Non-opioid medications for the relief of chronic breathlessness: current evidence

Recent advances in understanding the role of antidepressants to manage breathlessness in supportive and palliative care

PURPOSE OF REVIEW

Breathlessness is a prevalent and distressing symptom in palliative and supportive care, with limited licensed pharmacological options once disease-directed therapies are no longer effective. Antidepressants have been proposed as a potential treatment, even in the absence of comorbid mood disorders, due to their modulation of neural circuits and serotonin pathways involved in breathlessness perception. Despite their off-label use in clinical practice for managing refractory or chronic breathlessness, robust evidence supporting their efficacy is needed. This review critically evaluates the latest evidence on their potential benefits and safety in breathlessness management.

RECENT FINDINGS

Breathlessness is influenced by at least three interrelated axes: lung-brain, behavioural-functional, and psycho-social-spiritual. These mechanisms operate across diseases, making them relevant in palliative and supportive care. Despite promise from early case reports and small trials, two recent large, randomised studies of mirtazapine and sertraline found no benefit in alleviating breathlessness or improving other outcomes. The mirtazapine trial also reported more adverse events than placebo. Earlier trials were small with design limitations, reducing reliability. A 2016 trial of sertraline found benefits for depression in stable COPD. Recent concerns over increased morbidity associated with antidepressant use in respiratory disease highlight the need for early detection of people at risk of worsening breathlessness or depression and a holistic, individualised approach.

SUMMARY

Current evidence does not support antidepressants for breathlessness in respiratory disease. Non-pharmacological approaches should be first line, given their proven benefits and low risk. Off-label medicine use requires caution and should ideally be offered within a trial or evaluation. Given the complex nature of breathlessness, future research should focus on innovating and then testing treatments and therapies in well-designed trials with appropriate outcome measures and reporting of adverse events, health care use and informal carer effects.

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.

Characterization of Dyspnea in Veteran Lung Cancer Survivors Following Curative-Intent Therapy

PURPOSE

Dyspnea is highly prevalent in lung cancer survivors following curative-intent therapy. We aimed to identify clinical predictors or determinants of dyspnea and characterize its relationship with functional exercise capacity (EC).

METHODS

In an analysis of data from a cross-sectional study of lung cancer survivors at the VA San Diego Healthcare System who completed curative-intent therapy for stage I-IIIA disease ≥1 mo previously, we tested a thorough list of comorbidities, lung function, and lung cancer characteristics. We assessed dyspnea using the European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire Lung Cancer Module 13 (LC13) and functional EC using the 6-minute walk. We replicated results with the University of California San Diego Shortness of Breath Questionnaire.

RESULTS

In 75 participants at a median of 12 mo since treatment completion, the mean ± SD LC13-Dyspnea score was 35.3 ± 26.2; 60% had abnormally high dyspnea. In multivariable linear regression analyses, significant clinical predictors or determinants of dyspnea were (β [95% CI]) psychiatric illness (-20.8 [-32.4 to -9.09]), heart failure with reduced ejection fraction (-15.5 [-28.0 to -2.97]), and forced expiratory volume in the first second of expiration (-0.28 [-0.49 to -0.06]). Dyspnea was an independent predictor of functional EC (-1.54 [-2.43 to -0.64]). These results were similar with the University of California San Diego Shortness of Breath Questionnaire.

CONCLUSION

We identified clinical predictors or determinants of dyspnea that have pathophysiological bases. Dyspnea was independently associated with functional EC. These results have implications in efforts to reduce dyspnea and improve exercise behavior and functional EC in lung cancer survivors following curative-intent therapy.

Rationale for targeted self-management strategies for breathlessness in heart failure

To provide a conceptual rationale for targeted self-management strategies for breathlessness in chronic heart failure. Breathlessness is a defining symptom of chronic heart failure and is the primary cause for hospital readmissions and emergency room visits, resulting in extensive health care utilization. Chronic breathlessness, punctuated by acute physiological decompensation, is a sentinel symptom of the heart failure syndrome and often intensifies towards the end of life. Drawing upon evidence-based guidelines, physiological mechanisms and existing conceptual models for the management of breathlessness is proposed. Key elements of this model include adherence to evidence-based approaches (pharmacological and non-pharmacological management to optimize heart failure treatment), self-monitoring of symptoms, identification of modifiable factors (such as fluid overload), and targeted strategies for breathlessness including distraction and gas flow. Self-management is an essential component in heart failure management which could positively influences health outcomes and quality of life. Refining programs to focus on breathlessness may have the potential to reduce symptom burden and improve quality of life.

