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Holland AE, Spathis A, Marsaa K, Bausewein C, Ahmadi Z, Burge AT, Pascoe A, Gadowski AM, Collis P, Jelen T, Reilly CC, Reinke LF, Romero L, Russell AM, Saggu R, Solheim J, Vagheggini G, Vandendungen C, Wijsenbeek M, Tonia T, Smallwood N, Ekström M. European Respiratory Society clinical practice guideline on symptom management for adults with serious respiratory illness. Eur Respir J 2024; 63:2400335. [PMID: 38719772 DOI: 10.1183/13993003.00335-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 03/19/2024] [Indexed: 06/30/2024]
Abstract
Respiratory symptoms are ubiquitous and impair health-related quality of life in people with respiratory disease. This European Respiratory Society (ERS) task force aimed to provide recommendations for symptomatic treatment in people with serious respiratory illness. The ERS task force comprised 16 members, including representatives of people with serious respiratory illness and informal caregivers. Seven questions were formulated, six in the PICO (Population, Intervention, Comparison, Outcome) format, which were addressed with full systematic reviews and evidence assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). One question was addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. To treat symptoms in people with serious respiratory illness, the task force suggests the use of graded exercise therapy (conditional recommendation, low certainty of evidence); and suggests the use of a multicomponent services, handheld fan and breathing techniques (conditional recommendations, very low certainty of evidence). The task force suggests not to use opioids (conditional recommendation, very low certainty of evidence); and suggests either administering or not administering supplemental oxygen therapy (conditional recommendation, low certainty of evidence). The task force suggests that needs assessment tools may be used as part of a comprehensive needs assessment, but do not replace patient-centred care and shared decision making (conditional recommendation, low certainty of evidence). The low certainty of evidence, modest impact of interventions on patient-centred outcomes, and absence of effective strategies to ameliorate cough highlight the need for new approaches to reduce symptoms and enhance wellbeing for individuals who live with serious respiratory illness.
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Affiliation(s)
- Anne E Holland
- Departments of Physiotherapy and Respiratory Medicine, Alfred Health, Melbourne, Australia
- School of Translational Medicine, Monash University, Melbourne, Australia
- Institute for Breathing and Sleep, Melbourne, Australia
| | - Anna Spathis
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Kristoffer Marsaa
- Department of Multidisease, North Zealand Hospital, Copenhagen University, Hilleroed, Denmark
| | - Claudia Bausewein
- Department of Palliative Medicine, LMU University Hospital, LMU Munich, Munich, Germany
| | - Zainab Ahmadi
- Respiratory Medicine, Allergology and Palliative Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Angela T Burge
- School of Translational Medicine, Monash University, Melbourne, Australia
- Department of Physiotherapy, Alfred Health, Melbourne, Australia
| | - Amy Pascoe
- School of Translational Medicine, Monash University, Melbourne, Australia
| | - Adelle M Gadowski
- School of Translational Medicine, Monash University, Melbourne, Australia
| | - Phil Collis
- CPROR Birmingham University, Birmingham, UK
- Patient Advisory Group, European Lung Foundation, Sheffield, UK
| | - Tessa Jelen
- Patient Advisory Group, European Lung Foundation, Sheffield, UK
| | - Charles C Reilly
- Department of Physiotherapy, King's College Hospital, London, UK
- Cicely Saunders Institute of Palliative Care, Policy and Rehabilitation, King's College London, London, UK
| | - Lynn F Reinke
- College of Nursing, University of Utah, Salt Lake City, UT, USA
| | - Lorena Romero
- The Ian Potter Library, Alfred Health, Melbourne, Australia
| | - Anne-Marie Russell
- Institute of Clinical Sciences, University of Birmingham, Birmingham, UK
- Birmingham Regional NHS Interstitial Lung Disease and Occupational Lung Disease Service, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ravijyot Saggu
- Pharmacy Medicines Management Team, Central London Community Healthcare Trust, London, UK
| | - John Solheim
- EU-PFF - European Pulmonary Fibrosis Federation, Overijse, Belgium
- LHL-IPF, Jessheim, Norway
| | - Guido Vagheggini
- Department of Internal Medicine and Medical Specialties, Respiratory Failure Pathway, Azienda USL Toscana Nordovest, Pisa, Italy
- Fondazione Volterra Ricerche ONLUS, Volterra, Italy
| | - Chantal Vandendungen
- EU-PFF - European Pulmonary Fibrosis Federation, Overijse, Belgium
- ABFFP - Association Belge Francophone Contre la Fibrose Pulmonaire, Rebecq, Belgium
| | - Marlies Wijsenbeek
- Department of Respiratory Medicine, Erasmus University Medical Center, Center of Excellence for Interstitial Lung Disease, Rotterdam, The Netherlands
| | - Thomy Tonia
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Natasha Smallwood
- School of Translational Medicine, Monash University, Melbourne, Australia
- Department of Respiratory Medicine, Alfred Health, Melbourne, Australia
- Joint last authors
| | - Magnus Ekström
- Respiratory Medicine, Allergology and Palliative Medicine, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Joint last authors
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Liu M, Xiao W, Du L, Yu Y, Chen X, Mao B, Fu J. Effectiveness and safety of opioids on breathlessness and exercise endurance in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis of randomised controlled trials. Palliat Med 2023; 37:1365-1378. [PMID: 37710987 DOI: 10.1177/02692163231194838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/16/2023]
Abstract
BACKGROUND Opioids are recommended to treat advanced refractory dyspnoea despite optimal therapy by the American Thoracic Society clinical practice guidelines, while newly published randomised controlled trials of opioids in chronic obstructive pulmonary disease yield conflicting results. AIM This study aimed to evaluate the effectiveness and safety of opioids for patients with chronic obstructive pulmonary disease. DESIGN Systematic review and meta-analysis (PROSPERO CRD42021272556). DATA SOURCES Databases of PubMed, EMBASE and CENTRAL were searched from inception to 2022 for eligible randomised controlled trials. RESULTS Twenty-four studies including 975 patients, were included. In cross-over studies, opioids improved breathlessness (standardised mean difference, -0.43; 95% CI, -0.55 to -0.30; I2 = 18%) and exercise endurance (standardised mean difference, 0.22; 95% CI, 0.02-0.41; I2 = 70%). However, opioids failed to improve dyspnoea (standardised mean difference, -0.02; 95% CI, -0.22 to 0.19; I2 = 39%) and exercise endurance (standardised mean difference, 0.00; 95% CI, -0.27 to 0.27; I2 = 0%) in parallel control studies that administered sustained-release opioids for more than 1 week. The opioids used in most crossover studies were short-acting and rarely associated with serious adverse effects. Only minor side effects such as dizziness, nausea, constipation and vomiting were identified for short-acting opioids. CONCLUSIONS Sustained-release opioids did not improve dyspnoea and exercise endurance. Short-acting opioids appeared to be safe, have potential to lessen dyspnoea and improve exercise endurance, supporting benefit in managing episodes of breathlessness and providing prophylactic treatment for exertional dyspnoea.
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Affiliation(s)
- Meilu Liu
- Division of Pulmonary Medicine, Department of Internal Medicine, Institute of Integrated Traditional Chinese and Western Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Wei Xiao
- Division of Pulmonary Medicine, Department of Internal Medicine, Institute of Integrated Traditional Chinese and Western Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Longyi Du
- Division of Pulmonary Medicine, Department of Internal Medicine, Institute of Integrated Traditional Chinese and Western Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Yan Yu
- Division of Pulmonary Medicine, Department of Internal Medicine, Institute of Integrated Traditional Chinese and Western Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Xugui Chen
- Division of Pulmonary Medicine, Department of Internal Medicine, Institute of Integrated Traditional Chinese and Western Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Bing Mao
- Division of Pulmonary Medicine, Department of Internal Medicine, Institute of Integrated Traditional Chinese and Western Medicine, Sichuan University, Chengdu, Sichuan, China
| | - Juanjuan Fu
- Division of Pulmonary Medicine, Department of Internal Medicine, Institute of Integrated Traditional Chinese and Western Medicine, Sichuan University, Chengdu, Sichuan, China
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Sirohiya P, Pandey K, Sagiraju HKR, Bhatnagar S. Effectiveness of Morphine in Managing Refractory Dyspnoea in Patients with Coronavirus Disease (COVID-19). Indian J Palliat Care 2022; 28:443-446. [DOI: 10.25259/ijpc_112_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 07/16/2022] [Indexed: 11/04/2022] Open
Abstract
Opiates are generally used to relieve dyspnoea in advanced diseases such as cancer and lung diseases. However, little is known regarding the safety and efficacy of morphine for refractory dyspnoea in coronavirus disease 2019 (COVID-19) patients. We retrospectively reviewed records of 18 COVID-19-positive patients who were administered morphine for refractory dyspnoea during hospitalisation between May 2021 and June 2021. Details of morphine usage, vital signs, an 11-point dyspnoea numeric rating scale (DNRS) and adverse events at baseline, 24 h and 72 h after the start of treatment were abstracted from records. The final clinical outcome in terms of death or discharge was noted. All patients had severe refractory dyspnoea (DNRS score ≥7) at the time of administration of morphine and had not been relieved from standard care for the past 3 days. In the results, the mean (standard deviation [SD]) age was 47.1 (12) years, male was 13 (72.20%) patients and modified Medical Research Council Grade 4 was present in all 18 patients. The mean (SD) 1st day dose of morphine was 7.03 (1.53) mg and the mean (SD) duration of morphine use was 5.22 (3.00) days. Significant decreases in DNRS, respiratory rate and oxygen saturation were observed 24 h and 72 h after the start of morphine administration. Meanwhile, blood pressure and heart rate were not significantly altered after treatment. The finding of this single-centre retrospective study indicates that morphine may be considered for use in the management of refractory dyspnoea among COVID-19 patients.
