DOI: 10.1177/1049909114554796] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Breathlessness is defined as "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity." It is a common and distressing symptom reported by patients with advanced malignancy. It occurs in up to 70% of patients with advanced cancer, and the symptom is aggravated with disease progression. This article reviews the etiology, assessment, and measurement of dyspnea in patients with advanced cancer. Because of its complex biopsychological etiology and manifestations, multidisciplinary approach with combination of both pharmacological and nonpharmacological interventions provides the best treatment plan for patients with dyspnea.
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Lang JE, Hossain MJ, Lima JJ. Overweight children report qualitatively distinct asthma symptoms: analysis of validated symptom measures. J Allergy Clin Immunol 2014; 135:886-893.e3. [PMID: 25441640 DOI: 10.1016/j.jaci.2014.08.029] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 08/20/2014] [Accepted: 08/22/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Past studies of asthma in overweight/obese children have been inconsistent. The reason overweight/obese children commonly report worse asthma control remains unclear. OBJECTIVE To determine qualitative differences in symptoms between lean and overweight/obese children with early-onset, atopic asthma. METHODS We conducted a cross-sectional analytic study of lean (20% to 65% body mass index) and overweight/obese (≥85% body mass index) 10- to 17-year-old children with persistent, early-onset asthma. Participants completed 2 to 3 visits to provide a complete history, qualitative and quantitative asthma symptom characterization, and lung function testing. We determined associations between weight status and symptoms using multivariable linear and logistic regression methods. RESULTS Overweight/obese and lean asthmatic children displayed similar lung function. Despite lower fraction of exhaled nitric oxide (30.0 vs 62.6 ppb; P = .037) and reduced methacholine responsiveness (PC20FEV1 1.87 vs 0.45 mg/mL; P < .012), overweight/obese children reported more than thrice frequent rescue treatments (3.7 vs 1.1 treatments/wk; P = .0002) than did lean children. Weight status affected the child's primary symptom reported with loss of asthma control (Fisher exact test; P = .003); overweight/obese children more often reported shortness of breath (odds ratio = 11.8; 95% CI, 1.41-98.7) and less often reported cough (odds ratio = 0.26; 95% CI, 0.08-0.82). Gastroesophageal reflux scores were higher in overweight/obese children (9.6 vs 23.2; P = .003) and appear to mediate overweight/obesity-related asthma symptoms. CONCLUSIONS Overweight/obese children with early-onset asthma display poorer asthma control and a distinct pattern of symptoms. Greater shortness of breath and β-agonist use appears to be partially mediated via esophageal reflux symptoms. Overweight children with asthma may falsely attribute exertional dyspnea and esophageal reflux to asthma, leading to excess rescue medication use.
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Neder JA, O'Donnell CDJ, Cory J, Langer D, Ciavaglia CE, Ling Y, Webb KA, O'Donnell DE. Ventilation Distribution Heterogeneity at Rest as a Marker of Exercise Impairment in Mild-to-Advanced COPD. COPD 2014; 12:249-56. [PMID: 25230258 DOI: 10.3109/15412555.2014.948997] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The difference between total lung capacity (TLC) by body plethysmography and alveolar volume (VA) from the single-breath lung diffusing capacity measurement provides an index of ventilation distribution inequalities in COPD. The relevance of these abnormalities to dyspnea and exercise intolerance across the continuum of disease severity remains unknown. Two-hundred and seventy-six COPD patients distributed across GOLD grades 1 to 4 and 67 healthy controls were evaluated. The "poorly communicating fraction" (PCF) of the TLC was estimated as the ratio (%) of TLC to VA. Healthy subjects showed significantly lower PCF values compared to GOLD grades 1 to 4 (10 ± 3% vs. 17 ± 8% vs. 27 ± 10% vs. 37 ± 10% vs. 56 ± 11%, respectively; p < 0.05). Pulmonary gas exchange impairment, mechanical ventilatory constraints and ventilation-corrected dyspnea scores worsened across PCF tertiles (p < 0.05). Of note, GOLD grades 1 and 2 patients with the highest PCF values had pronounced exercise ventilatory inefficiency and dyspnea as a limiting symptom. In fact, dyspnea was a significant contributor to exercise limitation only in those with "moderate" or "extensive" PCF (p < 0.05). A receiver operating characteristics curve analysis revealed that PCF was a better predictor of severely reduced maximal exercise capacity than traditional pulmonary function indexes including FEV1 (area under the curve (95% confidence interval) = 0.85 (0.81-0.89), best cutoff = 33.4%; p < 0.01). In conclusion, PCF is a readily available functional marker of gas exchange and mechanical abnormalities relevant to dyspnea and exercise intolerance across the COPD grades.
