Dyspnea Intensity Research Articles

Comparison of clinical effectiveness of nurse led care among Chinese patients with cancer: A prospective study evaluating effective patient care compared to consultant oncologist

ObjectiveThe NLC model in oncology setting was not well established in China, and there was no study evaluating the clinical effectiveness of NLC versus oncologist-led care (OLC) in Chinese patients with cancer. We therefore designed a pilot study to evaluate the clinical usefulness after NLC versus OLC in Chinese patients with cancer. MethodsThis pilot, single center, prospective study was designed to evaluate clinical effectiveness of NLC versus oncologist-led care (OLC) in Chinese patients with cancer. Adult patients of either gender (aged between 20 and 65 years) who were diagnosed with any cancer at China were included. The patients’ with stage IV cancer or who were not willing to give written consent to participate in this study were excluded during screening phase of our study. We assessed the symptoms from each enrolled patients, the most common symptoms associated with any cancer patients are pain, dyspnea and constipation. Also distress symptoms (caused by pain and dyspnea) and low quality of life are seen in patients with advanced stage of cancer. ResultsA total of 220 patients who were visited in our hospital for consultation were enrolled and assigned to nurse led care and oncologist led care group (110 patients in each group). Pain intensity, dyspnea intensity and constipation intensity was recorded for patients of nurse led care and oncologist led care group. Pain intensity, dyspnea intensity and constipation intensity on numerical rating scale was numerically lesser in Nurse led care group as compared to oncologist led care group. However, the difference was not statistically significant (p>0.05). The mean QoL score of each key domain of QoL was higher in nurse led care group when compared to oncologist led care group. Overall, significant improvement in quality of life was observed in individuals underwent in nurse led care group than oncologist led care group. ConclusionThe results of this preliminary study showed that NLC results in better clinical outcome in terms of improvement in pain intensity, dyspnea intensity, symptom distress, constipation score, and QOL in comparison to oncologist led care among Chinese cancer patients. This study results can aid as a base for steering outsized clinical study to form the model of NLC among Chinese cancer patients.

Diagnosis of chronic heart failure in patients with chronic obstructive pulmonary disease

Aim. To identify methods for diagnosing early signs of heart failure in patients with chronic obstructive pulmonary disease. 
 Methods. We examined 54 patients with chronic obstructive pulmonary disease without exacerbation. Patients were divided into two groups: group 1 - 26 patients with chronic obstructive pulmonary disease in combination with chronic heart failure; group 2 - 28 patients with chronic obstructive pulmonary disease without chronic heart failure. The groups were comparable by age and severity of chronic obstructive pulmonary disease. Electrocardiography, echocardiography were performed with additional determination of the right heart chamber parameters, spirometry, X-ray, pulse oximetry. The level of highly sensitive C-reactive protein, blood acid-base composition and brain natriuretic peptide was evaluated. 
 Results. Patients with comorbidity have decreased exercise tolerance according to the 6-minute walk test and mMRS scale, higher body mass index and dyspnea intensity, larger linear dimensions of the heart chambers and their volume parameters. Heart failure with preserved ejection fraction was observed in 21 (80%) of patients in group 1, therefore, the signs of heart failure can be explained by diastolic dysfunction of the right and left ventricles. Among patients with chronic obstructive pulmonary disease and chronic heart failure in our study, extended linear dimensions and structural changes in the ventricles, indicating pre- and postcapillary hypertension, were significantly more common. 
 Conclusion. The use of tissue Doppler study allows more accurately determining the diastolic function of the right and left ventricles; the brain natriuretic peptide study is a sensitive marker of early forms of diastolic chronic heart failure.

The Effects of Repeated Dyspnea Exposure on Response Inhibition.

In order to treat dyspnea (=breathlessness) successfully, response inhibition (RI) as a major form of self-regulation is a premise. This is supported by research showing that self-regulation is associated with beneficial behavioral changes supporting treatment success in patients. Recent research showed that dyspnea has an impairing effect on RI, but the effects of repeated dyspnea exposure on RI remain unknown. Therefore, the present study tested the effects of repeated resistive load-induced dyspnea on RI over a 5-day period. Healthy volunteers (n = 34) performed the standard version of the Stroop task during baseline and dyspnea conditions on the first and fifth testing day and underwent an additional dyspnea exposure phase on each testing day. Variables of interest to investigate RI were reaction time, accuracy as well as the event-related potentials late positive complex (LPC) and N400 in the electroencephalogram. Reduced accuracy for incongruent compared to congruent stimuli during the dyspnea condition on the first testing day were found (p < 0.001). This was paralleled by a reduced LPC and an increased N400 for incongruent stimuli during the induction of dyspnea (p < 0.05). After undergoing dyspnea exposure, habituation of dyspnea intensity was evident. Importantly, on the fifth testing day, no differences between baseline, and dyspnea conditions were found for behavioral and electrophysiological measures of RI. These findings demonstrate that the impairing effect of dyspnea on RI disappeared after repeated dyspnea exposure in healthy participants. Translated to a clinical sample, it might cautiously be suggested that dyspnea exposure such as dyspnea perceived during physical exercise could reduce the impairing effect of dyspnea on RI which might have the potential to help increase self-regulation abilities and subsequent treatment efforts in dyspneic patients.

