Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis

Palliative home oxygen: practical framework for clinicians

The British Thoracic Society 2015 guidelines on home oxygen use in adults have been pivotal in guiding clinicians on the use of long-term oxygen therapy in improving survival outcomes for patients. However, guidance for use of home oxygen in the palliative care setting has not been as robust owing to the lack of evidence-based studies. Therefore, this narrative review aims to provide a clinical framework on the use of palliative home oxygen therapy by considering its prognostic and symptomatic benefits as well as offering pragmatic advice for palliative home oxygen in end-of-life care.

Comparison of the Life-Sustaining Treatment, Cardiopulmonary Resuscitation, and Palliative Care Implementation Rates between Homebound Patients with Malignant and Nonmalignant Disease Who Died in an Acute Hospital Setting: A Single-Center Retrospective Study

OBJECTIVE

This study investigated and compared the implementation of life-support treatment (LST), cardiopulmonary resuscitation (CPR) implementation rates, and the influence of acute illnesses on the introduction of palliative care (PC) to homebound patients with malignant and nonmalignant disease, who subsequently died in an acute hospital setting.

METHODS

Among the homebound patients admitted to the ward in our hospital from 2011 to 2018, we investigated and compared the attributes, underlying diseases, causes of death, and rates of implementation of LST, CPR, and PC between patients with malignant and nonmalignant disease who died in the ward, using data obtained from hospitalization records. Furthermore, acute illnesses related to the introduction of PC were examined.

RESULTS

Of the 551 homebound patients admitted to the ward of an acute hospital, 119 died in the ward. Of the deceased patients, 60 had malignant disease and 59 had nonmalignant disease. Patients with nonmalignant disease had higher rates of LST implementation and CPR and a lower rate of PC. Patients with infectious disease, who required antimicrobial drugs, had significantly lower PC introduction rates.

CONCLUSION

Understanding the influence of the timing of PC introduction in acute care for homebound patients with advanced chronic illness are issues to be considered.

Can guidelines rein in oxygen use? A retrospective cross-sectional study using routinely collected data

Oxygen is one of the most commonly used emergency therapies. Like other therapies, oxygen can cause harm if used inappropriately. During the COVID-19 pandemic, guidelines were released to optimize oxygen and medication use. In the current study, we examine whether oxygen and medication use during the first wave of the COVID-19 pandemic was in concordance with new guidelines. A retrospective cross-sectional study was conducted using routinely collected data from University of Birmingham NHS Foundation Trust in England. Patients were admitted between April 2020 and September 2020, were over the age of 18 years, and had a confirmed diagnosis of COVID-19. To assess adherence to the oxygen guidelines (i.e. SpO2 adherence), the percentage of times oxygen therapy was administered within, over, and under guideline specifications were calculated for patients overall, and then for patients with and without chronic obstructive pulmonary disease (COPD)/pulmonary disease separately. Next, two multinomial regression analyses were conducted to assess whether clinical processes, pre-admission diagnoses, and other demographic factors were related to oxygen use. Analysis 1 included patients not diagnosed with COPD/pulmonary disease. Analysis 2 included patients diagnosed with COPD/pulmonary disease. Results are reported as tallies, percentages, and odds ratios with 95% confidence intervals. To assess adherence to a new medication guideline, the percentage of patients administered oxygen and dexamethasone was calculated for those admitted after 25 June 2020. The overall number of patients included in our SpO2 adherence analyses was 8751 (female = 4168). Oxygen was used within guideline specifications less than half the time, i.e. 41.6% (n = 3638/8751); non-adherence involving under-administering (3.5%, n = 304/8751) was markedly lower than over-administering (55.0%, n = 4809/8751). Adherence was higher for patients without COPD (43.7%, n = 3383/7741) than with COPD (25.2%, n = 255/1010). Under-administering was low across groups (non-COPD 3.5%, n = 274/7741 and COPD 2.9%, n = 30/1010). Over-administering was markedly lower for non-COPD (52.3%, n = 4084/7741) than COPD (71.8%, n = 725/1010) patients. Diagnoses associated with over-administering varied across the groups. Regarding the dexamethasone guidelines, of the 6397 patients admitted after the 24th of June, only 12.6% (n = 805) received dexamethasone. Suboptimal use of oxygen and medication were common during the first wave of the COVID-19 pandemic. As found in previous studies, over-administering was more common than under-administering. The new guidelines issued during the COVID-19 pandemic were not by themselves sufficient to optimize oxygen use. Behavioural strategies are explored which may help policymakers optimize oxygen use.

[Oxygen therapy in intensive care]

PULSE OXIMETRY AND BLOOD GAS ANALYSES

Pulse oximetry has high sensitivity but low specificity for detecting hypoxemia. Arterial blood gas analyses are the gold standard for monitoring O2 therapy. Venous blood gas analyses should not be used in this setting. TARGET VALUES OF O2 THERAPY: The target range of acute O2 therapy for ventilated patients and nonventilated patients not at risk of hypercapnia should be between 92% and 96% for oxygen saturation (SpO2) measured by pulse oximetry. Indications for high-dose O2 therapy without a target range in critical care include carbon monoxide poisoning and patients with severe respiratory distress when SpO2 cannot be derived. Hyperoxemia, i.e., SpO2 values above 96%, has not improved survival in randomized trials of predominantly ventilated ICU patients. Under hyperoxemia in nonventilated patients at risk of hypercapnia (e.g., patients with chronic obstructive pulmonary disease), one in three patients is at risk of increasing carbon dioxide. Therefore, a target SpO2 of 88-92% should be aimed for in these patients. O2 TARGET RANGES ON EXTRACORPOREAL PROCEDURES: There are no randomized studies recommending other SpO2 target ranges for patients on extracorporeal procedures. These patients should always be monitored with arterial blood gases-in the case of peripheral VA-ECMO on the right arm and downstream of the oxygenator. HIGH-FLOW OXYGEN THERAPY FOR ACUTE HYPERCAPNIC RESPIRATORY FAILURE: High-flow oxygen therapy (HFNC) was not associated with reduced in-hospital mortality compared with conventional O2 in a meta-analysis of predominantly patients with acute hypoxemia (type I respiratory failure), although intubation rates were reduced. Also, in acute hypercapnic respiratory failure (type II), HFNC with high flow rates is not inferior to noninvasive ventilation (NIV).

Efficacy of supplemental oxygen for dyspnea relief in patients with advanced progressive illness: A systematic review and meta-analysis

BACKGROUND

Supplemental oxygen is widely used for dyspnea relief; however, its efficacy is yet to be verified. This study aimed to determine the efficacy of supplemental oxygen for dyspnea relief in patients with advanced progressive illness.

METHODS

In this systematic review, several databases, including MEDLINE and EMBASE, were searched to identify eligible randomized controlled trials (RCTs) on the topic published up to September 23, 2019. The search criteria included RCTs investigating patients with advanced progressive illness (advanced cancer, chronic obstructive pulmonary disease, and chronic heart failure). The study protocol was registered with PROSPERO (No. CRD42020161838). Separate analyses were pre-planned regarding the presence or absence of resting hypoxemia.