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Affiliation(s)
- Prashant Sirohiya
- Department of Oncoanaesthesia and Palliative Medicine, National Cancer Institute (Jhajjar), All India Institute of Medical Sciences, New Delhi, India,
| | - Khushboo Pandey
- Department of Oncoanaesthesia and Palliative Medicine, National Cancer Institute (Jhajjar), All India Institute of Medical Sciences, New Delhi, India,
| | | | - Sushma Bhatnagar
- Department of Oncoanaesthesia and Palliative Medicine, Dr. B.R. Ambedkar Institute Rotary Cancer Hospital and National Cancer Institute, All India Institute of Medical Sciences, New Delhi, India,
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Opioid Prescription Method for Breathlessness Due to Non-Cancer Chronic Respiratory Diseases: A Systematic Review. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19084907. [PMID: 35457773 PMCID: PMC9024433 DOI: 10.3390/ijerph19084907] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 04/01/2022] [Accepted: 04/11/2022] [Indexed: 02/04/2023]
Abstract
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.
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Lopez-Campos JL, Almagro P, Gómez JT, Chiner E, Palacios L, Hernández C, Navarro MD, Molina J, Rigau D, Soler-Cataluña JJ, Calle M, Cosío BG, Casanova C, Miravitlles M. Spanish COPD Guideline (GesEPOC) Update: Comorbidities, Self-Management and Palliative Care. Arch Bronconeumol 2022; 58:334-344. [PMID: 35315327 DOI: 10.1016/j.arbres.2021.08.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/09/2021] [Accepted: 08/09/2021] [Indexed: 12/20/2022]
Abstract
The current health care models described in GesEPOC indicate the best way to make a correct diagnosis, the categorization of patients, the appropriate selection of the therapeutic strategy and the management and prevention of exacerbations. In addition, COPD involves several aspects that are crucial in an integrated approach to the health care of these patients. The evaluation of comorbidities in COPD patients represents a healthcare challenge. As part of a comprehensive assessment, the presence of comorbidities related to the clinical presentation, to some diagnostic technique or to some COPD-related treatments should be studied. Likewise, interventions on healthy lifestyle habits, adherence to complex treatments, developing skills to recognize the signs and symptoms of exacerbation, knowing what to do to prevent them and treat them within the framework of a self-management plan are also necessary. Finally, palliative care is one of the pillars in the comprehensive treatment of the COPD patient, seeking to prevent or treat the symptoms of a disease, the side effects of treatment, and the physical, psychological and social problems of patients and their caregivers. Therefore, the main objective of this palliative care is not to prolong life expectancy, but to improve its quality. This chapter of GesEPOC 2021 presents an update on the most important comorbidities, self-management strategies, and palliative care in COPD, and includes a recommendation on the use of opioids for the treatment of refractory dyspnea in COPD.
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Affiliation(s)
- José Luis Lopez-Campos
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, España; Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España.
| | - Pere Almagro
- Servicio de Medicina Interna, Hospital Universitario Mutua de Tarrasa, Tarrasa, Barcelona, España
| | | | - Eusebi Chiner
- Servicio de Neumología, Hospital Universitario San Juan de Alicante, Alicante, España
| | - Leopoldo Palacios
- Unidad de Gestión Clínica El Torrejón, Distrito Sanitario Huelva-Costa y Condado-Campiña, Huelva, España
| | - Carme Hernández
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Dispositivo transversal hospitalización a domicilio, Dirección Médica y Enfermera, Hospital Clínic, Universidad de Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, España
| | | | - Jesús Molina
- Centro de Salud Francia, Dirección Asistencial Oeste, Fuenlabrada, Madrid, España
| | - David Rigau
- Centro Cochrane Iberoamericano, Barcelona, España
| | | | - Myriam Calle
- Servicio de Neumología, Hospital Clínico San Carlos, Departamento de Medicina, Facultad de Medicina, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, España
| | - Borja G Cosío
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitario Son Espases-IdISBa, Palma de Mallorca, Baleares, España
| | - Ciro Casanova
- Unidad de Investigación, Servicio de Neumología, Hospital Universitario de La Candelaria, Universidad de La Laguna, Santa Cruz de Tenerife, Tenerife, España
| | - Marc Miravitlles
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, España; Servicio de Neumología, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institut de Recerca (VHIR), Barcelona, España
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Lopez-Campos JL, Almagro P, Gómez JT, Chiner E, Palacios L, Hernández C, Navarro MD, Molina J, Rigau D, Soler-Cataluña JJ, Calle M, Cosío BG, Casanova C, Miravitlles M. [Translated article] Spanish COPD Guideline (GesEPOC) Update: Comorbidities, Self-Management and Palliative Care. ARCHIVOS DE BRONCONEUMOLOGÍA 2022. [DOI: 10.1016/j.arbres.2021.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Vozoris NT. A critical review of the respiratory benefits and harms of orally administered opioids for dyspnea management in COPD. Expert Rev Respir Med 2021; 15:1579-1587. [PMID: 34761704 DOI: 10.1080/17476348.2021.2005584] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Dyspnea occurring in chronic obstructive pulmonary disease (COPD) that is refractory to traditional management strategies is a common and challenging problem. Considerable attention has been paid to the off-label use of orally administered opioids as a pharmacotherapy option for refractory dyspnea in COPD. Multiple professional respiratory society guidelines express support for the application of oral opioids for this purpose. AREAS COVERED This manuscript will critically review randomized controlled trials undertaken to date that evaluate the efficacy of oral opioids for dyspnea in COPD, as well as phase IV observational studies that examine for potential opioid-related respiratory harms in the COPD population (literature was searched on PubMed up to June 2021). COPD guideline recommendations relating to opioids for dyspnea will subsequently be critiqued. EXPERT OPINION Opioid efficacy trials demonstrate at best a small improvement in dyspnea in limited numbers of individuals with COPD, whereas safety trials consistently show an increased risk of respiratory-related exacerbation, hospitalization and death in association with opioid use. In contrast to what is expressed in guidelines, the current body of evidence does not the support the wide application of opioids to manage refractory dyspnea among individuals with COPD, but instead, a highly selective and careful approach.
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Affiliation(s)
- Nicholas T Vozoris
- Division of Respirology, St. Michael's Hospital, Toronto, Canada.,Keenan Research Centre in the Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada.,Department of Medicine, University of Toronto, Toronto, Canada.,Chronic Disease and Pharmacotherapy Program, ICES (Formerly Known as Institute for Clinical Evaluative Sciences), Toronto, Canada
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Opioids in patients with COPD and refractory dyspnea: literature review and design of a multicenter double blind study of low dosed morphine and fentanyl (MoreFoRCOPD). BMC Pulm Med 2021; 21:289. [PMID: 34507574 PMCID: PMC8431258 DOI: 10.1186/s12890-021-01647-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Accepted: 08/30/2021] [Indexed: 12/02/2022] Open
Abstract
Background Refractory dyspnea or breathlessness is a common symptom in patients with advanced chronic obstructive pulmonary disease (COPD), with a high negative impact on quality of life (QoL). Low dosed opioids have been investigated for refractory dyspnea in COPD and other life-limiting conditions, and some positive effects were demonstrated. However, upon first assessment of the literature, the quality of evidence in COPD seemed low or inconclusive, and focused mainly on morphine which may have more side effects than other opioids such as fentanyl. For the current publication we performed a systematic literature search. We searched for placebo-controlled randomized clinical trials investigating opioids for refractory dyspnea caused by COPD. We included trials reporting on dyspnea, health status and/or QoL. Three of fifteen trials demonstrated a significant positive effect of opioids on dyspnea. Only one of four trials reporting on QoL or health status, demonstrated a significant positive effect. Two-thirds of included trials investigated morphine. We found no placebo-controlled RCT on transdermal fentanyl. Subsequently, we hypothesized that both fentanyl and morphine provide a greater reduction of dyspnea than placebo, and that fentanyl has less side effects than morphine.
Methods We describe the design of a robust, multi-center, double blind, double-dummy, cross-over, randomized, placebo-controlled clinical trial with three study arms investigating transdermal fentanyl 12 mcg/h and morphine sustained-release 10 mg b.i.d. The primary endpoint is change in daily mean dyspnea sensation measured on a numeric rating scale. Secondary endpoints are change in daily worst dyspnea, QoL, anxiety, sleep quality, hypercapnia, side effects, patient preference, and continued opioid use. Sixty patients with severe stable COPD and refractory dyspnea (FEV1 < 50%, mMRC ≥ 3, on optimal standard therapy) will be included.
Discussion Evidence for opioids for refractory dyspnea in COPD is not as robust as usually appreciated. We designed a study comparing both the more commonly used opioid morphine, and transdermal fentanyl to placebo. The cross-over design will help to get a better impression of patient preferences. We believe our study design to investigate both sustained-release morphine and transdermal fentanyl for refractory dyspnea will provide valuable information for better treatment of refractory dyspnea in COPD. Trial registration NCT03834363 (ClinicalTrials.gov), registred at 7 Feb 2019, https://clinicaltrials.gov/ct2/show/NCT03834363. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01647-8.
