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Hayek SM, Jones BA, Veizi E, Tran TQ, DeLozier SJ. Efficacy of Continuous Intrathecal Infusion Trialing with a Mixture of Fentanyl and Bupivacaine in Chronic Low Back Pain Patients. PAIN MEDICINE (MALDEN, MASS.) 2023; 24:796-808. [PMID: 36515491 PMCID: PMC10321766 DOI: 10.1093/pm/pnac195] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 11/11/2022] [Accepted: 12/06/2022] [Indexed: 12/15/2022]
Abstract
Intrathecal trialing is used as a screening prognostic measure prior to intrathecal drug delivery system implant. The purpose of this study was to determine the efficacy of a continuous intrathecal infusion of an admixture of bupivacaine and fentanyl in patients with chronic low back pain. Patients with refractory chronic low back pain in the setting of previous lumbar spine surgery and/or chronic vertebral compression fracture(s) were enrolled in a randomized double blind cross-over study comparing saline infusion to infusion of a solution containing bupivacaine combined with low-dose fentanyl over a 14-18 hour period. The primary outcome measure was the change in pain intensity at the end of the screening trial. Patients who experienced significant pain reduction from either infusion relative to baseline pain were offered a permanent implant. In total, 36 patients were enrolled, with 31 patients trialed and 25 implanted. At the end of the screening trial, pain scores, at rest or with activity, decreased appreciably in both groups; however, significantly better improvements occurred in the fentanyl/bupivacaine group compared to saline both with activity and at rest (P = .016 and .006, respectively). Treatment order appeared to affect outcome with saline demonstrating a placebo response. At 12 months following implant, primary and secondary outcome measures continued to be significantly reduced from baseline. Continuous intrathecal delivery of a combination of zlow-dose fentanyl with bupivacaine is superior to saline in screening intrathecal trialing for back pain reduction. With longer term delivery, a sustained reduction of chronic low back pain was also observed.
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Affiliation(s)
- Salim M Hayek
- Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Anesthesiology/Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Bradford A Jones
- Division of Pain Medicine, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Department of Anesthesiology/Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
- Pain Medicine Service, Northeast Ohio VA Health Care System (NEOHVAHCS), Cleveland, Ohio, USA
| | | | - Thang Q Tran
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - Sarah J DeLozier
- Clinical Research Center, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
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2
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Chen X, Moran T, Smallwood N. Real-world opioid prescription to patients with serious, non-malignant, respiratory illnesses and chronic breathlessness. Intern Med J 2022; 52:1925-1933. [PMID: 35384242 PMCID: PMC9795913 DOI: 10.1111/imj.15770] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 03/04/2022] [Accepted: 04/01/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Chronic breathlessness is a disabling symptom that is often under-recognised and challenging to treat despite optimal disease-directed therapy. Low-dose, oral opioids are recommended to relieve breathlessness, but little is known regarding long-term opioid prescription in this setting. AIM To investigate the long-term efficacy of, and side-effects from, opioids prescribed for chronic breathlessness to patients with advanced, non-malignant, respiratory diseases. METHODS A prospective cohort study of all patients managed by the advanced lung disease service, an integrated respiratory and palliative care service, at the Royal Melbourne Hospital from 1 April 2013 to 3 March 2020. RESULTS One hundred and nine patients were prescribed opioids for chronic breathlessness. The median length of opioid use was 9.8 (interquartile range (IQR) = 2.8-19.8) months. The most commonly prescribed initial regimen was an immediate-release preparation (i.e. Ordine) used as required (37; 33.9%). For long-term treatment, the most frequently prescribed regimen included an extended-release preparation with an as needed immediate-release (37; 33.9%). The median dose prescribed was 12 (IQR = 8-28) mg oral morphine equivalents/day. Seventy-one (65.1%) patients reported a subjective improvement in breathlessness. There was no significant change in the mean modified Medical Research Council dyspnoea score (P = 0.807) or lung function measurements (P = 0.086-0.727). There was no association between mortality and the median duration of opioid use (P = 0.201) or dose consumed (P = 0.130). No major adverse events were reported. CONCLUSION Within this integrated respiratory and palliative care service, patients with severe, non-malignant respiratory diseases safely used long-term, low-dose opioids for breathlessness with subjective benefits reported and no serious adverse events.