RESULTS

RCTs investigating supplemental oxygen for dyspnea relief in participants with and without resting hypoxemia (39 and five, respectively) were included in the study. Heterogeneity of supplemental oxygen for dyspnea in RCTs, including participants without resting hypoxemia was evident; hence, post-hoc analyses in four subgroups (supplemental oxygen during exercise or daily activities, short-burst oxygen, continuous supplemental oxygen, and supplemental oxygen during rehabilitation intervention) were conducted. In the meta-analysis, supplemental oxygen during exercise was found to improve dyspnea in patients without resting hypoxemia compared with that in the control (standardized mean difference = -0.57, 95% confidence interval = -0.77 to -0.38). However, supplemental oxygen for the other subgroups failed to improve patients' dyspnea.

CONCLUSION

The results of this systematic review do not support supplemental oxygen therapy for dyspnea relief in patients with advanced progressive illness, except during exercise.

Current Management Options for Dyspnea in Cancer Patients

OPINION STATEMENT

Dyspnea is one of the most frequent and distressing symptoms in patients with advanced cancer. As dyspnea deteriorates patients' quality of life markedly and tends to worsen as the disease progresses, comprehensive assessment and timely treatment of the underlying etiologies are essential. International guidelines recommend various non-pharmacological and pharmacological management options. However, there is a scarcity of confirmatory clinical trials on cancer dyspnea, and the overall level of evidence is weak. Recently, observational and survey studies indicated a wide range of practice patterns of palliative care specialists, providing important insight into the real-world management of dyspnea. In this paper, we summarize current management options for dyspnea in cancer patients, highlight major controversies in the literature, and propose future research directions toward quality care for patients with dyspnea and their families.

Sauerstoff in der Akuttherapie

Sauerstoff (O₂) ist ein Arzneimittel und soll in der Akuttherapie bei Vorliegen einer Hypoxämie ärztlich verordnet und dokumentiert, regelmäßig überwacht und reevaluiert werden. Zur Überwachung dient in der Akutmedizin die Pulsoxymetrie, bei Risikopatienten sind arterielle Blutgase zu bestimmen. Sowohl eine Hypoxämie als auch eine Hyperoxämie sind bei akut Kranken zu vermeiden. Es sollten Zielbereiche der O₂-Sättigung (S_pO₂ [pulsoxymetrisch gemessene O₂-Sättigung]) festgelegt werden. Diese hängen vom Hyperkapnierisiko und vom Beatmungsstatus ab: spontan atmende Patienten ohne bzw. mit Hyperkapnierisiko: Ziel‑S_pO₂ = 92–96 % bzw. 88–92 %, beatmete Patienten: arterielle O₂-Sättigung zwischen 92 und 96 %. Die Zielbereiche gelten bis auf wenige Ausnahmen für alle Erwachsenen unabhängig von der Diagnose. Die O₂-Applikationssysteme werden nach Patientensicherheit und -komfort ausgewählt. Bei Beendigung der O₂-Gabe kann es bei vulnerablen Menschen zur Reboundhypoxämie kommen.

Noninvasive respiratory supports for the relief of terminal breathlessness

PURPOSE OF REVIEW

Breathlessness is a common symptom in patients with respiratory failure in the terminal phase of their illness. Noninvasive methods of oxygen delivery are frequently used in the palliative setting. We review the evidence supporting noninvasive respiratory supports for the relief of terminal breathlessness in those with life-limiting illnesses.

RECENT FINDINGS

There is limited evidence to support the use of supplemental oxygen for patients without hypoxia. It is unclear whether the symptomatic benefit of oxygen therapy relates to the oxygen delivery and/or airflow across the nasal mucosa. Early trials suggest that high-flow nasal cannula (HFNC) oxygen therapy improves breathlessness at rest and on exertion for patients with cancer. Noninvasive ventilation (NIV) also appears to improve breathlessness in the palliative setting; however, potential harms include facial pressure injuries, claustrophobia and anxiety. Goals of care should be explicitly discussed and frequently reviewed given that these interventions have the potential for harm and can be challenging to withdraw.

SUMMARY

HFNC oxygen therapy and NIV appear to reduce breathlessness in the palliative setting. Further high-quality trials are needed to confirm the symptomatic benefits of noninvasive respiratory supports on breathlessness for patients with cancer.

Impact of end-of-life respiratory modalities on quality of dying and death and symptom relief in patients with interstitial lung disease: a multicenter descriptive cross-sectional study

BACKGROUND

Respiratory modalities applied at the end of life may affect the burden of distressing symptoms and quality of dying and death (QODD) among patients with end-stage interstitial lung disease (ILD); however, there have been few studies into respiratory modalities applied to these patients near death. We hypothesized that high-flow nasal cannula (HFNC) might contribute to improved QODD and symptom relief in patients with end-stage ILD.

OBJECTIVES

This multicenter study examined the proportion of end-of-life respiratory modalities in a hospital setting and explored its impact on QODD and symptom relief among patients dying with ILD.

METHODS

Consecutive patients with ILD who died in four participating hospitals in Japan from 2015 to 2019 were identified and divided into four groups according to end-of-life respiratory modality: conventional oxygen therapy (COT), HFNC, non-invasive ventilation (NIV), and invasive mechanical ventilation (IMV). In addition, a mail survey was performed to quantify the QODD and symptom relief at their end of life from a bereaved family's perspective. QODD and symptom relief were quantified using the Good Death Inventory (GDI) for patients with a completed bereavement survey. The impact of end-of-life respiratory modalities on QODD and symptom relief was measured by multivariable linear regression using COT as a reference.

RESULTS

Among 177 patients analyzed for end-of-life respiratory modalities, 80 had a completed bereavement survey. The most common end-of-life respiratory modality was HFNC (n = 76, 42.9%), followed by COT (n = 62, 35.0%), NIV (n = 27, 15.3%), and IMV (n = 12, 6.8%). Regarding the place of death, 98.7% of patients treated with HFNC died outside the intensive care unit. Multivariable regression analyses revealed patients treated with HFNC had a higher GDI score for QODD [partial regression coefficient (B) = 0.46, 95% CI 0.07-0.86] and domain score related to symptom relief (B = 1.37, 95% CI 0.54-2.20) than those treated with COT.

CONCLUSION

HFNC was commonly used in patients with end-stage ILD who died in the hospital and was associated with higher bereaved family ratings of QODD and symptom relief. HFNC might contribute to improved QODD and symptom relief in these patients who die in a hospital setting.

German S3 Guideline: Oxygen Therapy in the Acute Care of Adult Patients

BACKGROUND

Oxygen (O2) is a drug with specific biochemical and physiological properties, a range of effective doses and may have side effects. In 2015, 14% of over 55,000 hospital patients in the UK were using oxygen. 42% of patients received this supplemental oxygen without a valid prescription. Health care professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed.