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Verberkt CA, van den Beuken-van Everdingen MHJ, Dirksen CD, Schols JMGA, Wouters EFM, Janssen DJA. Cost-effectiveness of sustained-release morphine for refractory breathlessness in COPD: A randomized clinical trial. Respir Med 2021; 179:106330. [PMID: 33611087 DOI: 10.1016/j.rmed.2021.106330] [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: 10/14/2020] [Revised: 01/22/2021] [Accepted: 02/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Chronic breathlessness is a frequent symptom in advanced Chronic Obstructive Pulmonary Disease (COPD) and has major impact on quality of life, daily activities and healthcare utilization. Morphine is used as palliative treatment of chronic breathlessness. The aim is to analyze cost-effectiveness of regular, low-dose morphine in patients with advanced COPD from a healthcare and societal perspective. METHODS In a randomized controlled trial, participants with advanced COPD were assigned to 10 mg regular, oral sustained-release morphine or placebo twice daily for four weeks. Quality of life (COPD Assessment Test; CAT), quality-adjusted life years (QALY's; EQ-5D-5L), healthcare costs, productivity, and patient and family costs were collected. Incremental cost-effectivity ratio's (ICERs) using healthcare costs and CAT scores, and incremental cost-utility ratio's (ICURs) using societal costs and QALY's were calculated. RESULTS Data of 106 of 124 participants were analyzed, of which 50 were in the morphine group (mean [SD] age 65.4 [8.0] years; 58 [55%] male). Both ICER and ICUR indicated dominance for morphine treatment. Sensitivity analyses substantiated these results. From a healthcare perspective, the probability that morphine is cost-effective at a willingness to pay €8000 for an minimal clinically important difference of 2 points increase in CAT score is 63%. From a societal perspective, the probability that morphine is cost-effective at a willingness to pay €20,000 per QALY is 78%. CONCLUSION Morphine for four weeks is cost-effective regarding the healthcare and the societal perspective. To estimate the long-term costs and effects of morphine treatment, a study of longer follow-up should be performed. TRIAL REGISTRATION ClinicalTrials.gov (NCT02429050).
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Affiliation(s)
- Cornelia A Verberkt
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200MD, Maastricht, the Netherlands
| | | | - Carmen D Dirksen
- Department of Clinical Epidemiology and Medical Technology Assessment, Care and Public Health Research Institute (CAPHRI), Maastricht University Medical Center, P.O. Box 5800, 6202AZ, Maastricht, the Netherlands
| | - Jos M G A Schols
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200MD, Maastricht, the Netherlands; Department of Family Medicine, Care and Public Health Research Institute, P.O. Box 616, 6200MD, Maastricht University, Maastricht, the Netherlands
| | - Emiel F M Wouters
- Department of Research & Development, Ciro, P.O. Box 4009, 6080AA, Haelen, the Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), P.O. Box 5800, 6202AZ, Maastricht, the Netherlands; Ludwig Boltzmann Institute for Lung Health, Vienna, Austria
| | - Daisy J A Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health Medicine and Life Sciences, Maastricht University, P.O. Box 616, 6200MD, Maastricht, the Netherlands; Department of Research & Development, Ciro, P.O. Box 4009, 6080AA, Haelen, the Netherlands.
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Summary for Clinicians: Clinical Practice Guideline on Pharmacologic Management of Chronic Obstructive Pulmonary Disease. Ann Am Thorac Soc 2021; 18:11-16. [PMID: 32881603 DOI: 10.1513/annalsats.202007-880cme] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Verberkt CA, van den Beuken-van Everdingen MHJ, Schols JMGA, Hameleers N, Wouters EFM, Janssen DJA. Effect of Sustained-Release Morphine for Refractory Breathlessness in Chronic Obstructive Pulmonary Disease on Health Status: A Randomized Clinical Trial. JAMA Intern Med 2020; 180:1306-1314. [PMID: 32804188 PMCID: PMC7432282 DOI: 10.1001/jamainternmed.2020.3134] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
IMPORTANCE Morphine is used as palliative treatment of chronic breathlessness in patients with advanced chronic obstructive pulmonary disease (COPD). Evidence on respiratory adverse effects and health status is scarce and conflicting. OBJECTIVE To assess the effects of regular, low-dose, oral sustained-release morphine on disease-specific health status (COPD Assessment Test; CAT), respiratory outcomes, and breathlessness in patients with COPD. INTERVENTIONS Participants were randomly assigned to 10 mg of regular, oral sustained-release morphine or placebo twice daily for 4 weeks, with the possibility to increase to 3 times daily after 1 or 2 weeks. DESIGN, SETTING, AND PARTICIPANTS The Morphine for Treatment of Dyspnea in Patients With COPD (MORDYC) study was a randomized, double-blind, and placebo-controlled study of a 4-week intervention. Patients were enrolled between November 1, 2016, and January 24, 2019. Participants were recruited in a pulmonary rehabilitation center and 2 general hospitals after completion of a pulmonary rehabilitation program. Outpatients with COPD and moderate to very severe chronic breathlessness (modified Medical Research Council [mMRC] breathlessness grades 2-4) despite optimal pharmacological and nonpharmacological treatment were included. A total of 1380 patients were screened, 916 were ineligible, and 340 declined to participate. MAIN OUTCOMES AND MEASURES Primary outcomes were CAT score (higher scores represent worse health status) and arterial partial pressure of carbon dioxide (Paco2). Secondary outcome was breathlessness in the previous 24 hours (numeric rating scale). Data were analyzed by intention to treat. Subgroup analyses in participants with mMRC grades 3 to 4 were performed. RESULTS A total of 111 of 124 included participants were analyzed (mean [SD] age, 65.4 [8.0] years; 60 men [54%]). Difference in CAT score was 2.18 points lower in the morphine group (95% CI, -4.14 to -0.22 points; P = .03). Difference in Paco2 was 1.19 mm Hg higher in the morphine group (95% CI, -2.70 to 5.07 mm Hg; P = .55). Breathlessness remained unchanged. Worst breathlessness improved in participants with mMRC grades 3 to 4 (1.33 points lower in the morphine group; 95% CI, -2.50 to -0.16 points; P = .03). Five participants of 54 in the morphine group (9%) and 1 participant of 57 in the placebo group (2%) withdrew because of adverse effects. No morphine-related hospital admissions or deaths occurred. CONCLUSIONS AND RELEVANCE In this randomized clinical trial, regular, low-dose, oral sustained-release morphine for 4 weeks improved disease-specific health status in patients with COPD without affecting Paco2 or causing serious adverse effects. The worst breathlessness improved in participants with mMRC grades 3 to 4. A larger randomized clinical trial with longer follow-up in patients with mMRC grades 3 to 4 is warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02429050.
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Affiliation(s)
- Cornelia A Verberkt
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | | | - Jos M G A Schols
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Niels Hameleers
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands
| | - Emiel F M Wouters
- Department of Research & Development, CIRO, Horn, the Netherlands.,Department of Respiratory Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands.,Ludwig Boltzmann Institute for Lung Health, Vienna, Austria
| | - Daisy J A Janssen
- Department of Health Services Research, Care and Public Health Research Institute, Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, the Netherlands.,Department of Research & Development, CIRO, Horn, the Netherlands
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12
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Currow DC, Kochovska S, Ferreira D, Johnson M. Morphine for the symptomatic reduction of chronic breathlessness: the case for controlled release. Curr Opin Support Palliat Care 2020; 14:177-181. [PMID: 32740277 DOI: 10.1097/spc.0000000000000520] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Clinicians who seek to reduce the symptomatic burden of chronic breathlessness by initiating regular low-dose morphine has the choice of immediate or sustained-release formulations - which will be better for this often frail population, and which has the more robust evidence to inform its prescription? Both formulations can be used. RECENT FINDINGS For chronic breathlessness, three factors consistently favour the use of regular, low-dose, sustained-release morphine over immediate-release formulations: SUMMARY: As the evidence base expands for the symptomatic reduction of chronic breathlessness, pharmacological interventions will play a part. Using the best available evidence underpins patient-centred approaches that seek to predictably maximize the net effect.As such, the weight of evidence in patient-centred clinical care favours the use of regular, low-dose sustained-release morphine for the symptomatic reduction of chronic breathlessness.
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Affiliation(s)
- David C Currow
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
| | - Slavica Kochovska
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Diana Ferreira
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Discipline, Palliative and Supportive Services, Flinders University, South Australia, Australia
| | - Miriam Johnson
- IMPACCT, Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
- Wolfson Palliative Care Research Centre, University of Hull, Hull, United Kingdom
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13
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Nici L, Mammen MJ, Charbek E, Alexander PE, Au DH, Boyd CM, Criner GJ, Donaldson GC, Dreher M, Fan VS, Gershon AS, Han MK, Krishnan JA, Martinez FJ, Meek PM, Morgan M, Polkey MI, Puhan MA, Sadatsafavi M, Sin DD, Washko GR, Wedzicha JA, Aaron SD. Pharmacologic Management of Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med 2020; 201:e56-e69. [PMID: 32283960 PMCID: PMC7193862 DOI: 10.1164/rccm.202003-0625st] [Citation(s) in RCA: 191] [Impact Index Per Article: 47.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: This document provides clinical recommendations for the pharmacologic treatment of chronic obstructive pulmonary disease (COPD). It represents a collaborative effort on the part of a panel of expert COPD clinicians and researchers along with a team of methodologists under the guidance of the American Thoracic Society. Methods: Comprehensive evidence syntheses were performed on all relevant studies that addressed the clinical questions and critical patient-centered outcomes agreed upon by the panel of experts. The evidence was appraised, rated, and graded, and recommendations were formulated using the Grading of Recommendations, Assessment, Development, and Evaluation approach. Results: After weighing the quality of evidence and balancing the desirable and undesirable effects, the guideline panel made the following recommendations: 1) a strong recommendation for the use of long-acting β2-agonist (LABA)/long-acting muscarinic antagonist (LAMA) combination therapy over LABA or LAMA monotherapy in patients with COPD and dyspnea or exercise intolerance; 2) a conditional recommendation for the use of triple therapy with inhaled corticosteroids (ICS)/LABA/LAMA over dual therapy with LABA/LAMA in patients with COPD and dyspnea or exercise intolerance who have experienced one or more exacerbations in the past year; 3) a conditional recommendation for ICS withdrawal for patients with COPD receiving triple therapy (ICS/LABA/LAMA) if the patient has had no exacerbations in the past year; 4) no recommendation for or against ICS as an additive therapy to long-acting bronchodilators in patients with COPD and blood eosinophilia, except for those patients with a history of one or more exacerbations in the past year requiring antibiotics or oral steroids or hospitalization, for whom ICS is conditionally recommended as an additive therapy; 5) a conditional recommendation against the use of maintenance oral corticosteroids in patients with COPD and a history of severe and frequent exacerbations; and 6) a conditional recommendation for opioid-based therapy in patients with COPD who experience advanced refractory dyspnea despite otherwise optimal therapy. Conclusions: The task force made recommendations regarding the pharmacologic treatment of COPD based on currently available evidence. Additional research in populations that are underrepresented in clinical trials is needed, including studies in patients with COPD 80 years of age and older, those with multiple chronic health conditions, and those with a codiagnosis of COPD and asthma.