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Affiliation(s)
- Xinye Chen
- Department of MedicineEastern HealthMelbourneVictoriaAustralia
| | - Thomas Moran
- Department of MedicineThe Royal Melbourne HospitalMelbourneVictoriaAustralia
| | - Natasha Smallwood
- Department of Respiratory MedicineThe Alfred HospitalMelbourneVictoriaAustralia,Department of Allergy, Immunology and Respiratory MedicineCentral Clinical School, The Alfred Hospital, Monash UniversityMelbourneVictoriaAustralia
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3
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Naughton M, Redmond P, Durbaba S, Ashworth M, Molokhia M. Determinants of long-term opioid prescribing in an urban population- a cross sectional study. Br J Clin Pharmacol 2022; 88:3172-3181. [PMID: 35018644 PMCID: PMC9305420 DOI: 10.1111/bcp.15231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 04/12/2021] [Accepted: 12/07/2021] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Opioid prescribing has more than doubled in the UK between 1998 and 2016. Potential adverse health implications include dependency, falls and increased health expenditure. AIM To describe the predictors of long-term opioid prescribing (LTOP), (≥3 opioid prescriptions in a 90-day period). DESIGN AND SETTING A retrospective cross-sectional study in 41 General Practices in South London. METHOD Multi-level multivariable logistic regression to investigate the determinants of LTOP. RESULTS 2,679 (0.8%) out of 320,639 registered patients ≥18 years were identified as having LTOP. Patients Were most likely to have LTOP, if: they had ≥5 long term conditions (LTCs) (adjusted odds ratio [AOR] 36.5, 95% confidence interval [CI] 30.4-43.8) or 2-4 LTCs (AOR 13.8, CI 11.9-16.1), in comparison to no LTCs, ≥75 years compared to 18-24 years (AOR 12.31, CI 7.1-21.5), smokers compared to non-smokers (AOR 2.2, CI 2.0-2.5), females compared to males (AOR 1.9, CI 1.7-2.0) and in the most deprived deprivation quintile (AOR 1.6, CI 1.4-1.8) compared to the least deprived. In a separate model examining individual long-term conditions (LTCs), the strongest associations for LTOP were noted for sickle cell disease (SCD) (AOR 18.4, CI 12.8-26.4), osteoarthritis (AOR 3.0, CI 2.8-3.3), rheumatoid arthritis (AOR 2.8, CI 2.2-3.4), depression (AOR 2.6, CI 2.3-2.8) and multiple sclerosis (OR 2.5, CI 1.4-4.4). CONCLUSION LTOP was significantly higher in those aged ≥75 years, with multi-morbidity or specific LTCs: sickle cell disease, osteoarthritis, rheumatoid arthritis, depression, and multiple sclerosis. These characteristics may enable the design of targeted interventions to reduce LTOP.
