Palliative Care and Interventional Pulmonology

Since pulmonary pathologies, such as lung cancer and chronic obstructive pulmonary disease (COPD), are some of the leading causes of morbidity and mortality around the world, pulmonologists are likely to encounter patients with unmet palliative care needs. This article focuses on the symptoms and complications encountered by patients with terminal pulmonary conditions, briefly describes the non-interventional palliative strategies, and then discusses more advanced therapies available in the realm of interventional pulmonology. Most of the literature discussed here is derived from patients with lung cancer and COPD.

Nebulized Lidocaine Solution for Control of Intractable Cough in a Patient with Metastatic Malignant Melanoma

Clinical Pearls

Each of these special features conveys an idea, concept, or fact that may be useful in your pharmaceutical practice, but may not be widely known, published, or taught. A 76-year-old male with a diagnosis of metastatic malignant melanoma was experiencing problems with a chronic cough. The cough had initially been managed with guaifenesin with codeine syrup and later with benzonatate capsules, but had become intractable. The patient's paroxysmal coughing resulted in dyspnea, gagging, vomiting, and fatigue—and had a significant impact on the patient's quality of life. The patient was evaluated, and no significant comorbid conditions or drug therapies that might have been aggravating his condition were noted. The patient was evaluated for pharmacologic treatment options. After discussing the pros and cons of each modality, it was decided that nebulized lidocaine would be used as a palliative measure for controlling the patient's intractable cough. A follow-up review of the patient's clinical course revealed that lidocaine was effective in controlling the cough with no adverse consequences.

Palliative care in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the only major worldwide cause of mortality that is currently increasing in prevalence. Furthermore, COPD is incurable, and the only therapy that has been shown to increase survival is oxygen therapy in selected patients. Compared to patients with cancer, patients with COPD experience similar levels of pain, breathlessness, fatigue, depression, and anxiety and have a worse quality of life but have comparatively little access to palliative care. When these patients do receive palliative care, they tend to be referred later than patients with cancer. Many disease, patient-, and provider-related factors contribute to this phenomenon, including COPD's unpredictable course, misperceptions of palliative care among patients and physicians, and lack of advance care planning discussions outside of crisis situations. A new paradigm for palliative care would introduce palliative treatments alongside, rather than at the exclusion of disease-modifying interventions. This integrated approach would circumvent the issue of difficult prognostication in COPD, as any patient would receive individualized palliative interventions from the time of diagnosis. These points will be covered in this review, which discusses the challenges in providing palliative care to COPD patients, the strategies to mitigate the challenges, management of common symptoms, and the evidence for integrated palliative care models as well as some suggestions for future development.

Interventions for cough in cancer

BACKGROUND

This is an updated version of the original Cochrane review first published in Issue 9, 2010 on "Interventions for cough in cancer". Cough is a common symptom in patients with malignancies, especially in patients with lung cancer. Cough is not well controlled in clinical practice and clinicians have few management options to treat it.

OBJECTIVES

The primary objective was to determine the effectiveness of interventions, both pharmacological and non-pharmacological, (other than chemotherapy and external beam radiotherapy) in the management of cough in malignant disease (especially in lung cancer).

SEARCH METHODS

For this update, we searched for relevant studies in CENTRAL and DARE (The Cochrane Library); MEDLINE; EMBASE; PsycINFO; AMED and CINAHL to 9 June 2014. In addition, we searched for ongoing trials via the metaRegister of controlled trials (mRCT), ClinicalTrials.gov, the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) and the UK Clinical Research Network Study Portfolio.

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and clinical trials (quasi-experimental trials and trials where there is a comparison group but no mention of randomisation) in participants with primary or metastatic lung cancer or other cancers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles and abstracts of all studies for inclusion, and extracted data from all included studies independently before reaching consensus. A third review author arbitrated on any disagreement. Meta-analysis was not attempted due to the heterogeneity of the studies.

MAIN RESULTS

For the original version of the review, 17 studies met the inclusion criteria and examined either brachytherapy, laser or photodynamic therapy (eight studies) or a variety of pharmacological therapies (nine studies). Overall, there was an absence of credible evidence and the majority of studies were of low methodological quality and at high risk of bias. Brachytherapy in a variety of doses seemed to improve cough in selected participants, suggesting that possibly the lowest effective dose should be used to minimise side effects. Photodynamic therapy was examined in one study and, while improvements in cough were observed, its role in relationship to other therapies for cough was unclear. Some indication of positive effect was observed with morphine, codeine, dihydrocodeine, levodropropizine, sodium cromoglycate and butamirate citrate linctus (cough syrup), although all studies had significant risk of bias. For this update, we did not identify any additional trials for inclusion. Two ongoing trials were identified but no study results were available.

