Use of short-acting opioids in the management of breathlessness: an evidence-based review

Interstitial Lung Disease: A Review

Importance

Interstitial lung disease (ILD) consists of a group of pulmonary disorders characterized by inflammation and/or fibrosis of the lung parenchyma associated with progressive dyspnea that frequently results in end-stage respiratory failure. In the US, ILD affects approximately 650 000 people and causes approximately 25 000 to 30 000 deaths per year.

Observations

The most common forms of ILD are idiopathic pulmonary fibrosis (IPF), which accounts for approximately one-third of all cases of ILD, hypersensitivity pneumonitis, accounting for 15% of ILD cases, and connective tissue disease (CTD), accounting for 25% of ILD cases. ILD typically presents with dyspnea on exertion. Approximately 30% of patients with ILD report cough. Thoracic computed tomography is approximately 91% sensitive and 71% specific for diagnosing subtypes of ILDs such as IPF. Physiologic assessment provides important prognostic information. A 5% decline in forced vital capacity (FVC) over 12 months is associated with an approximately 2-fold increase in mortality compared with no change in FVC. Antifibrotic therapy with nintedanib or pirfenidone slows annual FVC decline by approximately 44% to 57% in individuals with IPF, scleroderma associated ILD, and in those with progressive pulmonary fibrosis of any cause. For connective tissue disease-associated ILD, immunomodulatory therapy, such as tocilizumab, rituximab, and mycophenolate mofetil, may slow decline or even improve FVC at 12-month follow-up. Structured exercise therapy reduces symptoms and improves 6-minute walk test distance in individuals with dyspnea. Oxygen reduces symptoms and improves quality of life in individuals with ILD who desaturate below 88% on a 6-minute walk test. Lung transplant may improve symptoms and resolve respiratory failure in patients with end-stage ILD. After lung transplant, patients with ILD have a median survival of 5.2 to 6.7 years compared with a median survival of less than 2 years in patients with advanced ILD who do not undergo lung transplant. Up to 85% of individuals with end-stage fibrotic ILD develop pulmonary hypertension. In these patients, treatment with inhaled treprostinil improves walking distance and respiratory symptoms.

Conclusions and Relevance

Interstitial lung disease typically presents with dyspnea on exertion and can progress to respiratory failure. First-line therapy includes nintedanib or pirfenidone for IPF and mycophenolate mofetil for ILD due to connective tissue disease. Lung transplant should be considered for patients with advanced ILD. In patients with ILD, exercise training improves 6-minute walk test distance and quality of life.

Episodic breathlessness in patients with cancer: definition, terminology, clinical features - integrative systematic review

PURPOSE

Breatlessness flares directly impair quality of life of patients with cancer. The aim of this review was to analyse and synthesise the available information related to its terminology, definition and clinical features in patients with cancer.

METHODS

Integrative systematic review according to Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Literature search was conducted in MEDLINE PubMed, CINAHLPlus, Web of Science, Cochrane Central Register Controlled Trials CENTRAL, Scopus and OpenAire.

RESULTS

Data from 1065 patients with cancer included in 12 studies were analysed. The preferred term for breathlessness flares was episodic dyspnoea (ED). The reported frequency of ED was 20.4% (70.9% in patients reporting background dyspnoea (BD)). ED intensity was moderate to severe with short duration (<10 min) in >80% of patients. The most common trigger was exertion (>90%) followed by emotional or environmental factors. ED management consisted mainly of pharmacological and non-pharmacological measures.

CONCLUSIONS

This systematic review shows that ED is common in patients with cancer, especially in those with BD. Further studies are urgently needed to better understand this condition and to develop specific therapeutic management.

PROSPERO REGISTRATION NUMBER

CRD42019126708.

Benefits and Harms of Continuous Intravenous Inotropic Support as Palliative Therapy: A Single-Institution, Retrospective Analysis

Use of continuous intravenous inotropic support (CIIS) strictly as palliative therapy for patients with ACC/AHA Stage D (end-stage) Heart Failure (HF) has increased significantly. The harms of CIIS therapy may detract from its benefits. To describe benefits (improvement in NYHA functional class) and harms (infection, hospitalization, days-spent-in-hospital) of CIIS as palliative therapy. Methods: Retrospective analysis of patients with end-stage HF initiated on CIIS as palliative therapy at an urban, academic center in the United States between 2014-2016. Clinical outcomes were extracted, and data were analyzed using descriptive statistics. Seventy-five patients, 72% male, 69% African American/Black, with a mean age 64.5 years (SD = 14.5) met study criteria. Mean duration of CIIS was 6.5 months (SD = 7.7). Most patients (69.3%) experienced improvement in NYHA functional class from class IV to class III. Sixty-seven patients (89.3%) were hospitalized during their time on CIIS, with a mean of 2.7 hospitalizations per patient (SD = 3.3). One-third of patients (n = 25) required at least one intensive care unit (ICU) admission while on CIIS therapy. Eleven patients (14.7%) experienced catheter-related blood stream infection. Patients spent an average of 20.6% (SD = 22.8), approximately 40 days, of their time on CIIS admitted to the study institution. Patients on CIIS as palliative therapy report improvement in functional class, survive 6.5 months following initiation, but spend a significant number of days in the hospital. Prospective studies quantifying the symptomatic benefit and the direct and indirect harms of CIIS as palliative therapy are warranted.