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Affiliation(s)
- Michael Naughton
- Department of Population Health Sciences & Environmental Sciences, King's College London
| | - Patrick Redmond
- School of Population Health & Environmental Sciences, King's College London
| | - Stevo Durbaba
- Department of Population Health Sciences, King's College London
| | - Mark Ashworth
- Department of Population Health Sciences, King's College London
| | - Mariam Molokhia
- Department of Population Health Sciences, King's College London
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4
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Iupati S, Bridge R, Allan S, Hewitt D. Intranasal Fentanyl Versus Placebo for Treatment of Episodic Breathlessness in Hospice Patients With Advanced Nonmalignant Diseases. J Pain Symptom Manage 2021; 61:1035-1041. [PMID: 33186729 DOI: 10.1016/j.jpainsymman.2020.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 10/02/2020] [Accepted: 11/02/2020] [Indexed: 11/29/2022]
Abstract
CONTEXT Episodic breathlessness is a distressing and difficult to treat symptom because of its short duration. Fast actioned intranasal fentanyl (INF) is potentially more suitable than oral opioids. OBJECTIVES To examine the feasibility, preliminary efficacy, and safety of INF for the treatment of episodic breathlessness from advanced nonmalignant conditions in hospice patients. METHODS Phase IIB, double-blind, randomized controlled, multisite, INF citrate solution vs. placebo crossover feasibility study. Opioid-tolerant patients were to treat six episodes of breathlessness using INF spray. The primary outcome was change in the Visual Analogue Scale for dyspnea (VAS-D) score from baseline to 15 minutes after study drug's administration (VAS-D15). Other outcomes were to collect demographic data and determine the use of rescue medications, safety, and feasibility of the study design. RESULTS Twenty-one of 49 eligible patients were enrolled, and 19 (90%) patients completed the study. The mean difference in VAS-D15 between fentanyl and placebo was -3.37 mm (95% CI = -10.35 to 3.61 mm; P = 0.337). There was no statistically significant or clinically meaningful difference between INF and placebo in relieving the sensation of discomfort in episodic breathlessness. No significant drug-related adverse event or detrimental effect on vital signs was observed. CONCLUSION We found no difference between INF and placebo in relieving episodic breathlessness in nonmalignant conditions. INF was well tolerated, and the study design proved to be feasible in hospice patients with advanced diseases. Future study using higher concentration of fentanyl solution may be warranted.
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Affiliation(s)
| | | | - Simon Allan
- Arohanui Hospice, Palmerston North, New Zealand
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5
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Buttery SC, Zysman M, Vikjord SAA, Hopkinson NS, Jenkins C, Vanfleteren LEGW. Contemporary perspectives in COPD: Patient burden, the role of gender and trajectories of multimorbidity. Respirology 2021; 26:419-441. [PMID: 33751727 DOI: 10.1111/resp.14032] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Accepted: 02/21/2021] [Indexed: 12/13/2022]
Abstract
An individual's experience of COPD is determined by many factors in addition to the pathological features of chronic bronchitis and emphysema and the symptoms that derive directly from them. Multimorbidity is the norm rather than the exception, so most people with COPD are living with a range of other medical problems which can decrease overall quality of life. COPD is caused by the inhalation of noxious particles or gases, in particular tobacco smoke, but also by early life disadvantage impairing lung development and by occupations where inhaled exposures are common (e.g. industrial, farming and cleaning work). Wealthy people are therefore relatively protected from developing COPD and people who do develop the condition may have reduced resources to cope. COPD is also no longer a condition that predominantly affects men. The prevalence of COPD among women has equalled that of men since 2008 in many high-income countries, due to increased exposure to tobacco, and in low-income countries due to biomass fuels. COPD is one of the leading causes of death in women in the USA, and death rates attributed to COPD in women in some countries are predicted to overtake those of men in the next decade. Many factors contribute to this phenomenon, but in addition to socioeconomic and occupational factors, there is increasing evidence of a higher susceptibility of females to smoking and pollutants. Quality of life is also more significantly impaired in women. Although most medications (bronchodilators and inhaled corticosteroids) used to treat COPD demonstrate similar trends for exacerbation prevention and lung function improvement in men and women, this is an understudied area and clinical trials frequently have a preponderance of males. A better understanding of gender-based predictors of efficacy of all therapeutic interventions is crucial for comprehensive patient care. There is an urgent need to recognize the increasing burden of COPD in women and to facilitate global improvements in disease prevention and management in this specific population. Many individuals with COPD follow a trajectory of both lung function decline and also multimorbidity. Unfavourable lung function trajectories throughout life have implications for later development of other chronic diseases. An enhanced understanding of the temporal associations underlying the development of coexisting diseases is a crucial first step in unravelling potential common disease pathways. Lessons can be learned from exploring disease trajectories of other NCD as well as multimorbidity development. Further research will be essential to explain how early life risk factors commonly influence trajectories of COPD and other diseases, how different diseases develop in relation to each other in a temporal way and how this ultimately leads to different multimorbidity patterns in COPD. This review integrates new knowledge and ideas pertaining to three broad themes (i) the overall burden of disease in COPD, (ii) an unappreciated high burden in women and (iii) the contrast of COPD trajectories and different multimorbidity patterns with trajectories of other NCD. The underlying pathology of COPD is largely irreversible, but many factors noted in the review are potentially amenable to intervention. Health and social care systems need to ensure that effective treatment is accessible to all people with the condition. Preventive strategies and treatments that alter the course of disease are crucial, particularly for patients with COPD as one of many problems.