METHODS

A national S3 guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. A literature search was performed until February 1, 2021, to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of evidence and for grading guideline recommendation, and a formal consensus-building process was performed.

RESULTS

The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are based depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort.

CONCLUSION

This is the first national guideline on the use of oxygen in acute care. It addresses health care professionals using oxygen in acute out-of-hospital and in-hospital settings.

[Oxygen in the acute care of adults : Short version of the German S3 guideline]

Hintergrund

Sauerstoff (O₂) ist ein Arzneimittel mit spezifischen Eigenschaften, einem definierten Dosis-Wirkungs-Bereich und O₂ hat unerwünschte Wirkungen. Im Jahr 2015 wurden 14 % einer Stichprobe von britischen Krankenhauspatienten mit Sauerstoff behandelt, davon hatten nur 42 % eine Verordnung. Gesundheitspersonal ist häufig unsicher über die Relevanz einer Hypoxämie und es besteht ein eingeschränktes Bewusstsein für die Risiken einer Hyperoxämie. In den letzten Jahren wurden zahlreiche randomisierte, kontrollierte Studien zur Sauerstofftherapie veröffentlicht.

Methoden

Im Rahmen des Leitlinienprogramms der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) wurde unter Beteiligung von 10 Fachgesellschaften diese S3-Leitlinie auf Basis einer Literaturrecherche bis zum 01.02.2021 entwickelt. Zur Literaturbewertung wurde das System des Oxford Centre for Evidence-Based Medicine (CEBM; „The Oxford 2011 Levels of Evidence“) verwendet. Die Bewertung der Evidenzqualität erfolgte anhand des Grading of Recommendations Assessment, Development and Evaluation (GRADE) und die Leitlinienempfehlungen wurden formal konsentiert.

Ergebnisse

Die Leitlinie enthält 34 evidenzbasierte Empfehlungen zu Indikation, Verordnung, Überwachung und Abbruch der Sauerstofftherapie in der Akutversorgung. Die Indikation für Sauerstoff ist hauptsächlich die Hypoxämie. Hypoxämie und Hyperoxämie sollten aufgrund der Assoziation mit einer erhöhten Sterblichkeit vermieden werden. Die Leitlinie empfiehlt Zielbereiche der Sauerstoffsättigung für die Sauerstoff-Akuttherapie ohne Differenzierung zwischen verschiedenen Diagnosen. Zielbereiche sind abhängig vom Hyperkapnierisiko und Beatmungsstatus. Die Leitlinie bietet einen Überblick über verfügbare Sauerstoffzufuhrsysteme und enthält Empfehlungen für deren Auswahl basierend auf Patientensicherheit und -komfort.

Fazit

Dies ist die erste nationale Leitlinie zum Einsatz von Sauerstoff in der Akutmedizin. Sie richtet sich an medizinisches Fachpersonal, das Sauerstoff außerklinisch und stationär anwendet, und ist bis zum 30.06.2024 gültig.

Critically ill cancer patient's resuscitation: a Belgian/French societies' consensus conference

To respond to the legitimate questions raised by the application of invasive methods of monitoring and life-support techniques in cancer patients admitted in the ICU, the European Lung Cancer Working Party and the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique, set up a consensus conference. The methodology involved a systematic literature review, experts' opinion and a final consensus conference about nine predefined questions1. Which triage criteria, in terms of complications and considering the underlying neoplastic disease and possible therapeutic limitations, should be used to guide admission of cancer patient to intensive care units?2. Which ventilatory support [High Flow Oxygenation, Non-invasive Ventilation (NIV), Invasive Mechanical Ventilation (IMV), Extra-Corporeal Membrane Oxygenation (ECMO)] should be used, for which complications and in which environment?3. Which support should be used for extra-renal purification, in which conditions and environment?4. Which haemodynamic support should be used, for which complications, and in which environment?5. Which benefit of cardiopulmonary resuscitation in cancer patients and for which complications?6. Which intensive monitoring in the context of oncologic treatment (surgery, anti-cancer treatment …)?7. What specific considerations should be taken into account in the intensive care unit?8. Based on which criteria, in terms of benefit and complications and taking into account the neoplastic disease, patients hospitalized in an intensive care unit (or equivalent) should receive cellular elements derived from the blood (red blood cells, white blood cells and platelets)?9. Which training is required for critical care doctors in charge of cancer patients?

Pharmacologic and Non-Pharmacologic Dyspnea Management in Advanced Cancer Patients

As there is a high propensity for patients with advanced malignancy to experience refractory dyspnea, it is necessary for physicians to be well-versed in the management of these patients' dyspneic symptoms. For symptomatic treatment of cancer patients with dyspnea, both pharmacologic and non-pharmacologic methods should be considered. The main source of pharmacologic symptom management for dyspnea is oral and parenteral opioids; benzodiazepines and corticosteroids may serve as helpful adjuncts alongside opioid treatments. However, oxygen administration and nebulized loop diuretics have not been shown to clinically benefit dyspneic cancer patients. Applying non-pharmacologic dyspnea management methods may be valuable palliative therapies for advanced cancer patients, as they provide benefit with negligible harm to the patient. Advantageous and minimally harmful non-pharmacologic dyspnea therapies include facial airflow, acupuncture and/or acupressure, breathing exercises, cognitive behavioral therapy, music therapy, and spiritual interventions. Thus, it is vital that physicians are prepared to provide symptomatic care for dyspnea in advanced cancer patients as to minimize suffering in this patient population during definitive cancer treatments or hospice care.

[German S3 Guideline - Oxygen Therapy in the Acute Care of Adult Patients]

BACKGROUND

 Oxygen (O₂) is a drug with specific biochemical and physiologic properties, a range of effective doses and may have side effects. In 2015, 14 % of over 55 000 hospital patients in the UK were using oxygen. 42 % of patients received this supplemental oxygen without a valid prescription. Healthcare professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed.

METHODS

 A S3-guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. Literature search was performed until Feb 1st 2021 to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used and for assessing the quality of evidence and for grading guideline recommendation and a formal consensus-building process was performed.

RESULTS

 The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O₂ therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort.

CONCLUSION

 This is the first national guideline on the use of oxygen in acute care. It addresses healthcare professionals using oxygen in acute out-of-hospital and in-hospital settings. The guideline will be valid for 3 years until June 30, 2024.