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14
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Kronborg-White S, Andersen CU, Kohberg C, Hilberg O, Bendstrup E. Palliation of chronic breathlessness with morphine in patients with fibrotic interstitial lung disease - a randomised placebo-controlled trial. Respir Res 2020; 21:195. [PMID: 32703194 PMCID: PMC7376842 DOI: 10.1186/s12931-020-01452-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 07/13/2020] [Indexed: 01/01/2023] Open
Abstract
Background Patients suffering from fibrotic interstitial lung diseases (fILD) have a poor prognosis and a high symptom burden. Palliative treatment includes relief of symptoms such as breathlessness. There is no evidence-based treatment for chronic breathlessness but opioids are often used despite concerns due to the hypothetical risk of respiratory depression. This study investigated the effect of oral morphine drops in patients with fILD on chronic breathlessness and safety. Methods In a double-blinded placebo-controlled study, 36 patients with fILD were randomised to either four daily doses of 5 mg of oral morphine drops or placebo for 1 week. Endpoints and safety parameters were obtained at baseline, at follow-up after 1 h and 1 week. Results The primary endpoint, the visual analogue score (VAS) of dyspnea was reduced by 1.1 ± 0.33 cm in the morphine group at follow-up compared to baseline (P < 0.01), whereas the reduction was 0.35 ± 0.47 cm in the placebo group. However, the difference between the two groups was not statistically significant (p = 0.2). Oral morphine drops did not affect respiratory frequency, pulse rate, blood pressure, peripheral saturation or the 6-min walk test. More patients treated with morphine reported constipation, nausea and confusion. Conclusion Oral administration of morphine drops, 20 mg a day, in patients with fILD did not significantly reduce dyspnea VAS score during 1 week compared to placebo. Oral morphine did not induce respiratory depression, but was related to an increased risk of constipation, nausea and confusion. Trial registration The trial is registered in clinicaltrials.gov (Identifier: NCT02622022). Registered 4 December 2015.
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Affiliation(s)
- Sissel Kronborg-White
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, 8200, Aarhus N, Denmark. .,Department of Internal Medicine, Viborg Regional Hospital, 8800, Viborg, Denmark.
| | | | - Charlotte Kohberg
- Department of Oncology, Odense University Hospital, Odense, 5000, Denmark
| | - Ole Hilberg
- Department of Internal Medicine, Lillebaelt Hospital, 7100, Vejle, Denmark
| | - Elisabeth Bendstrup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, 8200, Aarhus N, Denmark
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15
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Calverley PMA. Guidance for the Better Care of Patients with Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2020; 201:1022-1023. [PMID: 32283943 PMCID: PMC7193847 DOI: 10.1164/rccm.202002-0459ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Peter M A Calverley
- Institute of Ageing and Chronic DiseaseUniversity of LiverpoolLiverpool, United Kingdom
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16
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Matsuda Y, Morita T, Matsumoto H, Hosoi K, Kusama K, Kohashi Y, Morishita H, Kaku S, Ariyoshi K, Oyamada S, Inoue Y, Iwase S, Yamaguchi T, Nishikawa M. Morphine for dyspnoea in chronic obstructive pulmonary disease: a before-after efficacy study. BMJ Support Palliat Care 2019; 11:427-432. [PMID: 31732660 DOI: 10.1136/bmjspcare-2019-001929] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 08/07/2019] [Accepted: 11/04/2019] [Indexed: 11/03/2022]
Abstract
OBJECTIVES Dyspnoea in patients with chronic obstructive pulmonary disease (COPD) is frequent and often persists despite conventional treatment. This study aimed to evaluate the efficacy and safety of oral morphine for dyspnoea in Japanese COPD patients. METHODS We conducted a multi-institutional, prospective, before-after study of morphine in COPD patients with dyspnoea at rest in seven hospitals. Patients received 12 mg of oral morphine per day (or 8 mg per day if low body weight or renal impairment). Primary outcome was change in the numerical rating scale (NRS) of current dyspnoea in the evening from Day 0 to Day 2. Secondary outcomes included changes in dyspnoea intensity in the evening from Day 0 to Day 1, dyspnoea intensity between the morning from Day 0 to Day 1 and Day 2, vital signs, nausea, somnolence, anorexia and other adverse events (AEs). RESULTS A total of 35 patients were enrolled in this study between October 2014 and January 2018. One patient did not receive study treatment. Data from 34 patients was analysed. The NRS of dyspnoea intensity in the evening significantly decreased from 3.9 on Day 0 (95% CI: 3.1 to 4.8) to 2.4 on Day 2 (95% CI: 1.7 to 3.1; p=0.0002). Secondary outcomes significantly improved in a similar manner. There were no apparent changes in the mean scores of the opioid-related AEs and vital signs. One patient experienced grade 3 lung infection not associated with morphine. Other AEs were mild. CONCLUSION Oral morphine is effective in alleviating dyspnoea in Japanese COPD patients.Trial registrationUMIN000015288 (http://www.umin.ac.jp/ctr/index.htm).
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Affiliation(s)
- Yoshinobu Matsuda
- Department of Psychosomatic Internal Medicine, Kinki Chuo Chest Medical Center, Sakai, Japan
| | - Tatsuya Morita
- Department of Palliative and Supportive Care, Seirei Mikatahara General Hospital, Hamamatsu City, Shizuoka, Japan
| | - Hirotaka Matsumoto
- Department of Respiratory Medicine, Hyogo Prefectural Amagasaki General Medical Center, Amagasaki, Japan
| | - Keita Hosoi
- Department of Respiratory Medicine, Itami City Hospital, Itami, Japan
| | - Kayo Kusama
- Department of Respiratory Medicine, Sakai City Medical Center, Sakai, Japan
| | - Yasuo Kohashi
- Department of Respiratory Medicine, HARUHI Respiratory Medical Hospital, Kiyosu, Japan
| | - Hiroshi Morishita
- Department of Respiratory Medicine, Osaka Habikino Medical Center, Habikino, Japan
| | - Sawako Kaku
- Palliative and Supportive Care Division, Seirei Mikatahara General Hospital, Hamamatsu, Amagasaki, Japan
| | | | | | - Yoshikazu Inoue
- Clinical Research Center National Hospital Organization Kinki-Chuo Chest Medical Center, Sakai, Japan
| | - Satoru Iwase
- Department of Palliative Medicine, Saitama Medical University, Moroyama, Japan
| | - Takuhiro Yamaguchi
- Division of Biostatistics, Tohoku University Graduate School of Medicine, Sendai, Miyagi, Japan
| | - Mitsunori Nishikawa
- Department of Palliative Care, National Center for Geriatrics and Gerontology, Obu, Japan
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17
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Gainza-Miranda D, Sanz-Peces EM, Alonso-Babarro A, Varela-Cerdeira M, Prados-Sánchez C, Vega-Aleman G, Rodriguez-Barrientos R, Polentinos-Castro E. Breaking Barriers: Prospective Study of a Cohort of Advanced Chronic Obstructive Pulmonary Disease Patients To Describe Their Survival and End-of-Life Palliative Care Requirements. J Palliat Med 2019; 22:290-296. [PMID: 30388050 PMCID: PMC6391614 DOI: 10.1089/jpm.2018.0363] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND AIM Consensus has been reached on the need to integrate palliative care in the follow-up examinations of chronic obstructive pulmonary disease (COPD) patients. We analyzed the survival from the initiation of follow-up by a palliative home care team (PHCT) and described the needs and end-of-life process. SETTING AND DESIGN This study was a prospective observational cohort study of advanced COPD patients referred to a PHCT. Sociodemographic variables, survival from the start date of follow-up using the Kaplan-Meier model, health resource consumption, perceived quality of life, main symptomatology, opioid use, and advanced care planning (ACP) were analyzed. RESULTS Sixty patients were included. The median survival was 8.3 months. Forty-two patients died at the end of the study (85% at home or in palliative care units). The most frequent cause of death was respiratory failure in 39 patients (93%), with 29 of these patients requiring sedation (69%). Dyspnea at rest, with an average of 5 (standard deviation [SD] 2) points, was the main symptom. Fifty-five patients (91%) required opioids for symptom control. The median score in the St. George's Respiratory Questionnaire was 72 (SD 13). The mean number of visits by the home team was 7 (SD 6.5). The mean number of admissions during the monitoring period was 1.5 (SD 0.15). CONCLUSIONS The characteristics of the cohort appear suitable for a PHCT. The follow-up care provided by our multidisciplinary unit decreased the number of hospitalizations, favored the development of ACP, and enabled death at home or in palliative care units.