Improving the quality of life of people with advanced respiratory disease and severe breathlessness

Advanced respiratory disease imposes a greater symptom burden than many cancers but not does have comparable recognition of the need for supportive and palliative care or the infrastructure for its systematic delivery. Consequently, many people with advanced respiratory disease (and those closest to them) have a poor quality of life, disabled by chronic breathlessness, fatigue and other symptoms. They are socially isolated by the consequences of long-term illness and are often financially impoverished. The past decade has seen an increasing realisation that care for this group must improve and that symptom management must be prioritised. Clinical guidelines recommend person-centred care, including access to supportive and palliative care as needed, as part of standard medical practice. Advanced lung disease clinics and specialist breathlessness services (pioneered within palliative care) are developing within respiratory medicine services but are provided inconsistently. This review covers the comprehensive assessment of the patient with advanced respiratory disease, the importance of supporting carers and the current best practice in the management of breathlessness, fatigue and cough. It also suggests ways to incorporate person-centred care into the general respiratory clinic, assisted by better liaison with specialist palliative and primary care. Emerging evidence shows that excellent symptom management leads to better clinical outcomes and reduces inappropriate use of emergency medical services.

KEY POINTS

People living with advanced respiratory disease and severe chronic breathlessness (and those closest to them) have a poor quality of life.Chronic breathlessness is a disabling symptom, and acute-on-chronic/episodic breathlessness is frightening to experience and observe.Chronic breathlessness imposes profound physical limitations and psychosocial burdens on those suffering from it or living with someone experiencing it.Fatigue and cough are two other cardinal symptoms of advanced respiratory disease, with very detrimental effects on quality of life.The impact of all these symptoms can be alleviated to a variable extent by a predominantly non-drug complex intervention.Many of the interventions are delivered primarily by allied health or nursing professionals.Doctors, nurses and other health professionals also need to play an active part in promoting quality of life as part of excellent medical care.A person-centred, psychologically informed approach is needed by all clinicians treating patients with advanced respiratory disease.

EDUCATIONAL AIMS

To give specialist respiratory clinicians practical clinical tools to help improve the quality of life of their patients with advanced respiratory disease and chronic breathlessness.To outline the evidence base for these interventions with reference to definitive sources.To highlight the importance of person-centred care in people with respiratory disease at all stages of illness.

Strategies to relieve dyspnoea in patients with advanced chronic respiratory diseases. A narrative review

BACKGROUND AND OBJECTIVE

The management of symptoms in patients with advanced chronic respiratory diseases needs more attention. This review summarizes the latest evidence on interventions to relieve dyspnoea in these patients.

METHODS

We searched randomised controlled trials, observational studies, systematic reviews, and meta-analyses published between 1990 and 2019 in English in PubMed data base using the keywords. Dyspnoea, Breathlessness AND: pharmacological and non pharmacological therapy, oxygen, non invasive ventilation, pulmonary rehabilitation, alternative medicine, intensive care, palliative care, integrated care, self-management. Studies on drugs (e.g. bronchodilators) or interventions (e.g. lung volume reduction surgery, lung transplantation) to manage underlying conditions and complications, or tools for relief of associated symptoms such as pain, are not addressed.

RESULTS

Relief of dyspnoea has received relatively little attention in clinical practice and literature. Many pharmacological and non pharmacological therapies are available to relieve dyspnoea, and improve patients' quality of life. There is a need for greater knowledge of the benefits and risks of these tools by doctors, patients and families to avoid unnecessary fears which might reduce or delay the delivery of appropriate care. We need services for multidisciplinary care in early and late phases of diseases. Early integration of palliative care with respiratory, primary care, and rehabilitation services can help patients and caregivers.

CONCLUSION

Relief of dyspnoea as well as of any distressing symptom is a human right and an ethical duty for doctors and caregivers who have many potential resources to achieve this.

Updates in palliative care - recent advancements in the pharmacological management of symptoms

Symptom management is an important part of both palliative care and end-of-life care. This article will examine the recent research evidence about drugs commonly used for symptom management in adult patients receiving palliative care. In particular, the management of symptoms where recent palliative care-based evidence has changed recommended practice will be reviewed. This includes: breathlessness, delirium, nausea and vomiting in bowel obstruction, opioid-induced constipation and upper respiratory tract secretions. For each symptom, a review of recent pharmacological evidence has been undertaken, with emphasis on potential important changes to physicians' practice.

Fooling the brain to alleviate dyspnoea

Dyspnoea affects a multitude of patients with a multitude of diseases, and therefore concerns a multitude of physicians and other healthcare professionals. In view of the physical and psychological distress associated with dyspnoea, and in view of the pervasive impact of dyspnoea on the patient's psychological state and social life [1, 2], relieving dyspnoea should constitute a leading and universal clinical goal. Some have even proposed that failing to provide a patient with dyspnoea with “state of the art” management of this symptom would constitute an infringement of human rights [3, 4].

The application of a stream of air onto the face by a hand-held fan has a real place in the treatment of dyspnoea http://ow.ly/tKJk30dJ5Pv