Perspectives on palliative oxygen for breathlessness: systematic review and meta-synthesis

Oxygen therapy is frequently prescribed for the palliation of breathlessness, despite lack of evidence for its effectiveness in people who are not hypoxaemic. This study aimed to compare and contrast patients', caregivers' and clinicians' experiences of palliative oxygen use for the relief of chronic breathlessness in people with advanced life-limiting illnesses, and how this shapes prescribing.A systematic review and meta-synthesis of qualitative data was conducted. MEDLINE, CINAHL and PsycINFO were searched for peer-reviewed studies in English (2000-April 2019) reporting perspectives on palliative oxygen use for reducing breathlessness in people with advanced illnesses in any healthcare setting. After data extraction, thematic synthesis used line-by-line coding of raw data (quotes) to generate descriptive and analytical themes.Of 457 articles identified, 22 met the inclusion criteria by reporting perspectives of patients (n=337), caregivers (n=91) or clinicians (n=616). Themes common to these perspectives were: 1) benefits and burdens of palliative oxygen use, 2) knowledge and perceptions of palliative oxygen use beyond the guidelines, and 3) longitudinal trajectories of palliative oxygen use.There are differing perceptions regarding the benefits and burdens of using palliative oxygen. Clinicians should be aware that oxygen use may generate differing goals of therapy for patients and caregivers. These perceptions should be taken into consideration when prescribing oxygen for the symptomatic relief of chronic breathlessness in patients who do not quality for long-term oxygen therapy.

[Guideline for Long-Term Oxygen Therapy - S2k-Guideline Published by the German Respiratory Society]

Long-term oxygen therapy is of great importance both for reducing mortality and for improving performance in patients with chronic lung diseases. The prerequisites for Long-term oxygen therapy are adequate diagnostics and clearly defined indication. A causal distinction into chronic hypoxaemic and hypercapnic respiratory failure is reasonable, from which the differential indication for non-invasive ventilation results.The revised guideline covers the diagnostics and indication of chronic lung and heart diseases, the role of oxygen in terminal illness and gives a detailed description of available oxygen devices. The guideline is intended to help avoid undersupply, oversupply and false prescriptions. Furthermore, the chapter "Postacute Oxygen Therapy" discusses the procedure, relevant in everyday life, but not yet clearly defined, for prescribing oxygen therapy for the home at the end of an inpatient stay. Another important point, the correct prescription of mobile oxygen systems, is also presented in the guideline. This document is a revised version of the guideline for longterm oxygen therapy and replaces the version of 2008.

Oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care: a preliminary retrospective cohort study

Background

The role of oxygen therapy in end-of-life care for patients with advanced cancer is incompletely understood. We aimed to evaluate the association between oxygen use and survival in patients with advanced cancer and low oxygen saturation in home care.

Methods

We conducted a retrospective cohort study at a primary care practice in suburban Tokyo. Adult patients in home care with advanced cancer demonstrating first low oxygen saturation (less than 90%) detected in home visits were consecutively included in the study. Cox proportional hazards regression was used to investigate the effect of oxygen use on overall survival and survival at home, adjusted for systolic blood pressure, decreased level of consciousness, dyspnea, oral intake, performance status, and cardiopulmonary comorbidity.

Results

Of 433 identified patients with advanced cancer, we enrolled 137 patients (oxygen use, n = 35; no oxygen use, n = 102) who developed low oxygen saturation. In multivariable analysis, the adjusted hazard ratio (HR) of oxygen use was 0.68 (95% confidence interval 0.39–1.17) for death and 0.70 (0.38–1.27) for death at home. In patients with dyspnea, the HR was 0.35 (0.13–0.89) for death and 0.33 (0.11–0.96) for death at home; without dyspnea, it was 1.03 (0.49–2.17) for death and 0.84 (0.36–1.96) for death at home.

Conclusions

Oxygen use was not significantly associated with survival in patients with advanced cancer and low oxygen saturation, after adjusting for potential confounders. It may not be necessary to use oxygen for prolongation of survival in such patients, particularly in those without dyspnea.

Acute oxygen therapy: a cross-sectional study of prescribing practices at an English hospital immediately before COVID-19 pandemic

BACKGROUND

Approximately 14% of UK hospital in-patients receive supplemental oxygen therapy, only 57% have valid prescriptions. Oxygen must be optimally prescribed to ensure maximal therapeutic response whilst minimizing adverse outcomes (including fatality). This study investigates prescription compliance.

METHODS

All adults admitted to medical wards (18 February to 3 March 2020) were included. Analyses present proportions, descriptive statistics, and hypothesis testing. Ethical approval was unnecessary for this audit.

RESULTS

Of the 636 patients admitted, 66 (10%) were receiving oxygen therapy. Ages ranged from 34 to 100 years with 36 (54.5%) males and 30 (45.5%) females. The prescription was not documented in the oxygen section of the drug chart (n = 37, 56.1%, p = 0.389), nor did it have the physicians signature (n = 40, 60.6%, p = 0.110) nor date (n = 46, 69.7%, p = 0.002). Thirteen chronic obstructive pulmonary disease (COPD) patients (19.7%) were at risk of hypercapnic failure (p = 1.582x10^-6). Target oxygen saturation (SpO2) range had been documented for 30 (45.5%) patients. A target SpO2 range of 88-92% was documented for 9 patients (13.6%), a 94-98% range documented for 11 patients (16.7%). All patients had an invalid prescription.

CONCLUSION

We present real-world practice in naturalistic settings, immediately before pandemic-lockdown. Enhanced compliance is advocated to reduce risks of harm and mortality.

Management of Respiratory Symptoms in Those with Serious Illness

Respiratory symptoms are common in patients living with serious illness, both in cancer and nonmalignant conditions. Common symptoms include dyspnea (breathlessness), cough, malignant pleural effusions, airway secretions, and hemoptysis. Basic management of respiratory symptoms is within the scope of primary palliative care. There are pharmacologic and nonpharmacologic approaches to treating respiratory symptoms. This article provides clinicians with treatment approaches to these burdensome symptoms.

Airflow relieves chronic breathlessness in people with advanced disease: An exploratory systematic review and meta-analyses

BACKGROUND

Chronic breathlessness is a neglected symptom of advanced diseases.

AIM

To examine the effect of airflow for chronic breathlessness relief.

DESIGN

Exploratory systematic review and meta-analysis.

DATA SOURCES

Medline, CINAHL, AMED and Cochrane databases were searched (1985-2018) for observational studies or randomised controlled trials of airflow as intervention or comparator. Selection against predefined inclusion criteria, quality appraisal and data extraction was conducted by two independent reviewers with access to a third for unresolved differences. 'Before and after' breathlessness measures from airflow arms were analysed. Meta-analysis was carried out where possible.

RESULTS

In all, 16 of 78 studies (n = 929) were included: 11 randomised controlled trials of oxygen versus medical air, 4 randomised controlled trials and 1 fan cohort study. Three meta-analyses were possible: (1) Fan at rest in three studies (n = 111) offered significant benefit for breathlessness intensity (0-100 mm visual analogue scale and 0-10 numerical rating scale), mean difference -11.17 (95% confidence intervals (CI) -16.60 to -5.74), p = 0.06 I² 64%. (2) Medical air via nasal cannulae at rest in two studies (n = 89) improved breathlessness intensity (visual analogue scale), mean difference -12.0 mm, 95% CI -7.4 to -16.6, p < 0.0001 I² = 0%. (3) Medical airflow during a constant load exercise test before and after rehabilitation (n = 29) in two studies improved breathlessness intensity (modified Borg scale, 0-10), mean difference -2.9, 95% CI -3.2 to -2.7, p < 0.0001 I² = 0%.