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Affiliation(s)
- Daniel Gainza-Miranda
- Palliative Homecare Team Northern Area of Madrid, SERMAS, San Sebastian de los Reyes, Spain
| | - Eva Maria Sanz-Peces
- Palliative Homecare Team Northern Area of Madrid, SERMAS, San Sebastian de los Reyes, Spain
| | | | | | | | | | | | - Elena Polentinos-Castro
- Investigation Support Multidisciplinary Unit for Primary Care and Community North Area of Madrid, Madrid, Spain.
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18
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Verberkt CA, van den Beuken-van Everdingen MHJ, Schols JMGA, Datla S, Dirksen CD, Johnson MJ, van Kuijk SMJ, Wouters EFM, Janssen DJA. Respiratory adverse effects of opioids for breathlessness: a systematic review and meta-analysis. Eur Respir J 2017; 50:50/5/1701153. [PMID: 29167300 DOI: 10.1183/13993003.01153-2017] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 08/18/2017] [Indexed: 01/19/2023]
Abstract
Previous studies have shown that opioids can reduce chronic breathlessness in advanced disease. However, physicians remain reluctant to prescribe opioids for these patients, commonly due to fear of respiratory adverse effects. The aim of this study was to systematically review reported respiratory adverse effects of opioids in patients with advanced disease and chronic breathlessness.PubMed, Embase, the Cochrane Central Register of Controlled Trials, CINAHL, ClinicalTrials.gov and the reference lists of relevant systematic reviews were searched. Two independent researchers screened against predefined inclusion criteria and extracted data. Meta-analysis was conducted where possible.We included 63 out of 1990 articles, describing 67 studies. Meta-analysis showed an increase in carbon dioxide tension (0.27 kPa, 95% CI 0.08-0.45 kPa,) and no significant change in oxygen tension and oxygen saturation (both p>0.05). Nonserious respiratory depression (definition variable/not stated) was described in four out of 1064 patients. One cancer patient pretreated with morphine for pain needed temporary respiratory support following nebulised morphine for breathlessness (single case study).We found no evidence of significant or clinically relevant respiratory adverse effects of opioids for chronic breathlessness. Heterogeneity of design and study population, and low study quality are limitations. Larger studies designed to detect respiratory adverse effects are needed.
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Affiliation(s)
- Cindy A Verberkt
- Dept of Health Services Research, Maastricht University, Maastricht, The Netherlands
| | | | - Jos M G A Schols
- Dept of Health Services Research, Maastricht University, Maastricht, The Netherlands.,Dept of Family Medicine, Maastricht University, Maastricht, The Netherlands
| | - Sushma Datla
- Hull York Medical School, University of Hull, Hull, UK
| | - Carmen D Dirksen
- Dept of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | | | - Sander M J van Kuijk
- Dept of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Emiel F M Wouters
- CIRO, Centre of expertise for chronic organ failure, Horn, The Netherlands.,Dept of Respiratory Medicine, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
| | - Daisy J A Janssen
- Centre of Expertise for Palliative Care, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands.,CIRO, Centre of expertise for chronic organ failure, Horn, The Netherlands
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19
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Smallwood N, Le B, Currow D, Irving L, Philip J. Management of refractory breathlessness with morphine in patients with chronic obstructive pulmonary disease. Intern Med J 2016; 45:898-904. [PMID: 26332621 DOI: 10.1111/imj.12857] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 06/15/2015] [Indexed: 11/30/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a progressive, incurable illness, which leads to significant morbidity over long periods of time and mortality. Treatment aims to reduce symptoms, improve exercise capacity and quality of life, reduce exacerbations, slow disease progression and reduce mortality. However, breathlessness is common in patients with advanced COPD and remains undertreated. As all reversible causes of breathlessness are being optimally managed, consideration should be given to specific non-pharmacological and pharmacological treatment strategies for breathlessness. Low dose morphine has been shown to reduce safely and effectively breathlessness in patients with severe COPD and refractory dyspnoea. However, despite numerous guidelines recommending opioids in this clinical setting, many barriers limit their uptake by clinicians. Integration of palliative care earlier in the disease course can help to improve symptom control for people with severe COPD and refractory breathlessness. A multidisciplinary approach involving both respiratory and palliative care teams offers a new model of care for these patients.
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Affiliation(s)
- N Smallwood
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - B Le
- Department of Palliative Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - D Currow
- Palliative and Supportive Services, Division of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - L Irving
- Department of Respiratory and Sleep Medicine, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - J Philip
- Centre for Palliative Care, St Vincent's Hospital, Melbourne, Victoria, Australia
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20
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Barnes H, McDonald J, Smallwood N, Manser R. Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness. Cochrane Database Syst Rev 2016; 3:CD011008. [PMID: 27030166 PMCID: PMC6485401 DOI: 10.1002/14651858.cd011008.pub2] [Citation(s) in RCA: 73] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Breathlessness is a common and disabling symptom which affects many people with advanced cardiorespiratory disease and cancer. The most effective treatments are aimed at treating the underlying disease. However, this may not always be possible, and symptomatic treatment is often required in addition to maximal disease-directed therapy. Opioids are increasingly being used to treat breathlessness, although their mechanism of action is still not completely known. A few good sized, high quality trials have been conducted in this area. OBJECTIVES To determine the effectiveness of opioid drugs in relieving the symptom of breathlessness in people with advanced disease due to malignancy, respiratory or cardiovascular disease, or receiving palliative care for any other disease. SEARCH METHODS We performed searches on CENTRAL, MEDLINE, EMBASE, CINAHL, and Web of Science up to 19 October 2015. We handsearched review articles, clinical trial registries, and reference lists of retrieved articles. SELECTION CRITERIA We included randomised double-blind controlled trials that compared the use of any opioid drug against placebo or any other intervention for the relief of breathlessness. The intervention was any opioid, given by any route, in any dose. DATA COLLECTION AND ANALYSIS We imported studies identified by the search into a reference manager database. We retrieved the full-text version of relevant studies, and two review authors independently extracted data. The primary outcome measure was breathlessness and secondary outcome measures included exercise tolerance, oxygen saturations, adverse events, and mortality. We analysed all studies together and also performed subgroup analyses, by route of administration, type of opioid administered, and cause of breathlessness. Where appropriate, we performed meta-analysis. We assessed the evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach and created three 'Summary of findings' tables. MAIN RESULTS We included 26 studies with 526 participants. We assessed the studies as being at high or unclear risk of bias overall. We only included randomised controlled trials (RCTs), although the description of randomisation was incomplete in some included studies. We aimed to include double blind RCTs, but two studies were only single blinded. There was inconsistency in the reporting of outcome measures. We analysed the data using a fixed-effect model, and for some outcomes heterogeneity was high. There was a risk of imprecise results due to the low numbers of participants in the included studies. For these reasons we downgraded the quality of the evidence from high to either low or very low.For the primary outcome of breathlessness, the mean change from baseline dyspnoea score was 0.09 points better in the opioids group compared to the placebo group (ranging from a 0.36 point reduction to a 0.19 point increase) (seven RCTs, 117 participants, very low quality evidence). A lower score indicates an improvement in breathlessness. The mean post-treatment dyspnoea score was 0.28 points better in the opioid group compared to the placebo group (ranging from a 0.5 point reduction to a 0.05 point increase) (11 RCTs, 159 participants, low quality evidence).The evidence for the six-minute walk test (6MWT) was conflicting. The total distance in 6MWT was 28 metres (m) better in the opioids group compared to placebo (ranging from 113 m to 58 m) (one RCT, 11 participants, very low quality evidence). However, the change in baseline was 48 m worse in the opioids group (ranging from 36 m to 60 m) (two RCTs, 26 participants, very low quality evidence).The adverse effects reported included drowsiness, nausea and vomiting, and constipation. In those studies, participants were 4.73 times more likely to experience nausea and vomiting compared to placebo, three times more likely to experience constipation, and 2.86 times more likely to experience drowsiness (nine studies, 162 participants, very low quality evidence).Only four studies assessed quality of life, and none demonstrated any significant change. AUTHORS' CONCLUSIONS There is some low quality evidence that shows benefit for the use of oral or parenteral opioids to palliate breathlessness, although the number of included participants was small. We found no evidence to support the use of nebulised opioids. Further research with larger numbers of participants, using standardised protocols and with quality of life measures included, is needed.
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Affiliation(s)
- Hayley Barnes
- Alfred HealthDepartment of Allergy, Immunology and Respiratory MedicineMelbourneAustralia
| | - Julie McDonald
- Princess Margaret Cancer Centre, University Health NetworkDepartment of Supportive CareTorontoOntarioCanada
- Department of Medicine, University of TorontoDivision of Medical OncologyTorontoOntarioCanada
| | - Natasha Smallwood
- Royal Melbourne HospitalDepartment of Respiratory MedicineMelbourneAustralia
| | - Renée Manser
- and Department of Respiratory Medicine, Royal Melbourne HospitalDepartment of Haematology and Medical Oncology, Peter MacCallum Cancer Institute, St Andrew's Place, East Melbourne 3002, Victoria305 Grattan StreetMelbourneAustralia3000
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21
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Kohberg C, Andersen CU, Bendstrup E. Opioids: an unexplored option for treatment of dyspnea in IPF. Eur Clin Respir J 2016; 3:30629. [PMID: 26969472 PMCID: PMC4788766 DOI: 10.3402/ecrj.v3.30629] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/19/2016] [Accepted: 01/25/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Idiopathic pulmonary fibrosis (IPF) is the most common among the idiopathic interstitial pneumonias and has the worst prognosis, with a median survival of 3-5 years. The most common symptom in IPF is dyspnea, impacting on the patient's quality of life and life expectancy. Morphine in the treatment of dyspnea has been investigated but with conflicting results. This review aims to clarify the role of opioids in the treatment of dyspnea in patients with IPF. METHODS A literature search was performed using the MeSH and PubMed databases. As only very few studies included patients with IPF, studies conducted primarily with patients with chronic obstructive pulmonary disease were also included. In total, 14 articles were found. RESULTS Seven studies reported use of systemic morphine and seven studies of inhaled morphine. Five of the seven studies investigating systemic administration detected an improvement in either dyspnea or exercise capacity, whereas no beneficial effect on dyspnea was detected in any study using inhaled morphine. No severe adverse effects such as respiratory depression were reported in any study, although constipation was reported as a notable adverse effect. CONCLUSIONS Results were inconsistent, but in some studies systemic morphine administration showed a significant improvement in the dyspnea score on a visual analog scale without observation of severe side effects. Nebulized morphine had no effect on dyspnea.
