A Case of Heart Palpitations and Shortness of Breath

Editor's note: This is the next installment in a series on electrocardiogram (ECG) interpretation. Nurses in all settings should know the basics, as medications and physiological changes can cause cardiac arrhythmias. Each article will start with a brief case scenario and an ECG strip and then take you step by step through analyzing the heart rhythm.

Field Notes From the Frontline of a COVID-19 Outbreak: Dyspnea Management for Hospitalized Patients at End-of-Life

Northern New Jersey was inside one of the worst initial coronavirus disease 2019 pandemic epicenters in the United States. At the peak of the pandemic surge in mid-April 2020, New Jersey saw 8045 hospitalized patients with severe coronavirus disease 2019 symptoms, of which 2002 were in intensive care unit beds (86.3% of statewide capacity), including 1705 requiring mechanical ventilation. Because of the severity of pulmonary dysfunction/hypoxia, the unprecedented numbers of critically ill patients, the national opioid shortage, and transmission prevention measures for standard palliative care treatment protocols in place for refractory and/or end-of-life dyspnea were found to be ineffective in providing adequate symptom relief. The aim of the following Notes From the Field is to provide concise, pragmatic, and experiential reflection by 3 palliative care advanced practice nurses from 3 different hospital systems within the pandemic epicenter. The novel methods and opioid strategies implemented by their respective palliative care teams to ensure continued effective and appropriate treatment for end-of-life dyspnea are described. These accounts include Lessons Learned in order to assist others who may need to quickly implement changes in the future due to pandemic resurgence or second-wave events.

Managing chronic breathlessness in the community

Breathlessness or dyspnoea is a subjective experience that can be described as an unpleasant or uncomfortable awareness of breathing. It is a subjective experience for patients and often they learn to adapt to the limitations caused by their condition, which makes their breathlessness less apparent to others. Breathlessness can be subdivided in the context of chronic refractory breathlessness, such as acute breathlessness, which is either an episodic breathlessness or breathlessness crisis. Chronic refractory breathlessness is defined as breathlessness at rest or on minimal exertion that will persist chronically despite optimal treatment of the underlying causative factors. The role of the community nurse in managing the breathless patient should involve differentiating between different types of breathlessness and knowing how to effectively manage it in a holistic manner.

Assessment and management of refractory breathlessness in interstitial lung disease

Interstitial lung disease (ILD) refers to a cluster of fibroinflammatory conditions. There are limited treatment options and most patients have severe dyspnoea. The prognosis is poor. This study aims to evaluate current literature on the assessment and management of refractory breathlessness in ILD. Few tools are available to assess dyspnoea in advanced respiratory disease. Holistic assessment requires a combination of tools but there are few disease specific tools. The role of opioids is well established in the reduction of breathlessness, but there is insufficient evidence that benzodiazepines are beneficial. Non-pharmcolological breathlessness intervention services can give patients mastery of their disease, reduced distress due to breathlessness and were more cost effective. More research on holistic interventions for use in advanced disease needs to be done. Patient-reported outcome measures could elicit valuable evidence to describe the benefit of breathlessness management services in advanced respiratory disease.

Nurses' decision-making in ethically relevant clinical situations using the example of breathlessness: study protocol of a reflexive grounded theory integrating Goffman's framework analysis

INTRODUCTION

Decision-making (DM) in healthcare can be understood as an interactive process addressing decision makers' reasoning as well as their visible behaviour after the decision is made. Other key elements of DM are ethical aspects and the role as well as the treatment options of the examined professions. Nurses' DM to choose interventions in situations of severe breathlessness is such interactions. They are also ethically relevant regarding the vulnerability of affected patients and possible restrictions or treatment options. The study aims to explore which factors influence nurses' DM to use nursing interventions in situations where patients suffer from severe breathlessness.

METHODS AND ANALYSIS

Qualitative study including nurses in German hospital wards and hospices. A triangulation of different methods of data collection-participant observation and qualitative expert interviews-and analysis merge in a reflexive grounded theory approach which integrates Goffman's framework analysis. It allows an analysis of nurses' self-statements about DM, their behaviour in relevant clinical situations and its influences. Data collection and analysis will be examined simultaneously.

ETHICS AND DISSEMINATION

Informed consent will be gained from all participants and the institutional stakeholders. Ongoing consent has to be ensured since observations will take place in healthcare institutions and many patients will be highly vulnerable. The study has been evaluated and approved by the Witten/Herdecke University Ethics Committee, Witten, Germany. Results of the study will be published at congresses and in journal papers.