CONCLUSION

Airflow appears to offer meaningful relief of chronic breathlessness and should be considered as an adjunct treatment in the management of breathlessness.

Literature review of clinical benefits and reasons to prescribe palliative oxygen therapy in non-hypoxaemic patients

AIMS:

to review current guidelines and studies available to health professionals in the UK and explore the literature to identify reasons for the prescription of palliative oxygen therapy in non-hypoxaemic patients.

BACKGROUND:

oxygen therapy is often associated with the palliative treatment for breathlessness. Although prescription guidelines are available and the risks of oxygen therapy are known, the therapy is still prescribed for non-hypoxaemic patients.

DESIGN:

a literature search was conducted using relevant databases. Cited evidence from published guidelines was also consulted.

RESULTS:

the findings suggest that oxygen is no more effective than room air for treating dyspnoea for non-hypoxaemic patients, although two small studies of self-reported benefits from patients and carers indicate different perceptions of need.

CONCLUSION:

the findings suggest that there is a knowledge gap with regards understanding the reasons for the prescription of oxygen therapy for non-hypoxaemic patients.

Does special education in palliative medicine make a difference in end-of-life decision-making?

Background

Characteristics of the physician influence the essential decision-making in end-of-life care. However, the effect of special education in palliative medicine on different aspects of decision-making in end-of-life care remains unknown. The aim of this study was to explore the decision-making in end-of-life care among physicians with or without special competency in palliative medicine (cPM).

Methods

A questionnaire including an advanced lung cancer patient-scenario with multiple decision options in end-of-life care situation was sent to 1327 Finnish physicians. Decisions to withdraw or withhold ten life-prolonging interventions were asked on a scale from 1 (definitely would not) to 5 (definitely would) – first, without additional information and then after the family’s request for aggressive treatment and the availability of an advance directive. Values from chronological original scenario, family’s appeal and advance directive were clustered by trajectory analysis.

Results

We received 699 (53%) responses. The mean values of the ten answers in the original scenario were 4.1 in physicians with cPM, 3.4 in general practitioners, 3.4 in surgeons, 3.5 in internists and 3.8 in oncologists (p < 0.05 for physicians with cPM vs. oncologists and p < 0.001 for physicians with cPM vs. others). Younger age and not being an oncologist or not having cPM increased aggressive treatment decisions in multivariable logistic regression analysis. The less aggressive approach of physicians with cPM differed between therapies, being most striking concerning intravenous hydration, nasogastric tube and blood transfusions. The aggressive approach increased by the family’s request (p < 0.001) and decreased by an advance directive (p < 0.001) in all physicians, regardless of special education in palliative medicine.

Conclusion

Physicians with special education in palliative medicine make less aggressive decisions in end-of-life care. The impact of specialty on decision-making varies among treatment options. Education in end-of-life care decision-making should be mandatory for young physicians and those in specialty training.

Electronic supplementary material

The online version of this article (10.1186/s12904-018-0349-6) contains supplementary material, which is available to authorized users.

ILCOR Scientific Knowledge Gaps and Clinical Research Priorities for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care: A Consensus Statement

Despite significant advances in the field of resuscitation science, important knowledge gaps persist. Current guidelines for resuscitation are based on the International Liaison Committee on Resuscitation 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, which includes treatment recommendations supported by the available evidence. The writing group developed this consensus statement with the goal of focusing future research by addressing the knowledge gaps identified during and after the 2015 International Liaison Committee on Resuscitation evidence evaluation process. Key publications since the 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations are referenced, along with known ongoing clinical trials that are likely to affect future guidelines.

Symptomatic treatment of dyspnea in advanced cancer patients : A narrative review of the current literature

BACKGROUND

Dyspnea is a common, very distressing symptom in advanced cancer patients that challenges them, their relatives, and healthcare professionals. This narrative review summarizes important literature dealing with the evidence for opioids, benzodiazepines, oxygen, and steroids for treating dyspnea in advanced cancer patients.

METHODS

A selective literature search was undertaken in PubMed, Embase, and the Cochrane Library and extended with literature from the reference lists of included studies up to April 2016. Inclusion criteria were that patients were suffering from advanced cancer and were receiving either opioids, benzodiazepines, corticosteroids, or oxygen. The outcome of interest was the reduction of dyspnea measured via a visual analogue scale (VAS), a numerical rating scale (NRS), or a Borg scale. This narrative review describes in detail the findings of 13 studies.

RESULTS

Nine studies deal with the effectiveness of opioids for reducing dyspnea in advanced cancer patients. Five of these found a significant benefit to the use of opioids compared to a placebo. Three found no significant improvements, and two favored combinations of opioids and benzodiazepines. Few high-quality studies were available that used benzodiazepines (n = 3, no difference, significant improvement with midazolam + morphine, significant difference for midazolam) or oxygen (n = 2, both without significant difference). Only one study examined treating dyspnea with steroids in patients with advanced cancer, and that study indicated a benefit of steroids compared to a placebo.

CONCLUSIONS

Opioids are the drug of choice for treating refractory dyspnea in advanced cancer patients. Neither benzodiazepines nor oxygen showed significant benefit. In addition, there is insufficient literature available to draw a conclusion about the effectiveness of steroids for treating persistent dyspnea in advanced cancer patients.

A pragmatic, phase III, multisite, double-blind, placebo-controlled, parallel-arm, dose increment randomised trial of regular, low-dose extended-release morphine for chronic breathlessness: Breathlessness, Exertion And Morphine Sulfate (BEAMS) study protocol

INTRODUCTION

Chronic breathlessness is highly prevalent and distressing to patients and families. No medication is registered for its symptomatic reduction. The strongest evidence is for regular, low-dose, extended- release (ER) oral morphine. A recent large phase III study suggests the subgroup most likely to benefit have chronic obstructive pulmonary disease (COPD) and modified Medical Research Council breathlessness scores of 3 or 4. This protocol is for an adequately powered, parallel-arm, placebo-controlled, multisite, factorial, block-randomised study evaluating regular ER morphine for chronic breathlessness in people with COPD.

METHODS AND ANALYSIS

The primary question is what effect regular ER morphine has on worst breathlessness, measured daily on a 0-10 numerical rating scale. Uniquely, the coprimary outcome will use a FitBit to measure habitual physical activity. Secondary questions include safety and, whether upward titration after initial benefit delivers greater net symptom reduction. Substudies include longitudinal driving simulation, sleep, caregiver, health economic and pharmacogenetic studies. Seventeen centres will recruit 171 participants from respiratory and palliative care. The study has five phases including three randomisation phases to increasing doses of ER morphine. All participants will receive placebo or active laxatives as appropriate. Appropriate statistical analysis of primary and secondary outcomes will be used.