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Affiliation(s)
- Sara C Buttery
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Maéva Zysman
- Centre de Recherche cardio-thoracique de Bordeaux, Univ-Bordeaux, Pessac, France.,Service des Maladies Respiratoires, CHU Bordeaux, Pessac, France
| | - Sigrid A A Vikjord
- Department of Medicine and Rehabilitation, Levanger Hospital, Nord-Trøndelag Hospital Trust, Levanger, Norway.,HUNT Research Centre, Department of Public Health and Nursing, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology (NTNU), Levanger, Norway
| | | | - Christine Jenkins
- Respiratory Group, The George Institute for Global Health, Sydney, NSW, Australia
| | - Lowie E G W Vanfleteren
- COPD Center, Department of Respiratory Medicine and Allergology, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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6
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Zemljic-Harpf AE, Hoe LES, Schilling JM, Zuniga-Hertz JP, Nguyen A, Vaishnav YJ, Belza GJ, Budiono BP, Patel PM, Head BP, Dillmann WH, Mahata SK, Peart JN, Roth DM, Headrick JP, Patel HH. Morphine induces physiological, structural, and molecular benefits in the diabetic myocardium. FASEB J 2021; 35:e21407. [PMID: 33583084 PMCID: PMC10843897 DOI: 10.1096/fj.201903233r] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 01/12/2021] [Accepted: 01/19/2021] [Indexed: 01/03/2023]
Abstract
The obesity epidemic has increased type II diabetes mellitus (T2DM) across developed countries. Cardiac T2DM risks include ischemic heart disease, heart failure with preserved ejection fraction, intolerance to ischemia-reperfusion (I-R) injury, and refractoriness to cardioprotection. While opioids are cardioprotective, T2DM causes opioid receptor signaling dysfunction. We tested the hypothesis that sustained opioid receptor stimulus may overcome diabetes mellitus-induced cardiac dysfunction via membrane/mitochondrial-dependent protection. In a murine T2DM model, we investigated effects of morphine on cardiac function, I-R tolerance, ultrastructure, subcellular cholesterol expression, mitochondrial protein abundance, and mitochondrial function. T2DM induced 25% weight gain, hyperglycemia, glucose intolerance, cardiac hypertrophy, moderate cardiac depression, exaggerated postischemic myocardial dysfunction, abnormalities in mitochondrial respiration, ultrastructure and Ca2+ -induced swelling, and cell death were all evident. Morphine administration for 5 days: (1) improved glucose homeostasis; (2) reversed cardiac depression; (3) enhanced I-R tolerance; (4) restored mitochondrial ultrastructure; (5) improved mitochondrial function; (6) upregulated Stat3 protein; and (7) preserved membrane cholesterol homeostasis. These data show that morphine treatment restores contractile function, ischemic tolerance, mitochondrial structure and function, and membrane dynamics in type II diabetic hearts. These findings suggest potential translational value for short-term, but high-dose morphine administration in diabetic patients undergoing or recovering from acute ischemic cardiovascular events.
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Affiliation(s)
- Alice E. Zemljic-Harpf
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Louise E. See Hoe
- Department of Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Jan M. Schilling
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Juan P. Zuniga-Hertz
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Alexander Nguyen
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Yash J. Vaishnav
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Gianna J. Belza
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Boris P. Budiono
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Southport, QLD, Australia
| | - Piyush M. Patel
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Brian P. Head
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - Wolfgang H. Dillmann
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Sushil K. Mahata
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Jason N. Peart
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Southport, QLD, Australia
| | - David M. Roth
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
| | - John P. Headrick
- Heart Foundation Research Centre, Griffith Health Institute, Griffith University, Southport, QLD, Australia
| | - Hemal H. Patel
- VA San Diego Healthcare System, San Diego, CA, USA
- Department of Anesthesiology, University of California San Diego, La Jolla, CA, USA
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7
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Abstract
COPD is a significant health issue around the world. It is ultimately a fatal disease. Patients are under-referred to palliative care. Palliative care can improve breathlessness and provide other psychosocial interventions that can improve quality of life. https://bit.ly/2VQ8FrR.