Effect of high flow oxygen on exertional dyspnea in cancer patients: A double-blind randomized clinical trial.

11600 Background: High flow oxygen therapy is effective for hypoxemic respiratory failure. However, its effect on dyspnea in non-hypoxemic patients is unknown. In this 2x2 factorial, double-blind randomized clinical trial, we assessed the effect of flow rate (high vs. low) and gas (oxygen vs. air) on exertional dyspnea in cancer patients. Methods: Non-hypoxemic patients with cancer completed two structured cycle ergometer exercise tests with Low Flow Air [LFAir] at 2 L/min. They were then randomized to receive High Flow Oxygen [HFOx] with up to 60 L/min, High Flow Air [HFAir], Low Flow Oxygen [LFOx] or LFAir during a constant work rate exercise test at 80% maximum. Dyspnea intensity was assessed with the modified 0-10 Borg scale. The primary outcome was difference in the slope of dyspnea intensity vs. time during the third test. Secondary outcomes included difference in exercise time, vital signs, and adverse events. We estimated that 10 patients per arm will provide 86% power to detect a 1-standard deviation main effect and 86% power to detect a 2-SD interaction effect with an alpha of 5%. A linear mixed effects model was used to assess the impact of flow rate and gas on study outcomes. Results: 45 patients were randomized and 44 completed the study (10, 11, 12, 11 patients on HFOx, HFAir, LFOx, LFAir, respectively). The mean age was 63 (range 47-77); 18 (41%) were female; 34 (44%) had lung cancer; and 20 (46%) had metastatic disease. In mixed effects model, the association between the change in dyspnea intensity over time with flow rate differed significantly between oxygen and air (P = 0.04). Specifically, HFOx (slope difference -0.20, P &lt; 0.001) and LFOx (-0.14, P = 0.01) were significantly better than LFAir, but not HFAir (+0.09, P = 0.09). Exercise time also significantly increased with HFOx (difference +2.5 min, P = 0.009) compared to LFAir, but not HFAir (+0.63 min, P = 0.48) or LFOx (+0.39 min, P = 0.65). HFOx was well tolerated without significant adverse effects. Conclusions: The combination of high flow rate and oxygen improved dyspnea and exercise duration during constant work exercise test in non-hypoxemic cancer patients. Larger trials are needed to confirm the benefits of HFOx during exercises. Clinical trial information: NCT02357134.

The HEART of the matter: the integration of respiratory mechanics, exertional dyspnoea and exercise intensity.

The HEART of the matter: the integration of respiratory mechanics, exertional dyspnoea and exercise intensity.

Systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults.

Dyspnoea is a common symptom in advanced cancer, with a prevalence of up to 70% among patients at end of life. The cause of dyspnoea is often multifactorial, and may cause considerable psychological distress and suffering. Dyspnoea is often undertreated and good symptom control is less frequently achieved in people with dyspnoea than in people with other symptoms of advanced cancer, such as pain and nausea. The exact mechanism of action of corticosteroids in managing dyspnoea is unclear, yet corticosteroids are commonly used in palliative care for a variety of non-specific indications, including pain, nausea, anorexia, fatigue and low mood, despite being associated with a wide range of adverse effects. In view of their widespread use, it is important to seek evidence of the effects of corticosteroids for the management of cancer-related dyspnoea. To assess the effects of systemic corticosteroids for the management of cancer-related breathlessness (dyspnoea) in adults. We searched CENTRAL, MEDLINE, Embase, CINAHL, Science Citation Index Web of Science, Latin America and Caribbean Health Sciences (LILACS) and clinical trial registries, from inception to 25 January 2018. We included randomised controlled trials that included adults aged 18 years and above. We included participants with cancer-related dyspnoea when randomised to systemic corticosteroids (at any dose) administered for the relief of cancer-related dyspnoea or any other indication, compared to placebo, standard or alternative treatment. Five review authors independently assessed trial quality and three extracted data. We used means and standard deviations for each outcome to report the mean difference (MD) with 95% confidence interval (CI). We assessed the risk of bias and quality of evidence using GRADE. We extracted primary outcomes of sensory-perceptual experience of dyspnoea (intensity of dyspnoea), affective distress (quality of dyspnoea) and symptom impact (burden of dyspnoea or impact on function) and secondary outcomes of serious adverse events, participant satisfaction with treatment and participant withdrawal from trial. Two studies met the inclusion criteria, enrolling 157 participants (37 participants in one study and 120 in the other study), of whom 114 were included in the analyses. The studies compared oral dexamethasone to placebo, followed by an open-label phase in one study. One study lasted seven days, and the duration of the other study was 15 days.We were unable to conduct many of our predetermined analyses due to different agents, dosages, comparators and outcome measures, routes of drug delivery, measurement scales and time points. Subgroup analysis according to type of cancer was not possible.Primary outcomesWe included two studies (114 participants) with data at one week in the meta-analysis for change in dyspnoea intensity/dyspnoea relief from baseline. Corticosteroid therapy with dexamethasone resulted in an MD of lower dyspnoea intensity compared to placebo at one week (MD -0.85 lower dyspnoea (scale 0-10; lower score = less breathlessness), 95% CI -1.73 to 0.03; very low-quality evidence), although we were uncertain as to whether corticosteroids had an important effect on dyspnoea as results were imprecise. We downgraded the quality of evidence by three levels from high to very low due to very serious study limitations and imprecision.One study measured affective distress (quality of dyspnoea) and results were similar between groups (29 participants; very low-quality evidence). We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Both studies assessed symptom impact (burden of dyspnoea or impact on function) (113 participants; very low-quality evidence). In one study, it was unclear whether dexamethasone had an effect on dyspnoea as results were imprecise. The second study showed more improvement for physical well-being scores at days eight and 15 in the dexamethasone group compared with the control group, but there was no evidence of a difference for FACIT social/family, emotional or functional scales. We downgraded the quality of the evidence three times for imprecision, inconsistency, and serious study limitations.Secondary outcomesDue to the lack of homogenous outcome measures and inconsistency in reporting, we could not perform quantitative analysis for any secondary outcomes. In both studies, the frequency of adverse events was similar between groups, and corticosteroids were generally well tolerated. The withdrawal rates for the two studies were 15% and 36%. Reasons for withdrawal included lost to follow-up, participant or carer (or both) refusal, and death due to disease progression. We downgraded the quality of evidence for these secondary outcomes by three levels from high to very low due to serious study limitations, inconsistency and imprecision.Neither study examined participant satisfaction with treatment. There are few studies assessing the effects of systemic corticosteroids on cancer-related dyspnoea in adults with cancer. We judged the evidence to be of very low quality that neither supported nor refuted corticosteroid use in this population. Further high-quality studies are needed to determine if corticosteroids are efficacious in this setting.