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Affiliation(s)
- Charlotte Kohberg
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
| | | | - Elisabeth Bendstrup
- Department of Respiratory Diseases and Allergy, Aarhus University Hospital, Aarhus, Denmark
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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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Effects of Opioids on Breathlessness and Exercise Capacity in Chronic Obstructive Pulmonary Disease. A Systematic Review. Ann Am Thorac Soc 2015; 12:1079-92. [DOI: 10.1513/annalsats.201501-034oc] [Citation(s) in RCA: 140] [Impact Index Per Article: 15.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Janssen DJA, de Hosson SM, bij de Vaate E, Mooren KJM, Baas AAF. Attitudes toward opioids for refractory dyspnea in COPD among Dutch chest physicians. Chron Respir Dis 2015; 12:85-92. [PMID: 25676931 DOI: 10.1177/1479972315571926] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Dyspnea is the most frequently reported symptom of outpatients with advanced chronic obstructive pulmonary disease (COPD). Opioids are an effective treatment for dyspnea. Nevertheless, the prescription of opioids to patients with advanced COPD seems limited. The aims of this study are to explore the attitudes of Dutch chest physicians toward prescription of opioids for refractory dyspnea to outpatients with advanced COPD and to investigate the barriers experienced by chest physicians toward opioid prescription in these patients. All chest physicians (n = 492) and residents in respiratory medicine (n = 158) in the Netherlands were invited by e-mail to complete an online survey. A total of 146 physicians (response rate 22.5%) completed the online survey. Fifty percent of the physicians reported to prescribe opioids for refractory dyspnea in 20% or less of their outpatients with advanced COPD and 18.5% reported never to prescribe opioids in these patients. The most frequently reported barriers toward prescription of opioids were resistance of the patient, fear of possible adverse effects, and fear of respiratory depression. To conclude, Dutch chest physicians and residents in respiratory medicine rarely prescribe opioids for refractory dyspnea to outpatients with advanced COPD. This reluctance is caused by perceived resistance of the patient and fear of adverse effects, including respiratory adverse effects.
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Affiliation(s)
- Daisy J A Janssen
- Department of Research and Education, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands Centre of Expertise for Palliative Care, Maastricht University Medical Centre (MUMC+), Maastricht, The Netherlands
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Abstract
The aim of this paper is to review the evidence for a role for opioids as an intervention for exertion induced breathlessness with regard to exercise tolerance and breathlessness intensity. Current knowledge about exogenous opioids in exertion-induced breathlessness due to disease comes from a variety of phase 2 feasibility or pilot designs with differing duration, doses, drugs, exercise regimes, underlying aetiologies, and outcome measures. They provide interesting data but firm conclusions for either breathlessness severity or exercise endurance cannot be drawn. There are no adequately powered phase 3 trials of opioids which show improved exercise tolerance and/or exertion induced breathlessness. Low dose oral morphine seems well tolerated by most, and is beneficial for breathlessness intensity. Current work to investigate the effect on exercise tolerance is ongoing.
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Affiliation(s)
- Miriam J. Johnson
- Hull York Medical School, The University of Hull, Hull, United Kingdom
| | - David Hui
- Department of Palliative Care & Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David C. Currow
- Discipline, Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia
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Rocker GM, Simpson AC, Horton R, Sinuff T, Demmons J, Hernandez P, Marciniuk D. Opioid therapy for refractory dyspnea in patients with advanced chronic obstructive pulmonary disease: patients' experiences and outcomes. CMAJ Open 2013; 1:E27-36. [PMID: 25077099 PMCID: PMC3985973 DOI: 10.9778/cmajo.20120031] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Dyspnea that is refractory to conventional treatments affects up to 50% of patients with advanced chronic obstructive pulmonary disease (COPD). Although professional societies recommend opioids in this setting, evidence supporting their use over months is limited. We conducted a multicentre mixed-methods study to understand patients' experiences when opioids are added to optimized conventional treatments for advanced COPD. METHODS A total of 44 patients (median age 74, range 51-89 years) agreed to participate in this 6-month study. After baseline assessments, immediate-release morphine sulfate syrup (initially 0.5 mg twice daily) was slowly titrated upward based on weekly assessments of symptoms. We conducted semistructured interviews and collected contemporaneous measures of health-related quality of life, severity of dyspnea, anxiety, depression, global ratings of opioid "helpfulness" and adverse effects before, at 2 months and at 4-6 months after opioids were started. RESULTS Of the 44 patients, 32 (73%) completed the trial; 27 (90%) of 30 patients reported the opioid treatment as very (43%) or somewhat (47%) helpful. Three main themes emerged from the patients' overall positive experiences: small gains have big impact; realign hopes with reality; and "try it." Significant improvements were observed in median (interquartile range) scores between baseline and 4-6 months' assessment for health-related quality of life (Chronic Respiratory Questionnaire: 3.5 [2.8-4.0] v. 4.2 [3.6-4.8]; and Chronic Respiratory Questionnaire-Dyspnea domain: 2.8 [2.3-3.6] v. 3.9 [2.8-4.5]) and decreases in severity of dyspnea (numerical rating scale: 7.0 [5.0-8.0] v. 5.0 [4.0-6.0]). Adverse effects were minimal for most patients. INTERPRETATION Opioids were a helpful and acceptable intervention for refractory dyspnea in patients with advanced COPD. Many of the patients experienced sustained benefits over months, which supports recent recommendations to consider opioids in this setting. TRIAL REGISTRATION ClinicalTrial.gov, no. NCT00982891.
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Affiliation(s)
- Graeme M Rocker
- Division of Respirology, QEII Health Sciences Centre, Halifax, NS ; Division of Palliative Medicine, QEII Health Sciences Centre, Halifax, NS ; Faculty of Medicine, Dalhousie University, Halifax, NS
| | | | - Robert Horton
- Division of Palliative Medicine, QEII Health Sciences Centre, Halifax, NS ; Faculty of Medicine, Dalhousie University, Halifax, NS
| | - Tasnim Sinuff
- Department of Critical Care and Division of Respirology, Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont
| | - Jillian Demmons
- Division of Respirology, QEII Health Sciences Centre, Halifax, NS
| | - Paul Hernandez
- Division of Respirology, QEII Health Sciences Centre, Halifax, NS ; Faculty of Medicine, Dalhousie University, Halifax, NS
| | - Darcy Marciniuk
- Division of Respirology, Critical Care and Sleep Medicine, Department of Medicine, University of Saskatchewan, Saskatoon, Sask
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Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline. Can Respir J 2012; 18:69-78. [PMID: 21499589 DOI: 10.1155/2011/745047] [Citation(s) in RCA: 176] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Dyspnea is a cardinal symptom of chronic obstructive pulmonary disease (COPD), and its severity and magnitude increases as the disease progresses, leading to significant disability and a negative effect on quality of life. Refractory dyspnea is a common and difficult symptom to treat in patients with advanced COPD. There are many questions concerning optimal management and, specifically, whether various therapies are effective in this setting. The present document was compiled to address these important clinical issues using an evidence-based systematic review process led by a representative interprofessional panel of experts. The evidence supports the benefits of oral opioids, neuromuscular electrical stimulation, chest wall vibration, walking aids and pursed-lip breathing in the management of dyspnea in the individual patient with advanced COPD. Oxygen is recommended for COPD patients with resting hypoxemia, but its use for the targeted management of dyspnea in this setting should be reserved for patients who receive symptomatic benefit. There is insufficient evidence to support the routine use of anxiolytic medications, nebulized opioids, acupuncture, acupressure, distractive auditory stimuli (music), relaxation, handheld fans, counselling programs or psychotherapy. There is also no evidence to support the use of supplemental oxygen to reduce dyspnea in nonhypoxemic patients with advanced COPD. Recognizing the current unfamiliarity with prescribing and dosing of opioid therapy in this setting, a potential approach for their use is illustrated. The role of opioid and other effective therapies in the comprehensive management of refractory dyspnea in patients with advanced COPD is discussed.