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Affiliation(s)
- Rebecca Strutt
- Palliative Medicine, Liverpool Hospital, Sydney, Australia.,University of New South Wales, Sydney, Australia
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8
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Chen X, Treanor D, Le B, Smallwood N. Gaps in Opioid Prescription for Severe Breathlessness in Hospitalized Patients With Chronic Obstructive Pulmonary Disease or Interstitial Lung Disease. J Pain Symptom Manage 2020; 60:e36-e39. [PMID: 32446973 DOI: 10.1016/j.jpainsymman.2020.05.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 05/02/2020] [Accepted: 05/06/2020] [Indexed: 01/09/2023]
Affiliation(s)
- Xinye Chen
- Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Darran Treanor
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Brian Le
- Department of Palliative Care, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Natasha Smallwood
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Victoria, Australia; Department of Medicine, The Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.
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9
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Gentzler ER, Derry H, Ouyang DJ, Lief L, Berlin DA, Xu CJ, Maciejewski PK, Prigerson HG. Underdetection and Undertreatment of Dyspnea in Critically Ill Patients. Am J Respir Crit Care Med 2020; 199:1377-1384. [PMID: 30485121 DOI: 10.1164/rccm.201805-0996oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Rationale: Dyspnea is a common and distressing physical symptom among patients in the ICU and may be underdetected and undertreated. Objectives: To determine the frequency of dyspnea relative to pain, the accuracy of nurses and personal caregiver dyspnea ratings relative to patient-reported dyspnea, and the relationship between nurse-detected dyspnea and treatment. Methods: This was an observational study of patients (n = 138) hospitalized in a medical ICU (MICU). Nurses and patients' personal caregivers at the bedside reported on their perception of patients' symptoms. Measurements and Main Results: Dyspnea was assessed by patients, caregivers, and nurses with a numerical rating scale. Across all three raters, the frequency of moderate to severe dyspnea was similar or greater than that of pain (P < 0.05 for caregiver and nurse ratings). Personal caregivers' ratings of dyspnea had substantial agreement with patient ratings (κ = 0.65, P < 0.001), but nurses' ratings were not significantly related to patient ratings (κ = 0.19, P = 0.39). Nurse detection of moderate to severe pain was significantly associated with opioid treatment (odds ratio, 2.70; 95% confidence interval, 1.10-6.60; P = 0.03); however, nurse detection of moderate to severe dyspnea was not significantly associated with any assessed treatment. Conclusions: Dyspnea was reported at least as frequently as pain among the sampled MICU patients. Personal caregivers had good agreement with patient reports of moderate to severe dyspnea. However, even when detected by nurses, dyspnea appeared to be undertreated. These findings suggest the need for improved detection and treatment of dyspnea in the MICU.