A focus group for caregivers of hospice patients with severe dyspnea

The use of focus groups has grown in all aspects of our society, including the areas of politics and business. More recently, clinical research investigators have begun using focus groups to acquire important information from potential study subjects, such as patients and caregivers. Researchers use focus groups to help them design and test data collection measures, assess responses to proposed interventions, and obtain guidance on recruitment and retention methods for clinical trials. This report explains the basic requirements and methods for conducting focus groups. The authors conducted a focus group study based on six former caregivers of hospice patients with severe dyspnea. The paper describes the results of this study and illustrates how caregivers assisted in evaluating potential interventions for dyspnea, which will be tested in a future clinical trial. Subsequently, the researchers used the focus group data to adapt the guided-imagery intervention to the lifestyle and culture of the study subjects and their caregivers.

Primary care of chronic dyspnea in adults

Chronic dyspnea is the presence of shortness of breath lasting for a minimum of 4 weeks. It is a common complaint associated with many of the cardiopulmonary diseases seen in primary care. This article provides a systematic, evidence-based, and cost-effective approach to the evaluation of this complex symptom.

Oxygen is nonbeneficial for most patients who are near death

CONTEXT

Clinicians prescribe and administer oxygen in response to reports of dyspnea, in the face of dropping oxygen saturation, as a "routine" comfort intervention, or to support anxious family members. Oxygen may produce nasal irritation and increase the cost of care.

OBJECTIVES

To determine the benefit of administering oxygen to patients who are near death.

METHODS

A double-blind, repeated-measure observation with the patient as his/her own control was conducted. The Respiratory Distress Observation Scale(©) measured presence and intensity of distress at baseline and at every gas or flow change. Medical air, oxygen, and no flow were randomly alternated every 10 minutes via nasal cannula with patients who were near death, at risk for respiratory distress, with no distress at the baseline of testing. Each patient had two encounters under each condition, yielding six encounters per patient.

RESULTS

Patients were 66% female, 34% white, and 66% African American, and ages 56-97 years. Patients had heart failure (25%), chronic obstructive pulmonary disease (34%), pneumonia (41%), or lung cancer (9%). Most (91%) patients tolerated the protocol with no change in respiratory comfort. Three patients (9%) displayed distress and were restored to baseline oxygen; one patient died during the protocol while displaying no distress. Repeated-measure analysis of variance revealed no differences in the Respiratory Distress Observation Scale under changing gas and flow conditions.

CONCLUSION

The routine application of oxygen to patients who are near death is not supported. The n-of-1 trial of oxygen in clinical practice is appropriate in the face of hypoxemic respiratory distress.

The clinical and social dimensions of prescribing palliative home oxygen for refractory dyspnea

BACKGROUND

Chronic breathlessness is a significant problem in palliative care and oxygen is often prescribed in an attempt to ameliorate it. Often, this prescription falls outside the current funding guidelines for long-term home oxygen use. The aim of this qualitative study was to understand the factors that most influence Australian specialist palliative care nurses' initiation of home oxygen for their patients.

METHODS

A series of focus groups were held across three states in Australia in 2011 involving specialist palliative care nurses. The invitation to the nurses was sent by e-mail through their national association. Recorded and transcribed data were coded for themes and subthemes. A summary, which included quotes, was provided to participants to confirm.

RESULTS

Fifty-one experienced palliative care nurses participated in seven focus groups held in three capital cities. Two major themes were identified: 1) logistic/health service issues (not reported in this paper as specific to the Australian context) involving the local context of prescribing and, 2) clinical care issues that involved assessing the patient's need for home oxygen and ongoing monitoring concerns. Palliative care nurses involved in initiating or prescribing oxygen often reported using oxygen as a second-line treatment after other interventions had been trialed and these had not provided sufficient symptomatic benefit. Safety issues were a universal concern and a person living alone did not emerge as a specific issue among the nurses interviewed.

CONCLUSION

The role of oxygen is currently seen as a second-line therapy in refractory dyspnea by specialist palliative care nurses.

Considerations in developing and delivering a nonpharmacological intervention for symptom management in lung cancer: the views of patients and informal caregivers

CONTEXT

Few studies consider patient's and caregiver's preferences when developing nonpharmacological interventions. This is important to develop acceptable and accessible nonpharmacological interventions for patients with cancer.