Ventilatory response to CO2 in patients with epilepsy.

Severe periictal respiratory depression is thought to be linked to risk of sudden unexpected death in epilepsy (SUDEP) but its determinants are largely unknown. Interindividual differences in the interictal ventilatory response to CO2 (hypercapnic ventilatory response [HCVR] or central respiratory CO2 chemosensitivity) may identify patients who are at increased risk for severe periictal hypoventilation. HCVR has not been studied previously in patients with epilepsy; therefore we evaluated a method to measure it at bedside in an epilepsy monitoring unit (EMU) and examined its relationship to postictal hypercapnia following generalized convulsive seizures (GCSs). Interictal HCVR was measured by a respiratory gas analyzer using a modified rebreathing technique. Minute ventilation (VE ), tidal volume, respiratory rate, end tidal (ET) CO2 and O2 were recorded continuously. Dyspnea during the test was assessed using a validated scale. The HCVR slope (ΔVE /ΔETCO2 ) for each subject was determined by linear regression. During the video-electroencephalography (EEG) study, subjects underwent continuous respiratory monitoring, including measurement of chest and abdominal movement, oronasal airflow, transcutaneous (tc) CO2 , and capillary oxygen saturation (SPO2 ). Sixty-eight subjects completed HCVR testing in 151 ± (standard deviation) 58 seconds, without any serious adverse events. HCVR slope ranged from -0.94 to 5.39 (median 1.71) L/min/mm Hg. HCVR slope correlated with the degree of unpleasantness and intensity of dyspnea and was inversely related to baseline ETCO2 . Both the duration and magnitude of postictal tcCO2 rise following GCSs were inversely correlated with HCVR slope. Measurement of the HCVR is well tolerated and can be performed rapidly and safely at the bedside in the EMU. A subset of individuals has a very low sensitivity to CO2 , and this group is more likely to have a prolonged increase in postictal CO2 after GCS. Low interictal HCVR may increase the risk of severe respiratory depression and SUDEP after GCS and warrants further study.

Manipulation of mechanical ventilatory constraint during moderate intensity exercise does not influence dyspnoea in healthy older men and women.