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Affiliation(s)
| | | | | | - Lindsay Lief
- 2 Department of Medicine, Weill Cornell Medicine, New York, New York
| | - David A Berlin
- 2 Department of Medicine, Weill Cornell Medicine, New York, New York
| | | | | | - Holly G Prigerson
- 1 Center for Research on End-Of-Life Care and.,2 Department of Medicine, Weill Cornell Medicine, New York, New York
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10
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Smallwood N, Currow D, Booth S, Spathis A, Irving L, Philip J. Differing Approaches to Managing the Chronic Breathlessness Syndrome in Advanced COPD: A Multi-National Survey of Specialists. COPD 2018; 15:294-302. [PMID: 30204492 DOI: 10.1080/15412555.2018.1502264] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
This study explored the approaches of respiratory and palliative medicine specialists to managing the chronic breathlessness syndrome in patients with severe chronic obstructive pulmonary disease. A voluntary, online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom (UK). Five hundred and seventy-seven (33.0%) responses were received from 1,749 specialists, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Palliative medicine doctors in ANZ and the UK had similar approaches to managing chronic breathlessness, whereas respiratory and palliative medicine doctors had significantly different approaches (p < 0.0001). Both specialties most commonly recommended a combination of non-pharmacological and pharmacological breathlessness management strategies. Respiratory doctors focussed more on pulmonary rehabilitation, whereas palliative medicine doctors recommended breathing techniques, anxiety management and the handheld fan. Palliative medicine doctors (197 (74.9%)) recommended short acting oral morphine for breathlessness, as compared with 73 (41.2%) respiratory doctors (p < 0.0001). Respiratory doctors cited opioid concerns related to respiratory depression and lack of knowledge. Nineteen (10.7%) respiratory doctors made no specific recommendations for managing chronic breathlessness. Both specialties reported actively managing chronic breathlessness, albeit with differing approaches. Integrated services, which combine the complementary knowledge and approaches of both specialities, may overcome current gaps in care and improve the management of distressing, chronic breathlessness.
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Affiliation(s)
- Natasha Smallwood
- a Department of Respiratory and Sleep Medicine , The Royal Melbourne Hospital , Parkville , Victoria , Australia.,b Department of Medicine (Royal Melbourne Hospital) , University of Melbourne , Victoria , Australia
| | - David Currow
- c Faculty of Health , University of Technology Sydney , Ultimo , New South Wales , Australia
| | - Sara Booth
- d University of Cambridge , Cambridge , UK
| | - Anna Spathis
- e Cambridge University Hospitals NHS Foundation Trust , Cambridge , UK
| | - Louis Irving
- a Department of Respiratory and Sleep Medicine , The Royal Melbourne Hospital , Parkville , Victoria , Australia
| | - Jennifer Philip
- f Palliative Medicine , St Vincent's Hospital and Victorian Comprehensive Cancer Centre, University of Melbourne.,g St Vincent's Hospital , Fitzroy , Victoria , Australia
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11
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Duncan D, Ashby A. Managing chronic breathlessness in the community. Br J Community Nurs 2018; 23:318-321. [PMID: 29972663 DOI: 10.12968/bjcn.2018.23.7.318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Breathlessness or dyspnoea is a subjective experience that can be described as an unpleasant or uncomfortable awareness of breathing. It is a subjective experience for patients and often they learn to adapt to the limitations caused by their condition, which makes their breathlessness less apparent to others. Breathlessness can be subdivided in the context of chronic refractory breathlessness, such as acute breathlessness, which is either an episodic breathlessness or breathlessness crisis. Chronic refractory breathlessness is defined as breathlessness at rest or on minimal exertion that will persist chronically despite optimal treatment of the underlying causative factors. The role of the community nurse in managing the breathless patient should involve differentiating between different types of breathlessness and knowing how to effectively manage it in a holistic manner.
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Affiliation(s)
| | - Abigail Ashby
- Senior lecturer in Nursing, Bucks New University, Buckinghamshire
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12
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Fentanyl treatment for end-of-life dyspnoea relief in advanced cancer patients. Support Care Cancer 2018; 27:157-164. [PMID: 29915993 DOI: 10.1007/s00520-018-4309-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Accepted: 06/06/2018] [Indexed: 12/20/2022]
Abstract
PURPOSE We assessed the effects of subcutaneous-endovenous fentanyl on dyspnoea in a cohort of advanced cancer patients. METHODS We performed a retrospective study in a cohort of advanced cancer patients with dyspnoea at rest who received subcutaneous or intravenous fentanyl. Patients with no shortness of breath at rest or at minimal exertion, no rescue doses per 24 h, were deemed to be responders to fentanyl. The period of assessment was 6 days from the beginning of fentanyl treatment. RESULTS Seventy-two patients were evaluated: 65% males, 50% ≥ 75 years, Palliative Performance Scale (PPS) median of 30%. Seventy-six percent of the patients were responders to fentanyl. Fentanyl efficacy was not statistically related to age, gender, cancer type, previous opioid treatment, steroid and midazolam doses and PPS. The median fentanyl dose in responders was 25 mcg/h (interquartile range 12-70). It was significantly related to age (37 vs 12 mcg/h, for ≤ 75 vs > 75 years, respectively; p = 0.02). There was not a significant difference between fentanyl doses of responders and non-responder patients. Thirty-six, 23 and 15 patients had sustained improvements in dyspnoea over 48, 72 and 96 h. Fentanyl had no significant toxicity. The length of inclusion in the study and exclusion were related to low performance status (hazard ratio 0.961; 95%CI 0.927-0.996; Cox-regression) but not to fentanyl doses (hazard ratio 0.875; 95%CI 0.620-1.234; Cox-regression). CONCLUSION Our preliminary data suggest that subcutaneous-endovenous fentanyl may be associated with dyspnoea relief in dying patients. Further research is needed to confirm these findings.