OBJECTIVES

The objective of this study was to identify the views of patients with lung cancer and their informal caregivers on the desirable components of a novel nonpharmacological intervention for the management of the symptom cluster of cough, breathlessness, and fatigue, and their needs and preferences regarding uptake and delivery of the intervention.

METHODS

This study was qualitative in orientation, using semistructured interviews and framework analysis to elicit the views of 37 patients with lung cancer and 23 caregivers regarding the issues that were perceived to be important regarding the development and delivery of a nonpharmacological intervention.

RESULTS

A number of key issues were identified that carried important implications for patient participation and adherence to the intervention, including the perceived relevance of potential techniques; appreciable benefits in the short term; convenience; variation in patient preferences; timing of the intervention; venue; caregiver involvement; the provider of the intervention, and contact with other patients.

CONCLUSION

The data from this study have provided insight into the key issues that are likely to influence the development, uptake, and delivery of a nonpharmacological intervention to help manage the respiratory symptom cluster of cough, breathlessness, and fatigue. It is crucial that these findings are considered when developing and modeling a nonpharmacological symptom management intervention.

[Nurses end-of-life decision making. Professional nurses about the application of complementary care for patients with breathlessness]

Aim of this study was to explore the nursing professionals' experiences and handling of decisions to provide complementary care for patients with breathlessness at the end of life. Therefore, it presents one of the first studies in the German speaking area addressing genuine nursing decisions belonging to their responsibility. Based on Grounded Theory Methodology the data were collected and analysed synchronously. Results show a high professional and emphatic decision making process always focussing on the patient. "To consider the patient" emanates from their general attitude and is influenced by the possibility to be human themselves and by reflecting ones limitations. At the same time participants described a repertoire of complementary care procedures which they use in their daily nursing routine. This study illustrates the decision making process and outlines the general attitude influencing all decisions and actions of nurses to relieve breathlessness. Furthermore, it shows for the first time a range of currently used complementary care procedures to treat patients with breathlessness at the end of life.

[Palliative care of patients with terminal obstructive pulmonary disease]

Terminal chronic obstructive pulmonary disease (COPD) and advanced cancer have similar prognosis and symptom burden. However, palliative care of patients with terminal COPD has been neglected in Denmark. We describe the symptoms of terminal COPD and suggest criteria for defining the palliative phase of the disease. Furthermore we discuss the prognostic and ethical challenges for patients, their families and their caregivers. Finally, we summarize the current evidence for palliative treatment of dyspnoea and ways to evaluate response to treatment.

Health in partnership: family nursing practice for people with breathing difficulties

Reorienting the focus of health systems to incorporate a multifaceted approach that allows for comprehensive and humane health care is pending. Using the participatory paradigm approach, we describe a study of a partnership-based family nursing practice for people with breathing difficulties. We generated data through nine conversations with eight patients accompanied by a close family member (n = 6) and one wife, 15 conversations between the authors, and through a reflective journal. Narrative data analysis was conducted. Results that reveal the meaning and experience of the family nursing practice are presented in four interlacing descriptive statements: (a) surfacing and contextualizing health problems, (b) responsiveness of services, (c) security-stability-self-direction, and (d) unified family efforts- transformation. We conclude that the conceptual framework of partnership is a useful approach to nursing practice within a nurse clinic for people with advanced breathing difficulties and their families.

Evaluating tools that can be used to measure and manage breathlessness in chronic disease

Questionnaires used to assess breathlessness are usually research tools, which means that data on their value in assessing patients' symptoms in clinical practice is minimal. This article examines the questionnaires available and discusses their strengths and weaknesses to help nurses make informed choices about which breathlessness questionnaire is most suited to their practice.

[Nurses' knowledge, attitudes and behavior intentions in the care of terminal stage cancer patients with dyspnea]

The main purpose of this study was to explore the current status and correlations among key factors of influence, including knowledge, attitudes and behavior intentions, related to nurses' care for terminal cancer patients with dyspnea. This study was conducted using a crossing-sectional research method using convenience sampling. A total of 128 nurses working in a regional educational hospital in eastern Taiwan were surveyed by questionnaire. The conclusions of this study were: (1) "nursing measurement" was the most important factor affecting knowledge; (2) positive attitudes represent the result of the survey; (3) the most significant factor related to behavior intentions was "nursing measurement"; (4) knowledge was highly influenced by "nurse background" variables; (5) behavior intention was affected by "nurse background" variables; and (6) a positive correlation was identified between attitudes and behavior intentions. We recommend that training courses and practice related to palliative care should be incorporated into nursing education. To enhance nurses' knowledge and abilities in caring for dyspnea patients in the terminal cancer stage, it is also necessary to set up guidelines, including palliative care on-the-job training and cross-training programs.