ETHICS AND DISSEMINATION

Ethics approval has been obtained. Results of the study will be submitted for publication in peer-reviewed journals, findings presented at relevant conferences and potentially used to inform registration of ER morphine for chronic breathlessness.

TRIAL REGISTRATION NUMBER

NCT02720822; Pre-results.

Home oxygen therapy: evidence versus reality

INTRODUCTION

LTOT is a well-established treatment option for hypoxemic patients. Scientific evidence for its benefits of LTOT dates back to the 1980s, when two randomized controlled trials showed prolonged survival in COPD-patients undergoing LTOT for at least 15 hours/day. In contrast, the potential benefits of LTOT in non-COPD-patients has not been well researched and the recommendations for its application are primarily extrapolated from trials on COPD-patients. Recently, a large trial confirmed that COPD-patients who don't meet classic indication criteria, and have moderate desaturation at rest or during exercise, do not benefit from oxygen therapy. Also the significant technical evolution of LTOT devices has improved its application. Areas covered: A literature research was performed in pubmed regarding home oxygen therapy (terms: LTOT, ambulatory oxygen therapy, short burst oxygen therapy, nocturnal oxygen therapy). Expert commentary: LTOT proved a survival benefit for COPD patients about 30 years ago. Whether the results of these trials are still valid for patients under modern treatment guidelines remains unknown. Nevertheless, the classic indication criteria for LTOT still persist in guidelines, since there is a lack of updated evidence for the effects of LTOT in more severe hypoxemic patients.

The Breathing, Thinking, Functioning clinical model: a proposal to facilitate evidence-based breathlessness management in chronic respiratory disease

Refractory breathlessness is a highly prevalent and distressing symptom in advanced chronic respiratory disease. Its intensity is not reliably predicted by the severity of lung pathology, with unhelpful emotions and behaviours inadvertently exacerbating and perpetuating the problem. Improved symptom management is possible if clinicians choose appropriate non-pharmacological approaches, but these require engagement and commitment from both patients and clinicians. The Breathing Thinking Functioning clinical model is a proposal, developed from current evidence, that has the potential to facilitate effective symptom control, by providing a rationale and focus for treatment.

Hand-held Fan Airflow Stimulation Relieves Dyspnea in Lung Cancer Patients

Objective:

The main symptom of lung cancer is dyspnea which can lead to depression, anxiety, limited independent activities, and decreased quality of life. The purpose of this study was to identify the effect of airflow stimulation from a hand-held fan as nonpharmacological palliative intervention on dyspnea in patients with lung cancer.

Methods:

This study used open, randomized, controlled, crossover trial design involved 21 participants. Diaphragmatic breathing technique was used in control arm.

Results:

Wilcoxon test result showed that airflow stimulation significantly influenced dyspnea scale (P = 0.003) and respiratory rate (RR) (P = 0.008). Combination of airflow stimulation and diaphragmatic breathing can lower both dyspnea scale and RR significantly (P < 0.0001).

Conclusions:

This combination can be applied on nonhypoxemic dyspneic lung cancer patients.

Palliative Care of Adult Patients With Cancer

BACKGROUND

In Germany, the annual mortality rate from cancer in the year 2011 was 269.9 deaths per 100 000 persons; every fourth death was due to cancer. A central objective of palliative care is to maintain the best possible quality of life for cancer patients right up to the end of their lives.

METHODS

The PubMed, Embase, and Cochrane Library databases were systematically searched for pertinent publications, and the ones that were selected were assessed as recommended by the Scottish Intercollegiate Guidelines Network. As part of the German Guideline Program in Oncology, recommendations for the S3 Guideline on Palliative Care concerning seven different topics in the management of adult patients with incurable cancer were developed by a representative expert panel employing a consensus process.

RESULTS

Opioids are the drugs of first choice for severe and moderately severe cancer-related pain, and for breathlessness. No clinically relevant respiratory depression was observed in any study. When opioids are used, accompanying medication to prevent constipation is recommended. Drugs other than opioids are ineffective against breathlessness, but clinical experience has shown that benzodiazepines and opioids can be used in combination in advanced stages of disease, or if the patient suffers from marked anxiety. Depression should be treated even in patients with a short life expectancy; psychotherapy is indicated, and antidepressant medication is indicated as well if depression is at least moderately severe. Communication skills, an essential component of palliative care, play a major role in conversations between the physician and the patient about the diagnosis, the prognosis, and the patient's wish to hasten death. When the dying phase begins, tumor-specific treatments should be stopped.

CONCLUSION

Palliative care should be offered to cancer patients with incurable disease. Generalist and specialist palliative care constitute a central component of patient care, with the goal of achieving the best possible quality of life for the patient.

High-flow nasal cannula therapy for adult patients

High-flow nasal cannula (HFNC) oxygen therapy has several physiological advantages over traditional oxygen therapy devices, including decreased nasopharyngeal resistance, washing out of the nasopharyngeal dead space, generation of positive pressure in the pharynx, increasing alveolar recruitment in the lungs, humidification of the airways, increased fraction of inspired oxygen and improved mucociliary clearance. Recently, the use of HFNC in treating adult critical illness patients has significantly increased, and it is now being used in many patients with a range of different disease conditions. However, there are no established guidelines to direct the safe and effective use of HFNC for these patients. This review article summarizes the available published literature on the positive physiological effects, mechanisms of action, and the clinical applications of HFNC, compared with traditional oxygen therapy devices. The available literature suggests that HFNC oxygen therapy is an effective modality for the early treatment of critically adult patients.

[Management of refractory breathlessness in patients with advanced disease]

BACKGROUND

Breathlessness is a frequent and distressing symptom in advanced disease. It can have a significant impact on the quality of life of both patients and relatives.

OBJECTIVES

A summary of nonpharmacological and pharmacological measures for breathlessness based on existing evidence is provided.

MATERIALS AND METHODS

Analysis of primary studies, reviews and guidelines for the named symptoms and their management were analyzed.

RESULTS

Recognition and assessment are essential for the management of breathlessness. Management includes various nonpharmacological and pharmacological measures, which should be combined for best results. Nonpharmacological strategies comprise general information, management plan, hand-held fan, physical activity, and rollators. Opioids are the drugs of choice for intractable breathlessness. The evidence base for benzodiazepines and other drugs is rather weak.

CONCLUSION

A number of treatment options, especially in the nonpharmacological area, help the patients to better cope with their breathlessness.

Does home oxygen therapy (HOT) in addition to standard care reduce disease severity and improve symptoms in people with chronic heart failure? A randomised trial of home oxygen therapy for patients with chronic heart failure

BACKGROUND

Home oxygen therapy (HOT) is commonly used for patients with severe chronic heart failure (CHF) who have intractable breathlessness. There is no trial evidence to support its use.