The role of corticosteroids in the palliation of dyspnea in cancer patients: an evidence-based review

PURPOSE OF REVIEW

To provide an evidence-based review on the use of corticosteroids for dyspnea in cancer patients.

RECENT FINDINGS

Corticosteroids are commonly used for palliation of dyspnea; however, there is wide variation in how they are prescribed due to the paucity of high-quality evidence. Some clinicians would offer corticosteroids routinely regardless of the causes of dyspnea, while others would only prescribe corticosteroids selectively for specific indications, such as lymphangitic carcinomatosis, upper airway obstruction, superior vena cava obstruction, and cancer treatment-induced pneumonitis. Few mechanistic studies have been conducted to support the use of corticosteroids in cancer patients. Two double-blind, placebo-controlled randomized trials have examined the routine use of high-dose dexamethasone for dyspnea in cancer patients. A pilot study suggested some benefits, but the larger confirmatory trial revealed no improvement compared to the placebo and significantly more adverse events. The selective use of corticosteroids use is only based on observational studies such as case series.

SUMMARY

The unfavorable risk:benefit ratio of high-dose dexamethasone suggests that it should not be routinely prescribed for dyspnea in cancer patients. More research is needed to assess the selective use of corticosteroids and identify patients most likely be benefit from corticosteroid use.

They're Dying. Now What? The Impact of a 2-Hour End-of-Life Educational Intervention on Bedside Nurse Self-efficacy, Knowledge, and Clinical Practice

The palliative care team identified a lack of knowledge and confidence for nurses providing end-of-life care in a hospital. The team completed a quality improvement project establishing significant improvement in knowledge and self-efficacy after a 2-hour educational intervention. The next step was to study the impact on practice. Clinical management of pain, dyspnea, secretions, and agitation was compared for a 3-month period before and after intervention. Thirty-six patients were identified in the preintervention group, and 46 patients were in the postintervention group. A 2-sample proportion Z test ( α = .05, 2-tailed) showed no statistical significance in the number of doses of opioids administered between preintervention and postintervention groups; however, the number of patients in the postintervention group that received an opioid orally was significantly greater ( z = -2.098, P = .0357). A significantly lower proportion of the postintervention group received benzodiazepines ( z = -4.334, P < .00001). The postintervention group had a statistically significant lower proportion of anticholinergics administered ( z = -4.189, P < .00001). Significantly more patients in the postintervention group had oxygen titrated ( z = -3.196, P = .0014) and were on room air at the time of death ( z = -3.891, P = .0001). A 2-hour training led to statistically significant changes in the use of evidence-based interventions.

Managing symptoms at the end of life: a guide for non-palliative care nurses

Nurses, regardless of their area of practice, may have to care for a person in their last days and hours of life. However, many nurses outside of specialist palliative and end of life care settings do not feel adequately prepared for this. Nurses can usually obtain advice from specialists working in local hospices or palliative care centres, but they may still find it challenging to act on that advice if it is not underpinned by their own knowledge base. This article provides a guide to assist non-palliative care nurses in recognising dying and managing common symptoms at the end of life.

[Perceptions on handling of opioids: focus COVID-19 : A survey among anesthesiologists via the specialist societies DGAI/BDA]

BACKGROUND

Opioids are part of the daily routine in anesthesiology and palliative care; however, treatment of dyspnea with opioids is presented heterogeneously in guidelines. This may result in an uncertainty concerning opioid indications and ethical concerns, especially when caring for COVID-19 patients.

OBJECTIVE

We aimed to examine the perception of anesthesiologists concerning the handling of morphine as the reference opioid (subsequently termed M/O) for symptom control within and outside of a palliative care setting, including care for COVID-19 patients.

MATERIAL AND METHODS

Members of the German Society of Anesthesiology and Intensive Care Medicine (DGAI) and the Professional Association of German Anesthesiologists (BDA) received an anonymized online questionnaire (Survey Monkey®; Momentive Inc., San Mateo, CA, USA) in October 2020, containing questions regarding their perception of symptom management with M/O in general, and in particular concerning COVID-19 patients. Participants were asked to rate their perception within and outside a palliative care setting.