The perceived intensity of exertional breathlessness (i.e. dyspnoea) is higher in older women than in older men, possibly as a result of sex-differences in respiratory system morphology. During exercise at a given absolute intensity or minute ventilation, older women have a greater degree of mechanical ventilatory constraint (i.e. work of breathing and expiratory flow limitation) than their male counterparts, which may lead to a greater perceived intensity of dyspnoea. Using a single-blind randomized study design, we experimentally manipulated the magnitude of mechanical ventilatory constraint during moderate-intensity exercise at ventilatory threshold in healthy older men and women. We found that changes in the magnitude of mechanical ventilatory constraint within the physiological range had no effect on dyspnoea in healthy older adults. When older men and women perform moderate intensity exercise, mechanical ventilatory constraint does not contribute significantly to the sensation of dyspnoea. We aimed to determine the effect of manipulating mechanical ventilatory constraint during submaximal exercise on dyspnoea in older men and women. Eighteen healthy subjects (aged 60-80years; nine men and nine women) completed two days of testing. On day1, subjects were assessed for pulmonary function and performed a maximal incremental cycle exercise test. On day2, subjects performed three 6-min bouts of cycling at ventilatory threshold, in a single-blind randomized manner, while breathing: (i) normoxic helium-oxygen (HEL) to reduce the work of breathing (Wb ) and alleviate expiratory flow limitation (EFL); (ii) through an inspiratory resistance (RES) of ∼5 cmH2 OL-1 s-1 to increase Wb ; and (iii) ambient air as a control (CON). Oesophageal pressure, diaphragm electromyography, and sensory responses (category-ratio 10 Borg scale) were monitored throughout exercise. During the HEL condition, there was a significant decrease in Wb (men: -21±6%, women: -17±10%) relative to CON (both P<0.01). Moreover, if EFL was present during CON (four men and five women), it was alleviated during HEL. Conversely, during the RES condition, Wb (men: 42±19%, women: 50±16%) significantly increased relative to CON (both P<0.01). There was no main effect of sex on Wb (P=0.59). Across conditions, women reported significantly higher dyspnoea intensity than men (2.9±0.9vs. 1.9±0.8 Borg scale units, P<0.05). Despite significant differences in the degree of mechanical ventilatory constraint between conditions, the intensity of dyspnoea was unaffected, independent of sex (P=0.46). When older men and women perform moderate intensity exercise, mechanical ventilatory constraint does not contribute significantly to the sensation of dyspnoea.

Effects of Oral Morphine on Dyspnea in Patients with Cancer: Response Rate, Predictive Factors, and Clinically Meaningful Change (CJLSG1101).

Although the efficacy of parenteral morphine for alleviating dyspnea has been previously demonstrated in several studies, little is known regarding the efficacy of oral morphine for dyspnea among patients with cancer, including its response rate and predictive factors of effectiveness. Therefore, the aim of this study was to clarify the effectiveness of oral morphine on dyspnea in patients with cancer and elucidate the predictive factors of its effectiveness. In this multicenter prospective observational study, we investigated the change in dyspnea intensity in patients with cancer before and after the administration of oral morphine by using a visual analog scale (VAS). We also administered a self-assessment questionnaire to determine whether the patients believed oral morphine was effective. Eighty patients were enrolled in the study, and 71 of these patients were eligible. The least square mean of the VAS scores for dyspnea intensity was 53.5 at baseline, which decreased significantly to 44.7, 40.8, and 35.0 at 30, 60, and 120 minutes after morphine administration, respectively. Fifty-four patients (76.1%) reported that oral morphine was effective on the self-assessment questionnaire. Among the background factors, a high score for "sense of discomfort" on the Cancer Dyspnea Scale (CDS) and a smoking history of fewer pack-years were associated with greater effectiveness. Oral morphine was effective and feasible for treating cancer-related dyspnea. A higher score for "sense of discomfort" on the CDS and a smaller cumulative amount of smoking may be predictive factors of the effectiveness of oral morphine. This study demonstrated that oral morphine was effective in alleviating cancer-related dyspnea due to multiple factors including primary lung lesions, airway narrowing, and pleural effusion. Approximately 76% of patients reported that oral morphine was effective. A higher score for "sense of discomfort" on the Cancer Dyspnea Scale and a lower cumulative amount of smoking may be predictive factors for the effectiveness of oral morphine. Interestingly, respiratory rates in patients who reported the morphine to be effective decreased significantly after oral morphine administration, unlike the respiratory rates in "morphine-ineffective" patients.

Ventilatory and sensory responses to incremental exercise in adults with a Fontan circulation.

Many adults with single-ventricle congenital heart disease who have undergone a Fontan procedure have abnormal pulmonary function resembling restrictive lung disease. Whether this contributes to ventilatory limitations and increased dyspnea has not been comprehensively studied. We recruited 17 Fontan participants and 17 healthy age- and sex-matched sedentary controls. All participants underwent complete pulmonary function testing followed by a symptom-limited incremental cardiopulmonary cycle exercise test with detailed assessments of dyspnea and operating lung volumes. Fontan participants and controls were well matched for age, sex, body mass index, height, and self-reported physical activity levels (all P > 0.05), although Fontan participants had markedly reduced cardiorespiratory fitness and peak work rates ( P < 0.001). Fontan participants had lower values for most pulmonary function measurements relative to controls with 65% of Fontan participants showing evidence of a restrictive ventilatory defect. Relative to controls, Fontan participants had significantly higher breathing frequency, end-inspiratory lung volume (% total lung capacity), ventilatory inefficiency (high ventilatory equivalent for CO2), and dyspnea intensity ratings at standardized absolute submaximal work rates. There were no between-group differences in qualitative descriptors of dyspnea. The restrictive ventilatory defect in Fontan participants likely contributes to their increased breathing frequency and end-inspiratory lung volume during exercise. This abnormal ventilatory response coupled with greater ventilatory inefficiency may explain the increased dyspnea intensity ratings in those with a Fontan circulation. Interventions that enhance the ventilatory response to exercise in Fontan patients may help optimize exercise rehabilitation interventions, resulting in improved exercise tolerance and exertional symptoms. NEW & NOTEWORTHY This is the first study to comprehensively characterize both ventilatory and sensory responses to exercise in adults that have undergone the Fontan procedure. The majority of Fontan participants had a restrictive ventilatory defect. Compared with well-matched controls, Fontan participants had increased breathing frequency, end-inspiratory lung volume, and ventilatory inefficiency. These abnormal ventilatory responses likely form the mechanistic basis for the increased dyspnea intensity ratings observed in our Fontan participants during exercise.