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Rennard SI, Sun SX, Tourkodimitris S, Rowe P, Goehring UM, Bredenbröker D, Calverley PMA. Roflumilast and dyspnea in patients with moderate to very severe chronic obstructive pulmonary disease: a pooled analysis of four clinical trials. Int J Chron Obstruct Pulmon Dis 2014; 9:657-73. [PMID: 25018629 PMCID: PMC4075954 DOI: 10.2147/copd.s55738] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Purpose Breathlessness is a predominant symptom of chronic obstructive pulmonary disease (COPD), making it a valuable outcome in addition to lung function to assess treatment benefit. The phosphodiesterase-4 inhibitor roflumilast has been shown to provide small but significant improvements in dyspnea, as measured by the transition dyspnea index (TDI), in two 1-year studies in patients with severe to very severe COPD. Patients and methods To provide a more comprehensive assessment of the impact of roflumilast on dyspnea, post hoc analyses of four 1-year roflumilast studies (M2-111, M2-112, M2-124, and M2-125) in patients with moderate to very severe COPD were conducted. Results In this pooled analysis (N=5,595), roflumilast significantly improved TDI focal scores versus placebo at week 52 (treatment difference, 0.327; P<0.0001). Roflumilast was associated with significantly greater TDI responders and significantly fewer TDI deteriorators (≥1-unit increase or decrease from baseline, respectively) versus placebo at week 52 (P<0.01, both); these significant differences were apparent by week 8 and maintained until study end (P<0.05, all). At study end, the postbronchodilator forced expiratory volume in 1 second improvement in TDI responders was significantly greater with roflumilast versus placebo (P<0.05). Similar to the overall population, improvements in TDI focal scores at week 52 were small but consistently significant over placebo in patients with chronic bronchitis, regardless of exacerbation history, concomitant treatment with short-acting muscarinic antagonists or long-acting β2-agonists, or pretreatment with inhaled corticosteroids. Conclusion This analysis shows that patients treated with roflumilast to reduce exacerbation risk may also experience small but significant improvements in dyspnea, with accompanying improvements in lung function.
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Panek M, Pietras T, Szemraj J, Kuna P. Association analysis of the glucocorticoid receptor gene ( NR3C1) haplotypes (ER22/23EK, N363S, BclI) with mood and anxiety disorders in patients with asthma. Exp Ther Med 2014; 8:662-670. [PMID: 25009637 PMCID: PMC4079411 DOI: 10.3892/etm.2014.1734] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 05/08/2014] [Indexed: 12/28/2022] Open
Abstract
Chronic inflammation in the bronchi of long-term asthma patients worsens mood disorders, which has been shown to correlate with elevated levels of multiple proinflammatory cytokines. The glucocorticoid receptor (GR) gene, NR3C1, plays a key role in the control of inflammation. Disturbances in the structure and function of the GR alter the glucocorticoid regulation of the corticotropin-releasing hormone, which leads to nonspecific activation of numerous receptors in the brain and alters the metabolism. The aim of the present study was to evaluate the role of NR3C1 haplotypes in mood and anxiety disorders. The study included 235 patients with asthma and 216 healthy individuals. Genotyping of NR3C1 gene polymorphisms was performed using polymerase chain reaction-restriction fragment length polymorphism. Beck's Depression Inventory, State and Trait Anxiety Inventory tests and the Borg scale were applied for all the subjects. Significant differences in the levels of depression (P=0.000008) and dyspnea (P=0.000001) were observed between the patients and healthy subjects. In addition, a correlation was identified between spirometric parameters and the intensity of depression, anxiety and subjective dyspnea. The AA ER22/23EK, AA N363S and CC BclI haplotype of the NR3C1 gene was identified to significantly aggravate trait anxiety in patients with asthma (P=0.026). Therefore, the NR3C1 gene substantially modified the level of trait anxiety in asthma sufferers.
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Fortis S, Florindez J, Balasingham S, De Aguirre M, Amoateng-Adjepong Y, Manthous CA. Ventilator Settings Can Substantially Impact Patients' Comfort. J Intensive Care Med 2014; 30:286-91. [PMID: 24446238 DOI: 10.1177/0885066613519574] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 11/04/2013] [Indexed: 12/24/2022]
Abstract
BACKGROUND With increasing realization that sedatives may complicate care of mechanically ventilated patients, greater emphasis might turn to promoting comfort by titration of ventilator settings. HYPOTHESIS Patients with acute on chronic respiratory failure (ACRF) with underlying chronic obstructive pulmonary disease (COPD) demonstrate different levels of comfort in response to varying ventilator settings compared to those with underlying obesity hypoventilation syndrome (OHS). METHODS Patients recovering from ACRF with underlying COPD or OHS were randomized to varying combinations of ventilator modes (assist control and pressure support), tidal volumes, and inspiratory flows for 3 minutes/setting. For each ventilator setting, physiologic variables were recorded and patients indicated their level of comfort using a 10-point Borg scale. RESULTS In all, 20 patients, aged 68 ± 13 years (standard deviation) and ventilated for 4.9 days, were enrolled. Of 20 patients, 13 had COPD and 7 had OHS. No ventilator mode, flow, or tidal volume provided consistently greater comfort between the groups, but patients reported substantial ranges of comfort (up to 8 Borg points) across the ventilator settings studied. There were no significant differences in heart rate, blood pressure, or airway pressures within patients across ventilator settings or between the groups, but patients with OHS were more tachypneic compared to patients with COPD while breathing on assist control of 6 mL/kg (constant flow 60 L/min) and 8 mL/kg (decelerating flow 40 L/min). There was no correlation between comfort and systolic blood pressure, heart rate, or respiratory rate. CONCLUSION Ventilator parameters may impact patients' comfort substantially. Future studies may help identify evidence-based methodology for gauging comfort following changes in ventilator settings and the settings that are most likely to positively impact various groups of patients.