OBJECTIVES

To detect whether or not there was a quality-of-life benefit from HOT given as long-term oxygen therapy (LTOT) for at least 15 hours per day in the home, including overnight hours, compared with best medical therapy (BMT) in patients with severely symptomatic CHF.

DESIGN

A pragmatic, two-arm, randomised controlled trial recruiting patients with severe CHF. It included a linked qualitative substudy to assess the views of patients using home oxygen, and a free-standing substudy to assess the haemodynamic effects of acute oxygen administration.

SETTING

Heart failure outpatient clinics in hospital or the community, in a range of urban and rural settings.

PARTICIPANTS

Patients had to have heart failure from any aetiology, New York Heart Association (NYHA) class III/IV symptoms, at least moderate left ventricular systolic dysfunction, and be receiving maximally tolerated medical management. Patients were excluded if they had had a cardiac resynchronisation therapy device implanted within the past 3 months, chronic obstructive pulmonary disease fulfilling the criteria for LTOT or malignant disease that would impair survival or were using a device or medication that would impede their ability to use LTOT.

INTERVENTIONS

Patients received BMT and were randomised (unblinded) to open-label LTOT, prescribed for 15 hours per day including overnight hours, or no oxygen therapy.

MAIN OUTCOME MEASURES

The primary end point was quality of life as measured by the Minnesota Living with Heart Failure (MLwHF) questionnaire score at 6 months. Secondary outcomes included assessing the effect of LTOT on patient symptoms and disease severity, and assessing its acceptability to patients and carers.

RESULTS

Between April 2012 and February 2014, 114 patients were randomised to receive either LTOT or BMT. The mean age was 72.3 years [standard deviation (SD) 11.3 years] and 70% were male. Ischaemic heart disease was the cause of heart failure in 84%; 95% were in NYHA class III; the mean left ventricular ejection fraction was 27.8%; and the median N-terminal pro-B-type natriuretic hormone was 2203 ng/l. The primary analysis used a covariance pattern mixed model which included patients only if they provided data for all baseline covariates adjusted for in the model and outcome data for at least one post-randomisation time point (n = 102: intervention, n = 51; control, n = 51). There was no difference in the MLwHF questionnaire score at 6 months between the two arms [at baseline the mean score was 54.0 (SD 18.4) for LTOT and 54.0 (SD 17.9) for BMT; at 6 months the mean score was 48.1 (SD 18.5) for LTOT and 49.0 (SD 20.2) for BMT; adjusted mean difference -0.10, 95% confidence interval (CI) -6.88 to 6.69; p = 0.98]. At 3 months, the adjusted mean MLwHF questionnaire score was lower in the LTOT group (-5.47, 95% CI -10.54 to -0.41; p = 0.03) and breathlessness scores improved, although the effect did not persist to 6 months. There was no effect of LTOT on any secondary measure. There was a greater number of deaths in the BMT arm (n = 12 vs. n = 6). Adherence was poor, with only 11% of patients reporting using the oxygen as prescribed.

CONCLUSIONS

Although the study was significantly underpowered, HOT prescribed for 15 hours per day and subsequently used for a mean of 5.4 hours per day has no impact on quality of life as measured by the MLwHF questionnaire score at 6 months. Suggestions for future research include (1) a trial of patients with severe heart failure randomised to have emergency oxygen supply in the house, supplied by cylinders rather than an oxygen concentrator, powered to detect a reduction in admissions to hospital, and (2) a study of bed-bound patients with heart failure who are in the last few weeks of life, powered to detect changes in symptom severity.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN60260702.

FUNDING

This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 75. See the NIHR Journals Library website for further project information.

Patient considerations and drug selection in the treatment of idiopathic pulmonary fibrosis

Idiopathic pulmonary fibrosis (IPF) is a progressive interstitial lung disease of unknown cause. Approximately 5,000 people are diagnosed with IPF in the UK every year. People with IPF suffer significant morbidity and, without any curative treatment at present, survival rates remain poor with a median survival of 3 years. While treatment remains largely supportive, many drug therapies have been trialed in IPF over the years. Pirfenidone and nintedanib are newly licensed treatments for IPF and the first drugs to have shown convincing evidence of slowing disease progression. In addition to evaluating clinical evidence, we also discuss elements affecting drug choice from the viewpoint of patients and health care professionals. We discuss pharmacological and nonpharmacological aspects of providing best supportive care for patients with IPF. However, few good quality studies exist focusing on controlling symptoms specifically in patients with IPF, and recommendations are often extrapolated from evidence in other chronic diseases. In covering these topics, we hope to provide readers with a comprehensive review of the available evidence pertaining to all aspects of care for patients suffering with IPF.

Managing breathlessness: a palliative care approach

Breathlessness is an important and common symptom globally, affecting patients with a variety of malignant and non-malignant diseases. It causes considerable suffering to patients and also their families, and is a significant cost to healthcare systems. Optimal management of the symptom should therefore be of interest and importance to a wide range of clinicians. Best practice in the management of breathlessness consists of both non-pharmacological and pharmacological interventions as evidenced by recent randomised controlled trials of multidisciplinary breathlessness support services. As well as providing evidence for integration of early palliative care into respiratory services, these revealed that patient distress due to breathlessness can be significantly reduced and better outcomes can be achieved at lower cost than standard care.

When should I be considering home oxygen for my patients?

The ability to provide oxygen in a patient’s home can offer enormous benefits, including improvements in life expectancy when given in the appropriate setting. Confusingly, however, home oxygen is available in many forms, including long-term oxygen therapy (LTOT), ambulatory oxygen therapy (AOT), palliative oxygen therapy (POT) and short-burst oxygen therapy (SBOT)—each with varying degrees of supporting evidence. The British Thoracic Society (BTS) has recently published new guidance on home oxygen therapy, after collating the available evidence. This article aims to summarise those guidelines, focusing on who should and should not be considered for oxygen therapy. Although the BTS guidelines target a UK audience, many of the principles covered below are applicable internationally, even if the availability of certain oxygen modalities and supporting service arrangements may vary between different healthcare systems.

Pilot Study of a Brief Behavioral Intervention for Dyspnea in Patients With Advanced Lung Cancer

CONTEXT

Dyspnea is a common symptom in patients with advanced cancer that interferes with functional ability and quality of life (QOL). Although few evidence-based treatments for dyspnea exist, prior studies show support for nonpharmacological interventions that include elements of cognitive-behavioral therapy.

OBJECTIVES

To examine the feasibility and utility of delivering a brief behavioral intervention for dyspnea in patients with lung cancer.

METHODS

For this single-group pilot study, eligible patients included those with advanced lung cancer (Stage III or IV non-small cell or extensive-stage small cell lung cancer) receiving outpatient cancer treatment who reported at least moderate breathlessness. The manualized intervention consisted of two sessions in which nurse practitioners taught participants breathing and relaxation techniques within the infusion clinic and encouraged home practice. Participants completed measures of breathlessness (Modified Medical Research Council Dyspnea Scale), QOL (Functional Assessment of Cancer Therapy-Lung Trial Outcome Index), and anxiety and depression symptoms (Hospital Anxiety and Depression Scale) at baseline and within six weeks after enrollment.