Personalized Goal for Dyspnea and Clinical Response in Advanced Cancer Patients

BackgroundThe clinical response after comprehensive symptom management is difficult to determine in terms of a clinically important difference. Moreover, therapies should try to reach the threshold perceived by the individual patient for the determination of a favorable response to a treatment. MeasuresThe Edmonton Symptom Assessment Score (ESAS) was measured at admission (T0), and seven days after starting palliative care (T7). Patient Global Impression and Goal Response after one week of palliative care and its relation with the Personalized Dyspnea Goal were measured at T7. InterventionPatients admitted to palliative care units underwent a comprehensive symptom assessment by a specialist palliative care team. At T0, patients were asked about their Personalized Dyspnea Intensity Goal on ESAS. One week later (T7), after a comprehensive palliative care treatment, Personalized Dyspnea Intensity Goals were measured again. Patients were considered to have achieved a Patient Dyspnea Goal Response if dyspnea intensity (measured at T7) was equal or less than their expected Personalized Dyspnea Intensity Goal. At the same interval (T7), Patient Global Impression (improvement or deterioration) was measured. Outcomes279 patients were analyzed in this study. The mean Personalized Dyspnea Intensity Goal at T0 and T7 were 0.97 (SD 1.3), and 0.71 (SD 2.1), respectively. 263 patients (94.2%) indicated a Personalized Dyspnea Intensity Goal of ≤3 as a target at T0. Patients perceived a bit better, a better improvement, and a much better improvement with a mean decrease in dyspnea intensity of -2.1, -3.5, and -4.3 points on the dyspnea intensity scale, respectively. In 60 patients (21.5%), dyspnea intensity did not change, and in 4.7%, dyspnea intensity worsened. Patients perceived a Minimal Clinically Important Difference (little worse) with a mean increase in dyspnea intensity of 0.10, and they perceived a worse with a mean increase of 1.7 points. Higher dyspnea intensity at T0 and lower dyspnea intensity at T7 were independently related to Patient Global Impression. At T7, 93 (33.3%) patients achieved their Personalized Goal Response, based on Personalized Dyspnea Intensity. Patient Dyspnea Goal Response was associated with Memorial Delirium Assessment Scale score and Personalized Dyspnea Intensity Goal at T0, and inversely associated with dyspnea intensity at T0 and T7, and lower Karnofsky level. For Patient Dyspnea Goal Response, no significant differences among categories of dyspnea intensity were found (P>0.05). ConclusionPatient Dyspnea Goal Response and Patient Global Impression seem to be relevant for evaluating the effects of a comprehensive management of symptoms, including dyspnea, assisting decision making process. Some factors may be implicated in determining the individual target and clinical response. A personalized symptom goal may translate in terms of therapeutic intervention, according to the achievement of the patients' expectations. High values of dyspnea intensity, a lower Karnofsky level, as well as high level of Dyspnea Intensity Goal (that is less patients' expectations) favor the achievement of the target.

Prevalence and intensity of dyspnea, pain, and agitation among people dying with late stage dementia compared with people dying with advanced cancer: a single-center preliminary study in Brazil.

As death approaches, there may be similarities in terms of physical symptoms among dementia and cancer. This study aimed to estimate the prevalence and intensity of dyspnea, pain, and agitation among people dying with late stage dementia versus those dying with advanced cancer. Methods: A retrospective analysis, conducted in a post-acute care facility (PACF) in Rio de Janeiro, Brazil. We reviewed the electronic charts for the Edmonton Symptom Assessment System (ESAS) scores, from death backwards in time (3 days). A retrospective analysis, conducted in a post-acute care facility (PACF) in Rio de Janeiro, Brazil. We reviewed the electronic charts for the Edmonton Symptom Assessment System (ESAS) scores, from death backwards in time (3 days). We included 57 patients who died with dementia and 54 patients who died with cancer. The prevalence of dyspnea (dementia: n=34, 60% vs. cancer: n=39, 72%; P=0.23), and agitation (dementia: n=7, 13% vs. cancer: n=14, 25%; P=0.17) were statically similar between the two groups. Pain was less common in dementia (dementia: n=19, 34% vs. cancer: n=31, 57%; P=0.02). There were no significant differences in the percentage of patients with moderate to severe dyspnea (dementia: n=28, 49% vs. cancer: n=33, 61%; P=0.28), and moderate to severe agitation (dementia: n=4, 7% vs. cancer: n=12, 23%; P=0.09). Dementia patients were less likely to experience moderate to severe pain than cancer patients (dementia: n=14, 25% vs. cancer: n=25, 46%; P=0.03). The diagnosis of cancer was independently associated with pain, severe symptoms, and the co-occurrence of dyspnea, pain, and agitation (odds ratio >1). People dying with dementia and those dying with cancer experienced similar rates of dyspnea, and agitation. However, pain was significantly more prevalent and intense among people dying with cancer.