The patient with cancer-related dyspnea

Dyspnea can be challenging to manage because it often is exacerbated by anxiety. Patient positioning and relaxation and breathing techniques can help.

The moved to evidenced-based practice from a clinical nursing question

Registered nurses on a medical unit questioned whether current practice adequately met the emotional needs of patients with chronic obstructive pulmonary disease hospitalized for acute dyspnea. The unit's education committee surveyed nursing staff regarding priority nursing activities during dyspneic episodes. After discussion with staff development educators, several registered nurses met with the center's nurse researcher, formed a research team, and designed a descriptive study. Findings of the study gave evidence for clinical practice change and revision of care guidelines.

Clinical Dilemma: Dyspnea

OBJECTIVES

To review the current state of evidence for the nursing treatment of cancer-related dyspnea.

DATA SOURCES

Nursing and medical literature, published guidelines, and Cochrane Systematic reviews.

CONCLUSION

Limited evidence exists for the current strategies used to treat dyspnea among persons with cancer.

IMPLICATIONS FOR NURSING PRACTICE

Nurses must be cognizant of the level of evidence or the lack of scientific evidence supporting treatment strategies used. Keeping abreast of the developments in the area of dyspnea management is imperative as research adds to the current body of evidence. Nurses are uniquely positioned to add to the body of evidence through collaboration with nurse researchers.

Perceptions of Dyspnea and Helpful Interventions During the Advanced Stage of Lung Cancer

Dyspnea is a distressful but neglected symptom in oncology practice and research. The aim of this study was to describe the experience of dyspnea and helpful interventions in Chinese patients with advanced lung cancer admitted in the palliative care unit in 1 region in Hong Kong. A qualitative description approach using in-depth interviews was used to guide this study. Eleven participants agreed to be interviewed with age ranging from 51 to 80 years. They have been diagnosed with lung cancer from 1 to 12 months, and all required oxygen therapy from dyspnea. The results of content analysis revealed 4 main themes: (1) characteristics of dyspnea, (2) impact of dyspnea, (3) strategies used to manage dyspnea, and (4) nurses' role in managing dyspnea. Patients in this study found no Chinese words to adequately define and describe dyspnea and relied on sensations they experienced during the dyspnea episode. The impact of dyspnea was multidimensional, and patients used various strategies to manage dyspnea, including avoiding triggers and utilizing traditional Chinese medicine. Healthcare professionals were perceived to play a very inadequate role in assisting patients with dyspnea, and participants suggested that they should take a more active role in educating and supporting patients with dyspnea.

Dyspnea Management in Lung Cancer: Applying the Evidence From Chronic Obstructive Pulmonary Disease

PURPOSE/OBJECTIVES

To provide an overview of mechanisms of dyspnea and causes of dyspnea in chronic obstructive pulmonary disease (COPD) and lung cancer and to critically review current pharmacologic and nonpharmacologic management of dyspnea for COPD and lung cancer.

DATA SOURCES

Published articles, abstracts, textbooks, and the authors' personal experiences with dyspnea management in COPD and lung cancer.

DATA SYNTHESIS

The causes of dyspnea in cancer are more varied than the causes of dyspnea in COPD; however, many are similar, thus providing the justification for recommending best practice from COPD research to be used in lung cancer. Dyspnea in both diseases is treated by corticosteroids, bronchodilators, antianxiety drugs, local anesthetics, and oxygen. However, when dyspnea is severe, morphine is the first choice. Using specific breathing techniques, positioning, energy conservation, exercise, and some dietary modifications and nutrient supplements can help with dyspnea management.

CONCLUSIONS

Pharmacologic and nonpharmacologic management of dyspnea in COPD can be applied to dyspnea related to lung cancer. Further research in the management of dyspnea in lung cancer is required, particularly controlled studies with larger sample sizes, to determine the effectiveness of the application of COPD dyspnea management in lung cancer.

IMPLICATIONS FOR NURSING

Previous studies provide a guideline for applying dyspnea management for COPD to cancer. The theoretical frameworks used in previous studies can be modified for conducting further study.