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13
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Smallwood N, Gaffney N, Gorelik A, Irving L, Le B, Philip J. Junior doctors' attitudes to opioids for refractory breathlessness in patients with advanced chronic obstructive pulmonary disease. Intern Med J 2018; 47:1050-1056. [PMID: 28585274 DOI: 10.1111/imj.13521] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/29/2017] [Accepted: 05/29/2017] [Indexed: 11/28/2022]
Abstract
BACKGROUND Refractory breathlessness is a common, distressing symptom in patients with advanced chronic obstructive pulmonary disease (COPD). The judicious, off-licence prescription of opioids, together with other management strategies, can improve breathlessness, however, internationally there is profound reluctance to prescribe opioids for breathlessness in COPD. AIMS To understand Australian junior doctors' knowledge and attitudes regarding the management of refractory breathlessness and the role of opioids in COPD. METHODS All junior doctors undertaking basic training in internal medicine in Victoria were invited to complete an online survey. Knowledge, willingness, and experience prescribing opioids to COPD patients with refractory breathlessness, were examined. RESULTS Of the 243 responses received, most trainees (193, 86.5%) believed opioids have a role in treating refractory breathlessness in stable COPD outpatients, with 143 (64.1%) recommending morphine as first-line treatment for refractory breathlessness. One quarter (55, 24.7%) reported having themselves initiated an opioid and 102 (45.7%) had prescribed an opioid under senior supervision for management of breathlessness in COPD. Concern regarding adverse opioid effects was low, with 58 (26.0%) having no concerns prescribing an opioid to COPD patients. CONCLUSION This is the first study of doctors to demonstrate high awareness, confidence, willingness and experience in prescribing opioids for the off-licence indication of refractory breathlessness in COPD. These findings differ significantly from attitudes reported overseas and are unexpected given the doctors surveyed were recently qualified. The low awareness of possible adverse events and limited insight regarding knowledge gaps is concerning and highlights the significant need for greater education in palliative care.
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Affiliation(s)
- Natasha Smallwood
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Nicole Gaffney
- Department of Respiratory Medicine, Frankston Hospital, Melbourne, Victoria, Australia
| | - Alexandra Gorelik
- Melbourne EpiCentre, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Louis Irving
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Brian Le
- Department of Palliative Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Jennifer Philip
- Centre for Palliative Care, St Vincent's Hospital, Melbourne, Victoria, Australia
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Politis J, Le B, Smallwood N. Respiratory depression secondary to morphine use in a patient with COPD and refractory breathlessness. Eur Respir J 2017; 49:49/5/1601858. [DOI: 10.1183/13993003.01858-2016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Accepted: 02/12/2017] [Indexed: 11/05/2022]
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15
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Morel V. [Guidelines to integrate palliative management in patients with acute COPD exacerbation]. Rev Mal Respir 2017; 34:492-498. [PMID: 28495295 DOI: 10.1016/j.rmr.2017.03.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- V Morel
- Équipe mobile d'accompagnement et de soins palliatifs, CHU de Rennes, 2, rue de l'Hôtel-Dieu, 35064 Rennes cedex, France.