Predictors of mortality in patients with COPD after 9 years.

BackgroundCOPD is one of the leading causes of morbidity and mortality in the world; however, the most varied amounts of clinical and laboratory characteristics acts in different ways in the mortality among over time. Therefore, this study aimed to evaluate the predictors of mortality in patients with COPD after 9 years.Patients and methodsOne hundred and thirty-three patients with COPD were assessed at baseline by spirometry, pulse oximetry (SpO2), body composition, intensity of dyspnea, distance walked in the 6-minute walk test (6MWT), and Charlson Comorbidity Index (CCI).ResultsAfter 9 years, it was not possible to identify the lifetime of 4 patients who died and of 19 patients who stopped follow-up; thus, 110 patients were included in the analysis of predictors of mortality (67% male, 65±9 years old, and FEV1: 52.5 [40%–73%]). Male sex, age, SpO2, Body mass index, airway Obstruction, Dyspnea, and Exercise capacity (BODE) index, and frequency of exacerbations in the first 3 years of follow-up were considered in the model. Patients classified at baseline with BODE class 2 (HR: 2.62, 95% CI: 1.36–5.04; P=0.004), BODE class 3 (HR: 2.54, 95% CI: 1.15–5.61; P=0.02), and BODE class 4 (HR: 15.35, 95% CI: 3.11–75.75; P=0.001) showed increased risk of death compared to those with BODE class 1. The CCI (HR: 1.29, 95% CI: 1.00–1.68; P=0.04) and the number of exacerbations in the first 3 years (HR: 1.32, 95% CI: 1.00–1.76; P=0.04) also showed increased risk of death. By replacing the BODE index for the variables that compose it, those with body mass index ≤21 kg/m2 showed increased risk of death compared to those with body mass index (BMI)>21 kg/m2 (HR: 2.70, 95% CI: 1.38–5.25; P=0.003).ConclusionAfter 9 years, we identified that those with high BODE index, greater CCI, greater frequency of exacerbations in the first 3 years, and BMI ≤21 kg/m2 showed increased risk of death.

P3.01-10 Dyspnea as a Prognostic Factor in Hispanic Patients with Non-Small Cell Lung Cancer Cohort

Lung cancer is a commonly diagnosed cancer, and the leading cause of cancer death around the world. Over 80% of lung cancer patients in México are diagnosed in advanced stage. Common symptoms include cough, dyspnea, weight loss, and chest pain. Dyspnea is one of the most common symptoms in patients with lung cancer at initial presentation with a prevalence of 55–90%. The intensity of dyspnea is an important and validated factor for assessment of quality of life (QOL) in cancer patients. In addition, improvement of health-related QOL and symptoms, such as dyspnea, are related with the efficacy of chemotherapeutic regimens and favorable outcome in lung cancer. In this study, we investigated the association between the degree of dyspnea and clinical outcomes to identify the prognostic role of dyspnea in hispanic patients with non-small cell lung cancer (NSCLC). We retrospectively reviewed lung cancer database of Centro Oncologico Estatal ISSEMYM. From 2013 to 2016 we enrolled patients with diagnosis of advanced NSCLC. Clinicopathological information on age, sex, smoking history, histologic type, stage, Eastern Cooperative Oncology Group (ECOG) performance status, clinical outcomes and evaluation of symptoms of dyspnea at diagnosis using modified Medical Research Council (mMRC) scores from each patient were recorded. A total of 120 patients with diagnosis of NSCLC were identified, of these only in 65 patients (54%) the symptom of dyspnea were detected and evaluate using modified Medical Research Council (mMRC) scores at initial diagnosis. The median age was 58 years. Among those patient with dyspnea and mMRC scores available at diagnosis, 29 (45%) patients had an mMRC score ≥ 2, while 36 (55 %) had an mMRC score < 2. In multivariate analysis, poor performance status and an mMRC score ≥2 were found to be significant prognostic factors for patient survival. The overall median survival for all patients was 18 months. The overall survival of patients with dyspnea (mMRC grade 2 or higher) was significantly lower than that for patients without or low grade dyspnea (median survival, 17 months vs. 35 months, p<0.036). In conclusion, this study showed that the dyspnea mMRC mMRC grade 2 or higher in Hispanic patient with NSCLC were significantly associated with poor prognosis. Therefore, clinicians should pay more attention to evaluation and management of dyspnea.

Efficacy of immediate-release oxycodone for dyspnoea in cancer patient: cancer dyspnoea relief (CDR) trial.