AUTHORS' CONCLUSIONS

No new trials were included since the publication of the original version of this review, while 11 new studies that were identified were eventually excluded from this review. Therefore, our conclusions remain unchanged. No practice recommendations could be drawn from this review. There is an urgent need to increase the number and quality of studies evaluating the effects of interventions for the management of cough in cancer.

Interventions for cough in cancer

BACKGROUND

Cough is a common symptom in patients with malignancies, especially in patients with lung cancer. Cough is not well controlled in clinical practice and clinicians have few management options to treat it.

OBJECTIVES

The primary objective of this review was to determine the effectiveness of interventions, both pharmacological and non-pharmacological, (other than chemotherapy and external beam radiotherapy) in the management of cough in malignant disease (especially in lung cancer).

SEARCH STRATEGY

Databases searched included: The Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of Effectiveness (DARE) (The Cochrane Library issue 4, 2009); MEDLINE (1966 to May 2010); EMBASE (1980 to May 2010); CINAHL (1980 to May 2010); PSYCHINFO (1980 to May 2010); AMED (1985 to May 2010); SIGLE (1980 to May 2010); British Nursing Index (1985 to May 2010); CancerLit (1975 to May 2010). We searched for cough suppressants, antitussives and other drugs with antitussive activity as well as non-pharmacological interventions (see Appendices 1-4 for search terms).

SELECTION CRITERIA

We selected randomised controlled trials (RCTs) and clinical trials (quasi-experimental trials, and trials where there is a comparison group but no mention of randomisation) in participants with primary or metastatic lung cancer or other cancers.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts of all studies, and extracted data from all selected studies before reaching consensus. A third review author arbitrated with any disagreement. Meta-analysis was not attempted due to the heterogeneity of studies.

MAIN RESULTS

Seventeen studies met inclusion criteria and examined either brachytherapy, laser or photodynamic therapy (eight studies) or a variety of pharmacological therapies (nine studies). Overall, there was absence of credible evidence and the majority of studies were of low methodological quality and high risk of bias. Brachytherapy seemed to improve cough in a variety of doses in selected participants, suggesting that possibly the lowest effective dose should be used to minimise side effects. Photodynamic therapy was examined in one study, and while improvements in cough were observed, its role over other therapies for cough is unclear. Some indication of effect was observed with morphine, codeine, dihydrocodeine, levodropropizine, sodium cromoglycate and butamirate citrate linctus (cough syrup), although all studies had significant risk of bias.

AUTHORS' CONCLUSIONS

No practice recommendations could be drawn from this review. There is an urgent need to increase the number and quality of studies evaluating the effects of interventions in the management of cough in cancer.

Managing dyspnea and cough

Dyspnea, like pain, is a subjective experience that incorporates physical elements and affective components. Management of breathlessness in patients with cancer requires expertise that includes an understanding and assessment of the multidimensional components of the symptom, knowledge of the pathophysiologic mechanisms and clinical syndromes that are common in cancer, and familiarity with the indications and limitations of the available therapeutic approaches. Relief of breathlessness should be the goal of treatment at all stages of cancer. Good control of dyspnea will improve the patient's quality of life.

Management of dyspnea and cough in patients with cancer

The understanding and treatment of dyspnea in the cancer patient are where the science of pain management was 15 or 20 years ago. Very few studies have examined the pathophysiologic mechanisms that cause dyspnea in cancer patients, and few investigators have evaluated therapeutic strategies to control dyspnea in this patient group. The optimal therapy for dyspnea is treatment of the underlying cause. When this is not possible, opioids and phenothiazines provide effective symptomatic relief in most cases, but many unanswered questions remain. Are these the optimal drugs, and what are their optimal doses? What are the effects of chronic dosing? Which is the best route of administration? How serious are the risks of respiratory depression? A clear consensus supports the aggressive treatment of pain in terminally ill cancer patients, even if death is hastened as an unintended consequence. No such position has yet been reached in the management of dyspnea in the same population. As a result, dyspnea is addressed only very late in the course of the disease, perhaps reducing the patient's quality of life and function at earlier stages and resulting in a very small "therapeutic window" in the terminal phase. Clearly, a need exists for more research to determine the most effective management of this common and very distressing symptom.

Reversible delirium in terminally ill patients

Delirium is reported to be a common problem in terminally ill patients. The poor prognosis given to these patients may result in the failure to recognize the causes that are easily treated and may be reversible. We present four patients in whom a comprehensive assessment revealed a number of reversible causes of delirium, resulting in a treatment approach that significantly improved the patients' cognition and quality of life.