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Jennings AL, Davies AN, Higgins JPT, Anzures-Cabrera J, Broadley KE. WITHDRAWN: Opioids for the palliation of breathlessness in advanced disease and terminal illness. Cochrane Database Syst Rev 2012; 2012:CD002066. [PMID: 22786477 PMCID: PMC10734251 DOI: 10.1002/14651858.cd002066.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Breathlessness is a common symptom in people with advanced disease. The most effective treatments are aimed at treating the underlying cause of the breathlessness but this may not be possible and symptomatic treatment is often necessary. Strategies for the symptomatic treatment of breathlessness have never been systematically evaluated. Opioids are commonly used to treat breathlessness: the mechanisms underlying their effectiveness are not completely clear and there have been few good-sized trials in this area. OBJECTIVES To determine the effectiveness of opioid drugs given by any route in relieving the symptom of breathlessness in patients who are being treated palliatively. SEARCH METHODS An electronic search was carried out of Medline, Embase, CINAHL, T he Cochrane L ibrary, Dissertation Abstracts, Cancercd and SIGLE. Review articles and reference lists of retrieved articles were hand searched. Date of most recent search: May 1999. SELECTION CRITERIA Randomised double-blind, controlled trials comparing the use of any opioid drug against placebo for the relief of breathlessness were included. Patients with any illness suffering from breathlessness were included and the intervention was any opioid, given by any route, in any dose. DATA COLLECTION AND ANALYSIS Studies identified by the search were imported into a reference manager database. The full texts of the relevant studies were retrieved and data were independently extracted by two review authors. Studies were quality scored according to the Oxford Quality scale. The primary outcome measure used was breathlessness and the secondary outcome measure was exercise tolerance. Studies were divided into non-nebulised and nebulised and were analysed both separately and together. A qualitative analysis was carried out of adverse effects of opioids. Where appropriate, meta-analysis was carried out. MAIN RESULTS Eighteen studies were identified of which nine involved the non-nebulised route of administration and nine the nebulised route. A small but statistically significant positive effect of opioids was seen on breathlessness in the analysis of studies using non-nebulised opioids. There was no statistically significant positive effect seen for exercise tolerance in either group of studies or for breathlessness in the studies using nebulised opioids. AUTHORS' CONCLUSIONS There is evidence to support the use of oral or parenteral opioids to palliate breathlessness although numbers of patients involved in the studies were small. No evidence was found to support the use of nebulised opioids. Further research with larger numbers of patients, using standardised protocols and with quality of life measures is needed.
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Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O'Donnell DE. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012; 185:435-52. [PMID: 22336677 PMCID: PMC5448624 DOI: 10.1164/rccm.201111-2042st] [Citation(s) in RCA: 1109] [Impact Index Per Article: 92.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.
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Parshall MB, Schwartzstein RM, Adams L, Banzett RB, Manning HL, Bourbeau J, Calverley PM, Gift AG, Harver A, Lareau SC, Mahler DA, Meek PM, O'Donnell DE. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med 2012. [PMID: 22336677 DOI: 10.1164/rccm.201111–2042st] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome. PURPOSE The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea. METHODS An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members. RESULTS Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consistently shown dyspnea stimuli to be correlated with activation of cortico-limbic areas involved with interoception and nociception. Endogenous and exogenous opioids may modulate perception of dyspnea. Instruments for measuring dyspnea are often poorly characterized; a framework is proposed for more consistent identification of measurement domains. CONCLUSIONS Progress in treatment of dyspnea has not matched progress in elucidating underlying mechanisms. There is a critical need for interdisciplinary translational research to connect dyspnea mechanisms with clinical treatment and to validate dyspnea measures as patient-reported outcomes for clinical trials.
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Scientific Opinion on the risks for public health related to the presence of opium alkaloids in poppy seeds. EFSA J 2011. [DOI: 10.2903/j.efsa.2011.2405] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Banzett RB, Adams L, O'Donnell CR, Gilman SA, Lansing RW, Schwartzstein RM. Using laboratory models to test treatment: morphine reduces dyspnea and hypercapnic ventilatory response. Am J Respir Crit Care Med 2011; 184:920-7. [PMID: 21778294 PMCID: PMC3208656 DOI: 10.1164/rccm.201101-0005oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2011] [Accepted: 07/06/2011] [Indexed: 01/22/2023] Open
Abstract
RATIONALE Opioids are commonly used to relieve dyspnea, but clinical data are mixed and practice varies widely. OBJECTIVES Evaluate the effect of morphine on dyspnea and ventilatory drive under well-controlled laboratory conditions. METHODS Six healthy volunteers received morphine (0.07 mg/kg) and placebo intravenously on separate days (randomized, blinded). We measured two responses to a CO(2) stimulus: (1) perceptual response (breathing discomfort; described by subjects as "air hunger") induced by increasing partial pressure of end-tidal carbon dioxide (Pet(CO2)) during restricted ventilation, measured with a visual analog scale (range, "neutral" to "intolerable"); and (2) ventilatory response, measured in separate trials during unrestricted breathing. MEASUREMENTS AND MAIN RESULTS We determined the Pet(CO2) that produced a 60% breathing discomfort rating in each subject before morphine (median, 8.5 mm Hg above resting Pet(CO2)). At the same Pet(CO2) after morphine administration, median breathing discomfort was reduced by 65% of its pretreatment value; P < 0.001. Ventilation fell 28% at the same Pet(CO2); P < 0.01. The effect of morphine on breathing discomfort was not significantly correlated with the effect on ventilatory response. Placebo had no effect. CONCLUSIONS (1) A moderate morphine dose produced substantial relief of laboratory dyspnea, with a smaller reduction of ventilation. (2) In contrast to an earlier laboratory model of breathing effort, this laboratory model of air hunger established a highly significant treatment effect consistent in magnitude with clinical studies of opioids. Laboratory studies require fewer subjects and enable physiological measurements that are difficult to make in a clinical setting. Within-subject comparison of the response to carefully controlled laboratory stimuli can be an efficient means to optimize treatments before clinical trials.
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Affiliation(s)
- Robert B Banzett
- Division of Pulmonary and Critical Care, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, USA.
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Currow DC, McDonald C, Oaten S, Kenny B, Allcroft P, Frith P, Briffa M, Johnson MJ, Abernethy AP. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study. J Pain Symptom Manage 2011; 42:388-99. [PMID: 21458217 DOI: 10.1016/j.jpainsymman.2010.11.021] [Citation(s) in RCA: 192] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 11/24/2010] [Accepted: 12/03/2010] [Indexed: 10/18/2022]
Abstract
CONTEXT Randomized controlled trials can answer questions of efficacy, but long-term pharmacovigilance studies generate complementary safety data. OBJECTIVES Level I evidence supports short-term efficacy of opioids in reducing chronic refractory dyspnea. This study aimed to determine the minimum effective once-daily dose of sustained-release morphine, and whether net clinical benefits are sustained safely. METHODS In a Phase II dose increment study, 10mg daily of sustained-release morphine was administered, and increased in nonresponders by 10mg daily each week to a maximum of 30 mg daily. The participant was withdrawn if there were unacceptable side effects or no response to maximum dose. If participants had a 10% improvement in dyspnea over their own baseline, they joined a long-term Phase IV effectiveness/safety study at that dose. Complying with Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines, response and side effects are described, with demographic and clinical characteristics of responders. RESULTS Eighty-three participants (53 males, mean age 75 years, 54% with chronic obstructive pulmonary disease) provided more than 30 patient-years of data. Fifty-two participants derived ≥ 10% benefit (on average 35% improvement over baseline), giving a response rate of 62% (number needed to treat of 1.6: number needed to harm 4.6); for 70%, this dose was 10mg/24h. Benefit was maintained at three months for 28 (33%) people. Ranking of breathlessness was reduced significantly (P<0.001), but constipation increased (P<0.001) despite laxatives. There were no episodes of respiratory depression or hospitalizations as a result of the sustained-release morphine. Overall, one in three people continued to derive benefit at three months. CONCLUSION Ten milligrams of sustained-release oral morphine once daily is safe and effective for most people who respond.
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Affiliation(s)
- David C Currow
- Discipline, Palliative and Supportive Services, Flinders University, Bedford Park, SA, Australia.
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Janssen DJ, Spruit MA, Uszko-Lencer NH, Schols JM, Wouters EF. Symptoms, Comorbidities, and Health Care in Advanced Chronic Obstructive Pulmonary Disease or Chronic Heart Failure. J Palliat Med 2011; 14:735-43. [DOI: 10.1089/jpm.2010.0479] [Citation(s) in RCA: 146] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Daisy J.A. Janssen
- Program Development Centre, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
- CAPHRI, Nursing Home Medicine, Faculty of Health Medicine and Life Sciences/CAPHRI Maastricht University, Maastricht, The Netherlands
- Proteion Thuis, Horn, The Netherlands
| | - Martijn A. Spruit
- Program Development Centre, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
| | - Nicole H. Uszko-Lencer
- Program Development Centre, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
- Department of Cardiology, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - Jos M.G.A. Schols
- Department of General Practice, Nursing Home Medicine, Faculty of Health Medicine and Life Sciences/CAPHRI Maastricht University, Maastricht, The Netherlands
| | - Emiel F.M. Wouters
- Program Development Centre, CIRO+, Centre of Expertise for Chronic Organ Failure, Horn, The Netherlands
- Department of Respiratory Medicine, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
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Pulmonary Palliative Medicine. Palliat Care 2011. [DOI: 10.1016/b978-1-4377-1619-1.00033-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Abstract
PURPOSE OF REVIEW Pulmonary hypertension leads to progressive increase in pulmonary vascular resistance, heart failure, and death. Pulmonary arterial hypertension (PAH) is a subset of pulmonary hypertension affecting small pulmonary arteries and not associated with underlying heart or lung disease. Dyspnea and exercise intolerance are hallmarks of PAH and are used to monitor disease progression. This review focuses on recent advances in the pathophysiology and treatment of dyspnea in PAH. RECENT FINDINGS The etiological classification of pulmonary hypertension and World Health Organization functional class clinical classification, as used to guide management, have recently been revised. Dyspnea and PAH disease progression are best assessed by cardiopulmonary exercise testing and the six-minute walk test. Understanding of the molecular pathogenesis of PAH has led to new classes of treatments, including prostacyclin analogues, endothelin receptor antagonists, and phosphodiesterase-5 inhibitors. Prostanoids have the longest track record in treatment of PAH but a short half-life and cumbersome delivery systems limit their utility. More convenient endothelin receptor antagonists are becoming mainstream in PAH management. Phosphodiesterase-5 inhibitors improve exercise capacity and quality of life, although long-term outcome data are pending. Combination therapy with different medication classes appears promising for progressive disease. SUMMARY Establishing the cause and clinical severity of pulmonary hypertension is critical for management. The pathophysiology of dyspnea in PAH is complex and related to pulmonary vascular resistance. Although disease-specific treatments are now available, a cure for PAH remains elusive and trials of combination treatments to improve symptoms and outcomes are ongoing.