Guidelines recommend morphine as the first-line pharmacological treatment for cancer dyspnoea. However, trials with other opioids have not been performed. Our aim was to demonstrate the non-inferiority of oxycodone to morphine for relieving dyspnoea in cancer patients. We conducted a multicentre, open-label, parallel-group, randomized control trial. We randomly and equally assigned cancer patients on regular oxycodone who developed dyspnoea to get a single dose of oral immediate-release oxycodone or morphine. We evaluated the change in dyspnoea intensity (numeric rating scale: 0-10) and adverse events after the medication administration. This study was preconfidence interval -maturely terminated. All 17 enroled patients (8 using oxycodone, 9 using morphine) completed evaluations. In the oxycodone group, dyspnoea intensity decreased 1.75 points [95% confidence interval, 0.72-2.78] at 60 min and 1.50 points (95% confidence interval, -0.11 to 3.11) at 120 min. In the morphine group, dyspnoea decreased 1.33 points (95% confidence interval, 0.41-2.25) at 60 min and 1.00 point (95% confidence interval, -0.08 to 2.08) at 120 min. The differences did not fulfil the non-inferiority requirement. Although two and four patients in morphine group developed drowsiness at 60 and 120 min, no patient in oxycodone group developed significant adverse events. Although we did not show the non-inferiority of oxycodone, oxycodone may have some effectiveness for cancer dyspnoea without significant safety concern. UMIN-CTR: UMIN 000005760.

Dyspnoea in patients receiving noninvasive ventilation for acute respiratory failure: prevalence, risk factors and prognostic impact

Dyspnoea is a frequent and intense symptom in intubated patients, but little attention has been paid to dyspnoea during noninvasive mechanical ventilation in the intensive care unit (ICU).The objectives of this study were to quantify the prevalence, intensity and prognostic impact of dyspnoea in patients receiving noninvasive ventilation (NIV) for acute respiratory failure (ARF) based on secondary analysis of a prospective observational cohort study in patients who received ventilatory support for ARF in 54 ICUs in France and Belgium. Dyspnoea was measured by a modified Borg scale.Among the 426 patients included, the median (interquartile range) dyspnoea score was 4 (3-5) on admission and 3 (2-4) after the first NIV session (p=0.001). Dyspnoea intensity ≥4 after the first NIV session was associated with the Sequential Organ Failure Assessment Score (odds ratio (OR) 1.12, p=0.001), respiratory rate (OR 1.03, p=0.032), anxiety (OR 1.92, p=0.006), leaks (OR 2.5, p=0.002) and arterial carbon dioxide tension (OR 0.98, p=0.025). Dyspnoea intensity ≥4 was independently associated with NIV failure (OR 2.41, p=0.001) and mortality (OR 2.11, p=0.009), but not with higher post-ICU burden and altered quality of life.Dyspnoea is frequent and intense in patients receiving NIV for ARF and is associated with a higher risk of NIV failure and poorer outcome.

Observational study to analyze patterns of treatment of breakthrough dyspnea in cancer patients in clinical practice.

Although breakthrough dyspnea is very frequent in cancer patients, there are no precise recommendations for treating it. The main objective of this study was to analyze what treatments are used in clinical practice for the management of breakthrough dyspnea in cancer patients in Spain and the secondary objectives were to describe the characteristics of cancer patients with breakthrough dyspnea and the attributes of the disorder. Cancer patients over 18 years of age, with breakthrough dyspnea and a Karnofsky performance score of ≥30, who were treated at departments of oncology in institutes across Spain were included in this cross-sectional observational study. The characteristics of breakthrough dyspnea, history of treatment, anthropometric variables, Mahler dyspnea index, Borg scale, Edmonton Symptoms Assessment Scale, and patient satisfaction with current breakthrough dyspnea treatment were assessed. The mean age of the 149 included patients was 66 years (95% confidence interval: 64.3 to 67.9), and 53 were females (35.6%). The mean breakthrough dyspnea intensity was 5.85 (95% confidence interval 5.48 to 6.22, Borg scale). A total of 55.1% of the first-choice treatments consisted of opioids, followed by oxygen (17.3%). A total of 119 patients (79.9%) received monotherapy for breakthrough dyspnea. Patients presenting with basal dyspnea received oxygen in a greater proportion of cases (21.1% vs 7.4%; p = 0.07). Patients with predictable dyspnea received a greater proportion of opioids (70.9% vs 44.4%; p = 0.01). Opioids constitute first-line therapy for breakthrough dyspnea in routine clinical practice, though the scientific evidence supporting their use is scarce. Further information derived from controlled clinical trials is needed regarding the comparative efficacy of the different treatments in order to justify their use.

Dyspnea in Cancer Patients: A Well-Known and Neglected Symptom.