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16
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Bausewein C. [Management of refractory breathlessness in patients with advanced disease]. Internist (Berl) 2016; 57:978-982. [PMID: 27587195 DOI: 10.1007/s00108-016-0122-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- C Bausewein
- Klinik und Poliklinik für Palliativmedizin, Klinikum der Universität München, Marchioninistr. 15, 81377, München, Deutschland.
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17
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O'Donnell DE, Webb KA, Harle I, Neder JA. Pharmacological management of breathlessness in COPD: recent advances and hopes for the future. Expert Rev Respir Med 2016; 10:823-34. [PMID: 27115291 DOI: 10.1080/17476348.2016.1182867] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Activity-related breathlessness is often the dominant symptom in patients with chronic obstructive pulmonary disease (COPD) and usually persists despite optimal medical therapy. Currently, our inability to meaningfully alter the pathophysiology of the underlying disease means that we must focus our attention on relieving this distressing symptom so as to improve exercise tolerance and quality of life. AREAS COVERED The current review examines the neurobiology of breathlessness and constructs a solid physiological rationale for amelioration of this distressing symptom. We will examine the efficacy of interventions which: 1) reduce the increased central drive to breathe (opioids); 2) improve the respiratory system's ability to appropriately respond to this increased demand (bronchodilators); and 3) address the important affective dimension of breathlessness (anxiolytics). Expert commentary: Advances in our understanding of the mechanisms of activity-related breathlessness in COPD, and its measurement in the clinical domain, now set the stage for the development of effective management strategies on an individual patient basis.
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Affiliation(s)
- Denis E O'Donnell
- a Department of Medicine , Queen's University & Kingston General Hospital , Kingston , ON , Canada
| | - Katherine A Webb
- a Department of Medicine , Queen's University & Kingston General Hospital , Kingston , ON , Canada
| | - Ingrid Harle
- a Department of Medicine , Queen's University & Kingston General Hospital , Kingston , ON , Canada
| | - J Alberto Neder
- a Department of Medicine , Queen's University & Kingston General Hospital , Kingston , ON , Canada
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18
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[Dyspnea, itching and depression in palliative medicine]. Schmerz 2016; 30:193-208. [PMID: 26983746 DOI: 10.1007/s00482-016-0104-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Palliative medicine focuses on relieving burdening symptoms to improve quality of life. The most common symptoms are physical weakness, pain, loss of appetite, nausea as well as dyspnea, itching and depression. Frequently, good symptom control can be achieved using the most effective drug combination therapy or non-medicinal interventions. This article specifically addresses the physical symptoms dyspnea, itching and the psychological symptom depression.
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Verberkt C, van den Beuken-van Everdingen M, Franssen F, Dirksen C, Schols J, Wouters E, Janssen D. A randomized controlled trial on the benefits and respiratory adverse effects of morphine for refractory dyspnea in patients with COPD: Protocol of the MORDYC study. Contemp Clin Trials 2016; 47:228-34. [DOI: 10.1016/j.cct.2016.01.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Revised: 01/18/2016] [Accepted: 01/23/2016] [Indexed: 10/22/2022]
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20
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Cherny NI, Kloke M, Cervantes A, Pentheroudakis G. Reply to the letter to the editor 'How much evidence isn't in evidence-based guidelines?' by Johnson et al. Ann Oncol 2015; 27:550-1. [PMID: 26602775 DOI: 10.1093/annonc/mdv583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- N I Cherny
- Department of Medical Oncology, Cancer Pain and Palliative Medicine Service, Shaare Zedek Medical Center, Jerusalem, Israel
| | - M Kloke
- Department of Palliative Medicine and Institute for Palliative Care, Kliniken Essen-Mitte, Academic Teaching Hospital University Essen-Duisburg, Essen, Germany
| | - A Cervantes
- Department of Hematology and Medical Oncology, Biomedical Research Institute INCLIVA, University of Valencia, Valencia, Spain
| | - G Pentheroudakis
- Department of Medical Oncology, University of Ioannina, Ioannina, Greece
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