RESULTS

Of the 32 patients enrolled in the study (56.3% females; mean age 63.34 [SD] = 7.96 years), 84.4% (N = 27) completed all study procedures. Comparing the baseline to postassessments, we found significant improvements in Modified Medical Research Council Dyspnea Scale (P < 0.001), Functional Assessment of Cancer Therapy-Lung Trial Outcome Index (P = 0.01), and Hospital Anxiety and Depression Scale-depression subscale (P < 0.001) scores.

CONCLUSION

In this sample of patients with advanced lung cancer and dyspnea, we observed a high completion rate for the two-session behavioral intervention. Patients also reported improvements in dyspnea, QOL, and mood. Follow-up randomized controlled trials are needed to examine the efficacy of brief behavioral interventions for cancer-related dyspnea.

Eligibility for home oxygen programs and funding across Canada

BACKGROUND

In Canada, although medical insurance is generally universal, significant differences exist in the provision of home oxygen therapy across the country.

OBJECTIVE

To systematically compare the terms of reference for home oxygen across Canada, with a focus on the clinical inclusion criteria to the programs.

METHODS

The authors searched the terms of reference of the 10&nbsp;Canadian provinces and three territories, focusing on general eligibility criteria for home oxygen (including blood gas criteria, and eligibility criteria for ambulatory and nocturnal oxygen), and compared the eligibility criteria to the widely accepted criteria of the Nocturnal Oxygen Therapy Trial (NOTT) trial, the clinical recommendations of the Canadian Thoracic Society and the results of Cochrane reviews.

RESULTS

The terms of reference for nine provinces were retrieved. All jurisdictions have similar criteria for long-term oxygen therapy, with slight differences in the thresholds of prescription and the clinical criteria defining 'pulmonary hypertension' or 'cor pulmonale'. The use of oxyhemoglobin saturation as a criterion for funding is inconsistent. All nine provinces fund nocturnal oxygen, all with different clinical criteria. Funding for portable oxygen widely varies across provinces, whether the ambulatory equipment is offered to patients on long-term oxygen therapy or to those who have isolated exercise-induced desaturation. The terms of reimbursement are very heterogeneous.

CONCLUSIONS

Heterogeneity exists in the criteria for eligibility to home oxygen programs and funding across Canada. Terms of prescription and reimbursement of oxygen are not necessarily supported by available evidence from the current literature in several Canadian jurisdictions.

Academic detailing of general practitioners by a respiratory physician for diagnosis and management of refractory breathlessness: a randomised pilot study

Background

Academic detailing (AD; also known as educational visiting) facilitates the translation of evidence into practice and has been widely adopted internationally to facilitate practice change. The potential of AD linked to a specific patient and delivered by a specialist physician to general practitioners has not been evaluated.

This pilot study assessed the feasibility and acceptability of AD on the knowledge and confidence of GPs caring for people with advanced cancer who had breathlessness at the end of life.

Methods

In this randomised controlled pilot, 35 patient/GP dyads were randomised to AD or usual care. Key messages included: ensuring reversible causes were optimally treated; non-pharmacological and pharmacological treatments were considered; and oxygen considered for hypoxaemic patients.

Results

Acceptability: The majority of GPs randomised to AD agreed to participate, reporting benefits to practice. The majority of GPs in the control group requested a copy of academic detailing written materials at study completion.

Feasibility: AD visits to GPs’ offices could be timetabled reasonably easily, with 24 detailing visits occurring.

Self-reported knowledge and beliefs: Ninety two percent of GPs reported the topics covered in the AD sessions were useful, with 83 % reporting an increase in knowledge and confidence. AD sessions resulted in 58 % of GPs reporting a change in their approach to the management of breathlessness. By contrast, 81 % of the usual care group reported low confidence in the management and knowledge of breathlessness.

Conclusion

AD was acceptable and feasible to participating GPs. This pilot supports proceeding to a fully powered study.

Caring for Dying Patients in the Intensive Care Unit

Critically ill patients receiving palliative care at the end of life are at high risk for experiencing pain, dyspnea, and death rattle. Nearly all these patients are at risk for the development of delirium. Patients who are alert may experience anxiety. Advanced practice nurses and staff nurses are integral to detecting and treating these symptoms. Pain, dyspnea, and anxiety should be routinely assessed by patient self-report when possible. Routine behavioral screening for delirium is recommended. Behavioral observation tools to detect pain and dyspnea and proxy assessments guide symptom identification when the patient cannot provide a self-report. Evidence-based interventions are offered for both prevention and treatment of pain, dyspnea, anxiety, and delirium. Death rattle does not produce patient distress, and current pharmacological treatment lacks an evidence base. Pain management has a robust evidence base compared to management of dyspnea, anxiety, and delirium among this population; well-designed, adequately powered studies are needed.

Uptake of systematic reviews and meta-analyses based on individual participant data in clinical practice guidelines: descriptive study

OBJECTIVE

To establish the extent to which systematic reviews and meta-analyses of individual participant data (IPD) are being used to inform the recommendations included in published clinical guidelines.

DESIGN

Descriptive study.

SETTING

Database maintained by the Cochrane IPD Meta-analysis Methods Group, supplemented by records of published IPD meta-analyses held in a separate database.

POPULATION

A test sample of systematic reviews of randomised controlled trials that included a meta-analysis of IPD, and a separate sample of clinical guidelines, matched to the IPD meta-analyses according to medical condition, interventions, populations, and dates of publication.

DATA EXTRACTION

Descriptive information on each guideline was extracted along with evidence showing use or critical appraisal, or both, of the IPD meta-analysis within the guideline; recommendations based directly on its findings and the use of other systematic reviews in the guideline.

RESULTS

Based on 33 IPD meta-analyses and 177 eligible, matched clinical guidelines there was evidence that IPD meta-analyses were being under-utilised. Only 66 guidelines (37%) cited a matched IPD meta-analysis. Around a third of these (n=22, 34%) had critically appraised the IPD meta-analysis. Recommendations based directly on the matched IPD meta-analyses were identified for only 18 of the 66 guidelines (27%). For the guidelines that did not cite a matched IPD meta-analysis (n=111, 63%), search dates had preceded the publication of the IPD meta-analysis in 23 cases (21%); however, for the remainder, there was no obvious reasons why the IPD meta-analysis had not been cited.

CONCLUSIONS

Our results indicate that systematic reviews and meta-analyses based on IPD are being under-utilised. Guideline developers should routinely seek good quality and up to date IPD meta-analyses to inform guidelines. Increased use of IPD meta-analyses could lead to improved guidelines ensuring that routine patient care is based on the most reliable evidence available.