RESULTS AND DISCUSSION

A total of 1365 anesthesiologists participated; 46% women. Most anesthesiologists were 41-60 years old (58%), worked in a hospital setting (78%), in the operating theatre (63%) and in intensive care units (49%). The majority (57%) reported > 20 years of professional experience (52%) and partial involvement in palliative care (57%). Perception of M/O handling was mostly "certain and confident" (88%) and "clearly regulated" (85%) within a palliative care setting but rated substantially lower for outside palliative care (77%/63%). When caring for COVID-19 patients, handling of M/O was even less often rated "certain and confident" (40%) or "clearly regulated" (29%) outside palliative care. Dyspnea (95%/75%), relief of the dying process (84%/51%), agitation (59%/27%) and anxiety/panic (61%/33%) were more frequently rated as general indications for morphine within versus outside palliative care. The majority of anesthesiologists disputed that M/O is given with the intention to hasten death within (87%) and outside (93%) palliative care. Highest difference in route of administration was reported for the subcutaneous administration of M/O within (76%) versus outside (33%) palliative care, followed by the intravenous route (57%/79%), while oral (66/62%) and transdermal (48%/39%) administration were reported to be used comparatively frequently. Most participants (85%) wanted more frequent involvement of palliative care consultation teams but also more team conferences (75%), supervision (72%), and training on opioid management (69%).

CONCLUSION

Anesthesiologists perceived considerable uncertainty in using M/O for nonpalliative care medical settings. Highest uncertainty was seen for the care of patients with COVID-19. The prevalent use of the subcutaneous route for M/O application in palliative care can serve as inspiration for areas outside palliative care as well. Uniform interdisciplinary guidelines for symptom control including dyspnea, education and involvement of a palliative care consultation team should be more considered in the future.

Opioid Prescription Method for Breathlessness Due to Non-Cancer Chronic Respiratory Diseases: A Systematic Review

A previous pooled analysis demonstrated significant relief of breathlessness following opioid administration in patients with chronic obstructive pulmonary disease. However, in clinical practice, it is important to know the characteristics of patients responding to opioids, the best prescription methods, and the evaluation measures that can sufficiently reflect these effects. Thus, we performed a systematic review of systemic opioids for non-cancer chronic respiratory diseases. Fifteen randomized controlled studies (RCTs), four non-randomized studies, two observational studies, and five retrospective studies were included. Recent RCTs suggested that regular oral opioid use would decrease the worst breathlessness in patients with a modified Medical Research Council score ≥ 3 by a degree of 1.0 or less on a scale of 1–10. Ergometer or treadmill tests indicated mostly consistent significant acute effects of morphine or codeine. In two non-randomized studies, about 60% of patients responded to opioids and showed definite improvement in symptoms and quality of life. Furthermore, titration of opioids in these studies suggested that a major proportion of these responders had benefits after administration of approximately 10 mg/day of morphine. However, more studies are needed to clarify the prescription method to reduce withdrawal due to adverse effects, which would lead to significant improvements in overall well-being.

The placenta as a target of opioid drugs†

Opioid drugs are analgesics increasingly being prescribed to control pain associated with a wide range of causes. Usage of pregnant women has dramatically increased in the past decades. Neonates born to these women are at risk for neonatal abstinence syndrome (also referred to as neonatal opioid withdrawal syndrome). Negative birth outcomes linked with maternal opioid use disorder include compromised fetal growth, premature birth, reduced birthweight, and congenital defects. Such infants require lengthier hospital stays necessitating rising health care costs, and they are at greater risk for neurobehavioral and other diseases. Thus, it is essential to understand the genesis of such disorders. As the primary communication organ between mother and conceptus, the placenta itself is susceptible to opioid effects but may be key to understanding how these drugs affect long-term offspring health and potential avenue to prevent later diseases. In this review, we will consider the evidence that placental responses are regulated through an endogenous opioid system. However, maternal consumption of opioid drugs can also bind and act through opioid receptors express by trophoblast cells of the placenta. Thus, we will also discuss the current human and rodent studies that have examined the effects of opioids on the placenta. These drugs might affect placental hormones associated with maternal recognition of pregnancy, including placental lactogens and human chorionic gonadotropin in rodents and humans, respectively. A further understanding of how such drugs affect the placenta may open up new avenues for early diagnostic and remediation approaches.

Management of Dyspnea in Advanced Cancer: ASCO Guideline

PURPOSE

To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer.

METHODS

ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020.

RESULTS

The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea.

RECOMMENDATIONS

A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed. Additional information is available at www.asco.org/supportive-care-guidelines .