___________________________________________ Palliative Care and Pain Management at the End of Life
Etiology Physical causes of dyspnea vary according to the life-limiting disease and/or comorbid conditions and include pleural effu- sion, airway obstruction, pulmonary embolism, pericardial effusion, and asthma [54]. Progressive dyspnea is a common feature of end-stage, diffuse metastatic carcinoma of the lung. Pain and psychological conditions such as anxiety and depres- sion may augment the severity or prolong the duration of dyspnea [54; 213]. Prevention Measures to reduce anxiety can help to prevent dyspnea or reduce its severity. In addition, patients with heart failure or lung diseases should be advised to conserve energy. Assessment Practice guidelines recommend that clinicians regularly assess dyspnea in patients receiving end-of-life care [47; 54; 213]. Intercurrent, reversable causes of dyspnea include pleural/ pericardial effusion and pulmonary embolism. Assessment should involve asking the patient to note the severity and/or distress related to dyspnea, as objective testing, such as respi- ratory rate, arterial blood gas levels, and pulse oximetry, do not always correlate with a patient’s experience of shortness of breath [213]. Tools for patient-reported dyspnea include a modified Borg scale, a visual analog scale, or a numerical scale [213; 308]. In addition to asking about the severity of breathlessness, the clinician should ask about other symptoms, especially concurrent chest pain, and about the activities that cause dyspnea. Patients with dyspnea often modify their activi- ties to avoid dyspnea, so the clinician should ask the patient if he or she has changed or stopped any activities because of dyspnea [54]. Because of the link between psychological factors and dyspnea, the clinician should also evaluate the patient’s psychosocial status. Physical assessment of the patient should include evaluation of breath sounds, heart rate, respiratory rate, jugular pressure, and functional status. Select imaging studies, such as chest x-ray, chest CT, and echocardiogram, may identify a suspected, treatable cause of dyspnea [54; 122]. Management The American College of Physicians, the American Thoracic Society, the Canadian Thoracic Society (endorsed by the ACCP), and the NCCN have developed evidence-based guidelines for the management of dyspnea [47; 54; 122; 213; 309; 310]. In addition, evidence-based recommendations for managing dyspnea in people with advanced heart failure are available [108]. A stepwise approach to managing dyspnea should be taken, with the first step being treatment of the underlying cause, if one can be identified [54]. Nonpharma- cologic interventions should be used first; if the response is inadequate, pharmacologic interventions may be added.
Supplemental oxygen is commonly used to treat dyspnea. Strong evidence supports the use of oxygen and pulmonary rehabilitation for dyspnea, and supplemental oxygen may pro- vide relief of dyspnea for people with advanced lung or heart disease who have hypoxemia at rest or with minimal activity [47; 54; 212; 213; 309; 310]. However, data suggest that oxygen offers no benefit to patients who do not have hypoxemia [108]. A variety of nonpharmacologic interventions have been sug- gested in several practice guidelines, although the evidence base varies ( Table 13 ) [122; 213; 309; 310]. In a systematic review of nonpharmacologic interventions and an update of that review for dyspnea in people with advanced malignant and nonmalignant diseases, there was strong evidence for chest wall vibration and neuroelectrical muscle stimulation and moderate evidence for walking aids and breathing train- ing [311; 312]. The updated review found low strength of evidence for acupuncture/acupressure, no evidence for the use of music, and insufficient evidence to recommend the use of a fan, music, relaxation, counseling and support, and psychotherapy [311; 312]. A subsequent small randomized controlled trial demonstrated that a handheld fan directed at the face reduced breathlessness [313]. Opioids represent the primary recommended pharmacologic intervention for intractable dyspnea in people with advanced cancer and lung disease [47; 213; 309]. A systematic review and meta-analysis (18 randomized controlled trials) demonstrated a significant positive effect of opioids on breathlessness [315]. Guidelines recommend that oral or parenteral opioids be considered for all patients with severe and unrelieved dyspnea; nebulized opioids have not had an effect when compared with placebo [47; 212; 213; 309]. Oral morphine is the most NONPHARMACOLOGIC INTERVENTIONS FOR DYSPNEA RECOMMENDED IN PRACTICE GUIDELINES Chest wall vibration Neuroelectrical muscle stimulation Walking aids Breathing training Inspiratory muscle training Physical activity Handheld fan directed at the face Pursed-lip breathing Cool compress on the forehead Cool room
Open windows Activity pacing Noninvasive positive pressure ventilation Relaxation techniques Acupuncture/acupressure Psychosocial support Patient and family education Source: [122; 213; 309; 310; 311; 313; 314]
Table 13
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MDCA1525
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