Dyspnea is a very common and well-known symptom in patients with advanced cancer, but it is often neglected by physicians. Moreover, despite the high frequency of dyspnea, few controlled studies have been conducted on cancer patients. In most cases, this 'awareness of breathing with difficulty' and its severity can only be judged by the patient. Moderate or severe dyspnea is described in 20-80% of patients with advanced cancer and breathlessness is considered a prognostic factor for shorter survival, either alone or associated with other parameters. I reviewed the literature and guidelines on the topic with the aims to focus on what is known and on future pathways to follow for the diagnosis and treatment of dyspnea. There is no uniformity regarding the definition of dyspnea; consequently, there is still no general agreement about which tools are the best to use in clinical practice to detect the presence and severity of this symptom. In addition to the difficulty of assessing the symptom, a further limit concerns the management of dyspnea: a very limited number of therapies, both pharmacological and otherwise, are currently available that lead to satisfactory outcomes. Opioids such as morphine remain the cornerstone of treating dyspnea. Dyspnea is a complex, multidimensional symptom that results from an interaction between factors and their causes, perception and expression. The main target of assessment and management is the intensity of dyspnea, as expressed by the patient, rather than the objective parameters of the disease. Although dyspnea is a very common symptom, debilitating and often difficult to control, especially in the terminal phase of the disease, few controlled studies have been conducted on cancer patients. Dyspnea remains a well-known but neglected symptom in advanced and terminal cancer patients. Future studies should be conducted regarding the careful assessment and management of this symptom.

Experimentally Manipulating Mechanical Ventilatory Constraint During Exercise Does Not Influence Dyspnea in Older Men and Women

During exercise at a standardized metabolic work load, the perception of dyspnea is higher in older women than older men, which is thought to be related to sex-differences in mechanical ventilatory constraint; however, this hypothesis has yet to be experimentally tested. PURPOSE: To determine the effect of manipulating the magnitude of mechanical ventilatory constraint during submaximal exercise on dyspnea in older men and women. METHODS: Thirteen healthy subjects (60-80 y; n=7 women) completed two days of testing. On Day 1, subjects performed pulmonary function testing and a maximal incremental cycle exercise test. On Day 2, esophageal pressure (Pes) and diaphragm electromyography (EMGdi) were recorded during three constant load cycle exercise tests (6 min each) at ventilatory threshold (VTh). Constant load exercise tests were performed under three conditions in a single blind, randomized, counterbalanced fashion: i) breathing normoxic helium-oxygen gas (HeO2) to reduce the work of breathing (W b ) and alleviate expiratory flow limitation (EFL); ii) inspiratory resistance (RES) of 5 cmH2O·l-1·s-1 to increase W b ; and iii) control (CON) breathing room air. During exercise on Day 2, Pes-derived measures of Wb, EMGdi, and EFL were assessed. RESULTS: During the HeO2 condition, there was a significant decrease in Wb (men=-20±4%, women= -16±5%) and EMGdi (men= -11±7%, women= -9±7%) relative to CON (both p<0.01). Moreover, if EFL was present during the CON condition (n=3 men, n=5 women), it was alleviated during HeO2. Conversely, during the RES condition, there was a significant increase in Wb (men= 34±11%, women= 50±12%) and EMGdi (men=32±15%, women= 23±12%) relative to CON (both p<0.01). The effect of condition on Wb and EMGdi was not significantly different between the sexes (both p>0.05). Across conditions, women reported significantly higher levels of dyspnea than men (3.3±0.4 vs. 1.9±0.4 Borg units, p<0.05). However, despite significant differences in the degree of mechanical ventilatory constraint between conditions, there was no effect of condition on the perception of dyspnea intensity, regardless of sex (p=0.46). CONCLUSION: Our results suggest that during short bouts of exercise at VTh, sex-differences in dyspnea in older adults are not related to sex-differences in mechanical ventilatory constraint.

Episodic Breathlessness inPatients with Advanced Cancer: Characteristics and Management.

The aim of this review is to present the way in which episodic breathlessness (EB) has been recognized over the years, with regard to definition, characteristics, and management of these acute episodes that have serious consequences for patients. EB is characterized by a sudden increase in intensity of dyspnea over a short duration of time, leading to high levels of anxiety. A significant aggravation of dyspnea may occur in patients with a background of dyspnea or intermittently even without basal breathlessness. Often, known precipitating factors may trigger EB. Flares of breathlessness are accompanied by degrees of psychological distress, although it is unclear whether psychological factors may precede or be induced by EB. In any case, there is a reinforcing circuit. The duration of EB ranges from 10-30min. Given the specific temporal pattern, requiring rapid intervention, substances with a short onset of action are suitable to overlap this phenomenon. Short-onset opioids could provide a clinical effect overlapping the onset and duration of an episode, resembling what has been largely reported for breakthrough pain. Although data are still insufficient to suggest specific recommendations, strategies such asavoiding exertion, pacing or using devices, or keeping calmhave been described. Few controlled studies have investigated the effects of different formulations of opioids. Some data were gathered from studies assessing the pre-emptive use of rapid onset opioids, such as transmucosal preparations of fentanyl, followed by a provocative test, while other studies attempted to reproduce real-life conditions, given as needed. All these trials were insufficiently powered to address the efficacy of fentanyl products over oral morphine or placebo, reflecting the difficulties in patient recruiting and finalizing the studies. Strategies to prevent the occurrence of EB should be taken into consideration, including optimization of the condition of persistent dyspnea or treating psychologic or environmental causes.