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Johnson MJ, Bland JM, Oxberry SG, Abernethy AP, Currow DC. Clinically important differences in the intensity of chronic refractory breathlessness. J Pain Symptom Manage 2013; 46:957-63. [PMID: 23608121 DOI: 10.1016/j.jpainsymman.2013.01.011] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2012] [Revised: 01/23/2013] [Accepted: 01/28/2013] [Indexed: 11/21/2022]
Abstract
CONTEXT Clinically important differences in chronic refractory breathlessness are ill defined but important in clinical practice and trial design. OBJECTIVES To estimate the clinical relevance of differences in breathlessness intensity using distribution and patient anchor methods. METHODS This was a retrospective data analysis from 213 datasets from four clinical trials for refractory breathlessness. Linear regression was used to explore the relationship between study effect size and change in breathlessness score (0-100mm visual analogue scale) and to estimate the change in score equivalent to small, moderate, and large effect sizes. Pooled individual blinded patient preference data from three randomized controlled trials were analyzed. The difference between the mean change in Day 4 minus baseline scores between preferred and non-preferred arms was calculated. RESULTS There was a strong relationship between change in score and effect size (P = 0.001; R(2) = 0.98). Values for small, moderate, and large effects were -5.5, -11.3, and -18.2mm. The participant preference change in score was -9mm (95% CI, -15.8, -2.1) (P = 0.008). CONCLUSION This larger dataset supports a clinically important difference of 10mm. Studies should be powered to detect this difference.
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Kaplan A, Gruffydd-Jones K, van Gemert F, Kirenga BJ, Medford ARL. A woman with breathlessness: a practical approach to diagnosis and management. PRIMARY CARE RESPIRATORY JOURNAL : JOURNAL OF THE GENERAL PRACTICE AIRWAYS GROUP 2013; 22:468-76. [PMID: 24270362 PMCID: PMC6442845 DOI: 10.4104/pcrj.2013.00100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 10/26/2013] [Indexed: 02/05/2023]
Abstract
Worsening breathless in a patient with severe chronic obstructive pulmonary disease (COPD) is a common diagnostic and management challenge in primary care. A systematic approach to history-taking and examination combined with targeted investigation of pulmonary, cardiovascular, thromboembolic and systemic causes is essential if co-morbidities are to be identified and managed. Distinguishing between heart failure and COPD is a particular challenge as symptoms and signs overlap. In low and middle income countries additional priorities are the detection of infections such as tuberculosis and human immunodeficiency virus (HIV). Clinicians need to be alert to the possibility of atypical presentations (such as pain-free variants of angina) and less common conditions (including chronic thromboembolic pulmonary hypertension) in order not to overlook important potentially treatable conditions.
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Baker K, Mitchell G, Thompson AG, Stieler G. Diagnostic accuracy of basic lung ultrasound in breathless patients over 60 years of age; stressing the protocol. Australas J Ultrasound Med 2013; 16:176-182. [PMID: 28191194 PMCID: PMC5030058 DOI: 10.1002/j.2205-0140.2013.tb00244.x] [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: 11/26/2022] Open
Abstract
Introduction: Emergency department differentiation of pulmonary oedema from chronic obstructive airways disease causing acute breathlessness is inaccurate 25% of the time despite clinical acumen, clinician-reported chest x-ray and ECG. This research investigates whether a basic lung ultrasound protocol (LUS) could improve identification of pulmonary oedema in breathless elderly patients. Method: Researchers prospectively sampled patients over 60 years, describing any breathlessness on presentation to a suburban emergency department. LUS studies were acquired by experienced or novice sonologists, interpreted by a blinded reviewer and compared with cardiologist chart audit for diagnosis at admission (gold standard). The admitting doctor's diagnosis, blinded to LUS, was compared with the chart audit result. Results: 204 LUS were collected, 145 by experienced sonologist and 59 by inexperienced. Diagnostic accuracy compared to cardiologist audit was 86.2% (95% CI 80.9 to 90.3), significantly higher than 70.2%, diagnostic accuracy for admission diagnosis, difference in proportion of 16% (95%CI 7.7 to 24.4%). Conclusion: A simple lung scanning protocol can help exclude pulmonary oedema in any breathless elderly patient.
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