The Use of Nebulized Opioids in the Management of Dyspnea: Evidence Synthesis

PURPOSE/OBJECTIVES

To analyze the evidence about the use of nebulized opioids to treat dyspnea using the Priority Symptom Management (PRISM) level-of-evidence framework and to make a practice recommendation.

DATA SOURCES

Computerized database and manual search for articles and abstracts that included experimental trials, chart reviews, and case studies.

DATA SYNTHESIS

20 articles with evaluable evidence were identified. Analysis was complex because of heterogeneous variables and outcome measures. A major limitation is small sample sizes. The majority of PRISM level I and II studies indicated unfavorable evidence.

CONCLUSIONS

Scientific data supporting the use of nebulized opioids to treat dyspnea in patients with chronic pulmonary disease, including malignancy, are lacking.

IMPLICATIONS FOR NURSING

Insufficient data identify a need for further research with random crossover designs involving larger samples that are stratified according to prior opioid use. Consistency of study variables should be emphasized.

Clinical Judgments About Endotracheal Suctioning: What Cues Do Expert Pediatric Critical Care Nurses Consider?

Making accurate and timely judgments based on multiple ways of knowing is an essential skill in critical care nursing practice. Studies have proposed that positive patient outcomes are linked to expert judgments in a variety of critical care situations; however, little is known about clinical judgments related to specific critical care nursing interventions. This article presents a qualitative nursing research study which examined the cues that expert pediatric critical care nurses used in making clinical judgments about suctioning intubated and ventilated, critically ill children. The participants' words and actions attest that the 'sensing' and 'thinking' of the process of cue use, are interwoven with, and integral to, the 'doing,' which is the process of skilled performance.

Non-invasive interventions for improving well-being and quality of life in patients with lung cancer—A systematic review of the evidence

Despite advances in lung cancer treatment, the outlook for most patients remains grim. Many of them face a short survival time during which they may suffer physical and psychological problems related with the cancer and the treatment side-effects. There is a need for a high quality care to support patients and reduce symptoms as much as possible. This systematic review found that a specialised nursing programme to reduce breathlessness was effective and that after patients' treatment had finished, those cared by nurses did as well or even better than those cared by doctors.

Palliative care for breathless patients in the community

Breathlessness is one of the commonest symptoms experienced by people receiving palliative care. However, misunderstanding of the nature of palliative care may hinder assessment, management and evaluation of care and may contribute to the fear associated with living with breathlessness in the community. Knowledge of related anatomy and physiology of breathlessness is vital in informing nursing care and interventions. Pharmacological interventions have their place, but the focus of nursing care should be on systematic holistic assessment. Using this, nurses should adopt a proactive role in supporting and helping patients to adapt to change by maximizing coping strategies.

Is Internet-based support for dyspnea self-management in patients with chronic obstructive pulmonary disease possible? Results of a pilot study

BACKGROUND

As of 2003, approximately 67% of US adults have Internet access. The purpose of this study was to determine the feasibility and preliminary efficacy of an Internet-based dyspnea self-management program (iDSMP) for people with chronic obstructive pulmonary disease. A related aim was to compare the differential effects of the iDSMP on 2 different groups: (1) to test a "booster" effect and (2) to evaluate the program as a primary intervention.

METHODS

Two groups (n = 16) were evaluated at baseline and at 3 months after completing the iDSMP, which included education, exercise, self-monitoring, and support. Dyspnea, self-efficacy, perception of available support, and exercise behavior were measured. Paired, independent t tests and Mann-Whitney U tests were used.

RESULTS

Most subjects (87%) reported that the program increased their access to information and resources for managing dyspnea. Dyspnea with activities of daily living and self-efficacy for managing the symptom showed significant improvements (both P < .01), whereas more modest changes were noted in perceived support and exercise behavior in the overall sample. There were no differences between the 2 groups on these outcomes.

CONCLUSIONS

The findings suggest that additional investigations of Internet-based interventions to promote self-management in patients with chronic obstructive pulmonary disease are warranted.

Assessment and nursing care of the patient with dyspnoea

Breathlessness is a subjective experience, which has been described as an unpleasant or uncomfortable awareness of breathing, or of the need to breathe (Gift, 1990). Patients experiencing breathlessness are often described as being dyspnoeic, or having dyspnoea. This is derived from the Greek word, which, when translated, means 'difficulty in breathing'.