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Contemporary issues in refractory dyspnoea in advanced chronic obstructive pulmonary disease. Curr Opin Support Palliat Care 2010; 4:56-62. [DOI: 10.1097/spc.0b013e328338c1c6] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Mahler DA, Selecky PA, Harrod CG, Benditt JO, Carrieri-Kohlman V, Curtis JR, Manning HL, Mularski RA, Varkey B, Campbell M, Carter ER, Chiong JR, Ely EW, Hansen-Flaschen J, O'Donnell DE, Waller A. American College of Chest Physicians Consensus Statement on the Management of Dyspnea in Patients With Advanced Lung or Heart Disease. Chest 2010; 137:674-91. [DOI: 10.1378/chest.09-1543] [Citation(s) in RCA: 199] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Gallagher R, Roberts D. A Systematic Review of Oxygen and Airflow Effect on Relief of Dyspnea at Rest in Patients with Advanced Disease of Any Cause. J Pain Palliat Care Pharmacother 2009. [DOI: 10.1080/j354v18n04_02] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Cachia E, Ahmedzai SH. Breathlessness in cancer patients. Eur J Cancer 2008; 44:1116-23. [PMID: 18424030 DOI: 10.1016/j.ejca.2008.03.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2008] [Accepted: 03/11/2008] [Indexed: 12/01/2022]
Abstract
Breathlessness (or dyspnoea) is a common symptom experienced by cancer patients. It may be iatrogenic and is often caused or aggravated by co-morbidity. Recent studies have elucidated the neural and chemical controls of breathing which may be involved in the production of dyspnoea. A rational approach involves making a diagnosis of aetiology and treating reversible causes wherever possible. The main approaches for palliation of dyspnoea include anti-cancer treatments; drugs; oxygen and airflow; non-medical approaches. Further research is needed to clarify the best pharmacological regimens and the place of more invasive interventions.
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Affiliation(s)
- Elaine Cachia
- Palliative Medicine, Sheffield Teaching Hospitals Foundation NHS Trust
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The management of dyspnea in cancer patients: a systematic review. Support Care Cancer 2008; 16:329-37. [DOI: 10.1007/s00520-007-0389-6] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2007] [Accepted: 12/05/2007] [Indexed: 10/22/2022]
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Rabe KF, Hurd S, Anzueto A, Barnes PJ, Buist SA, Calverley P, Fukuchi Y, Jenkins C, Rodriguez-Roisin R, van Weel C, Zielinski J. Global strategy for the diagnosis, management, and prevention of chronic obstructive pulmonary disease: GOLD executive summary. Am J Respir Crit Care Med 2007; 176:532-55. [PMID: 17507545 DOI: 10.1164/rccm.200703-456so] [Citation(s) in RCA: 4728] [Impact Index Per Article: 278.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) remains a major public health problem. It is the fourth leading cause of chronic morbidity and mortality in the United States, and is projected to rank fifth in 2020 in burden of disease worldwide, according to a study published by the World Bank/World Health Organization. Yet, COPD remains relatively unknown or ignored by the public as well as public health and government officials. In 1998, in an effort to bring more attention to COPD, its management, and its prevention, a committed group of scientists encouraged the U.S. National Heart, Lung, and Blood Institute and the World Health Organization to form the Global Initiative for Chronic Obstructive Lung Disease (GOLD). Among the important objectives of GOLD are to increase awareness of COPD and to help the millions of people who suffer from this disease and die prematurely of it or its complications. The first step in the GOLD program was to prepare a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD, published in 2001. The present, newly revised document follows the same format as the original consensus report, but has been updated to reflect the many publications on COPD that have appeared. GOLD national leaders, a network of international experts, have initiated investigations of the causes and prevalence of COPD in their countries, and developed innovative approaches for the dissemination and implementation of COPD management guidelines. We appreciate the enormous amount of work the GOLD national leaders have done on behalf of their patients with COPD. Despite the achievements in the 5 years since the GOLD report was originally published, considerable additional work is ahead of us if we are to control this major public health problem. The GOLD initiative will continue to bring COPD to the attention of governments, public health officials, health care workers, and the general public, but a concerted effort by all involved in health care will be necessary.
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Affiliation(s)
- Klaus F Rabe
- Leiden University Medical Center, Pulmonology, P.O. Box 9600, NL-2300 RC, Leiden, The Netherlands.
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Ambrosino N, Simonds A. The clinical management in extremely severe COPD. Respir Med 2007; 101:1613-24. [PMID: 17383170 DOI: 10.1016/j.rmed.2007.02.011] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2006] [Revised: 02/14/2007] [Accepted: 02/15/2007] [Indexed: 10/23/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) affects 6% of the general population and is the fourth-leading cause of death in the United States with severe and very severe disease accounting for 15% and 3% of physician diagnoses of COPD. Guidelines make few recommendations regarding providing the provision of care for the most severe stages of disease, namely Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages III and IV with chronic respiratory failure. The effectiveness of inhaled drug therapy in very severe patients has not been assessed yet. Health care systems in many countries include public funding of long-term oxygen therapy for eligible candidates. Currently, there is little evidence for the use of mechanical ventilatory support in the routine management of hypercapnic patients. Pulmonary rehabilitation should be considered as a significant component of therapy, even in the most severe patients. Although Lung Volume Reduction Surgery has been shown to improve mortality, exercise capacity, and quality of life in selected patients, this modality is associated with significant morbidity and an early mortality rate in the most severe patients. Despite significant progress over the past 25 years, both short- and long-term outcomes remain significantly inferior for lung transplantation relative to other "solid" organ recipients. Nutritional assessment and management is an important therapeutic option in patients with chronic respiratory diseases. Morphine may significantly reduce dyspnoea and does not significantly accelerate death. No consistent improvement in dyspnoea over placebo has been shown with anxiolytics. Supplemental oxygen during exercise reduces exertional breathlessness and improves exercise tolerance of the hypoxaemic patient. Non-invasive ventilation has been used as a palliative treatment to reduce dyspnoea. Hypoxaemic COPD patients, on long-term oxygen therapy, may show reduced health-related quality of life, cognitive function, and depression. Only a small proportion of patients with severe COPD discuss end-of-life issues with their physicians.
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Affiliation(s)
- Nicolino Ambrosino
- U.O. Pneumologia, Dipartimento Cardio-Toracico, Azienda Ospedaliero-Universitaria Pisana, Via Paradisa 2, Cisanello, 56124 Pisa, Italy.
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Clemens KE, Klaschik E. Symptomatic therapy of dyspnea with strong opioids and its effect on ventilation in palliative care patients. J Pain Symptom Manage 2007; 33:473-81. [PMID: 17397708 DOI: 10.1016/j.jpainsymman.2006.09.015] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2006] [Revised: 09/04/2006] [Accepted: 09/06/2006] [Indexed: 11/30/2022]
Abstract
This study assessed the effect of opioid treatment on ventilation in dyspneic palliative care patients who received symptomatic treatment with strong opioids. The assessments measured changes in peripheral arterial oxygen saturation (SaO(2)), transcutaneous arterial pressure of carbon dioxide (tcPCO(2)), respiratory rate (f), and pulse rate (PF) during the titration phase with morphine or hydromorphone. The aims of the study were to verify the efficacy of opioids for the management of dyspnea, assess the effect on ventilation, and show whether nasal O(2) insufflation before opioid application leads to a decrease in the intensity of dyspnea. Eleven patients admitted to our palliative care unit were included in this prospective, nonrandomized trial. At admission, all patients suffered from dyspnea. tcPCO(2), SaO(2), and PF were measured transcutaneously by means of a SenTec Digital Monitor (SenTec AG, Switzerland). During O(2) insufflation, the intensity of dyspnea did not change. In contrast, the opioid produced a significant improvement in the intensity of dyspnea (P=0.003). Mean f decreased as early as 30 minutes after the first opioid administration, declining from 41.8+/-4.7 (35.0-50.0) to 35.5+/-4.2 (30.0-40.0), and after 90 minutes, to 25.7+/-4.5 (20.0-32.0) breaths/min. Other monitored respiratory parameters, however, showed no significant changes. There was no opioid-induced respiratory depression.
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Affiliation(s)
- Katri Elina Clemens
- Department of Science and Research in Palliative Medicine, University of Bonn, and Center for Palliative Medicine, Malteser Hospital Bonn/Rhein-Sieg Bonn, Germany.
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Groninger JH, Muir JC. Pulmonary Palliative Medicine. Palliat Care 2007. [DOI: 10.1016/b978-141602597-9.10029-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Fabbri L, Pauwels RA, Hurd SS. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: GOLD Executive Summary updated 2003. COPD 2006; 1:105-41; discussion 103-4. [PMID: 16997745 DOI: 10.1081/copd-120030163] [Citation(s) in RCA: 194] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Del Fabbro E, Dalal S, Bruera E. Symptom control in palliative care--Part III: dyspnea and delirium. J Palliat Med 2006; 9:422-36. [PMID: 16629572 DOI: 10.1089/jpm.2006.9.422] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Egidio Del Fabbro
- Department of Palliative Care and Rehabilitation Medicine, University of Texas MD Anderson Cancer Center, Houston, 77030, USA
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