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IntroductIon Dyspnea is the primary com-plaint of patients with advanced lung or heart dis-ease. For example, of patients with chroniclung disease experience dyspnea in the last year oflife.1 In SUPPOR (Study to Understand PatientPreferences and Outcomes of reatment), inves-tigators found that dyspnea was the overridingcomplaint of patients who died of their chron-ic obstructive pulmonary disease (COPD), and

that serious dyspnea was far more common( ) than serious pain ( ). 2 Tese inves-tigators reported that patients with COPD were

more likely to die with poor control of dyspneathan patients who had lung cancer. 3

Te experience of dyspnea includes sensory(how severe is it?) and affective (how unpleasantis it?) components. Based on a neurophysio logicalmodel, breathlessness is thought to be similar tothe perception of pain. 4 Clearly, both symptomscan result in human suffering, and dying patientsfear breathlessness and pain. Anxiety, depression,

and other psycho logical factors occur frequentlyin patients with advanced disease, and inuencebreathlessness. 5 Dyspnea is a distressing symp-

Correspondence to:Donald A. Mahler, MD, FCCP,DartmouthHitchcock Medical Center,Pulmonary and Critical Care Medicine,One Medical Center Drive, Lebanon,NH 03 7560001, USAphone: +16036505533,fax: +16036500580, email:donald.a.mahler@hitchcock.orgReceived: March 30, 2010.Accepted: March 30, 2010.

Conflict of interests: none declared.Pol Arch Med Wewn. 2010;120 (5): 160166Copyright by Medycyna Praktyczna,Krakw 2010

Key words

ethical issues, opioidmedications, oxygentherapy, patient

reported dyspnea

orIGInAL ArtIcLe

Management of dyspnea in patients withadvanced lung or heart diseasePractical guidance from the American College of Chest Physicians Consensus Statement

Donald A. Mahler 1, Paul A. Selecky 2, Christopher G. Harrod 3

1 Dartmouth Medical School, Lebanon, New Hampshire, United States2 Hoag Hospital, Newport Beach, California, United States3 American College of Chest Physicians, Northbrook, Illinois, United States

AbstrAct

IntroductIon Patients with advanced lung or heart disease are not generally being treated consistently and effectively for relief of dyspnea.objectIves The aim of the paper was to review available literature and to provide consensus statements using the Delphi method relevant to the topic condition.PAtIents And methods A panel of experts of the American College of Chest Physicians (ACCP)defined the topic condition as dyspnea that persists at rest or with minimal activity and is distressful despite optimal therapy of advanced lung or heart disease. After a literature review, the panel

developed 23 statements that were assessed for agreement/disagreement on a 5point Likert scaleusing 2 rounds of the Delphi method.resuLts For the first round of the Delphi method, the survey was sent to the 15 expert panel members.Some statements were modified if deemed appropriate. For the second round of the Delphi method,23 statements were sent to 56 clinicians from 5 relevant specialty NetWork steering committees ofthe ACCP. Agreement of at least 70% was achieved for 20 of the 23 statements.concLusIons There was consensus that: patients with advanced lung or heart disease shouldbe asked about the intensity and distress of their breathlessness; pursedlips breathing, relaxation,oxygen for those with hypoxemia, noninvasive positive pressure ventilation, and oral/parental opioidscan provide relief of dyspnea; therapies should be started with the understanding that the patientand clinician will reassess whether the specific treatments are relieving dyspnea without causing

adverse effects; and it is important to communicate about palliative and endoflife care.

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families should be reassured that they will be pro-vided the means to effectively treat this symptom(agreement ).6 Terapies should generally be started withthe understanding that the patient and clinicianwill reassess whether specic treatments are serv-ing the goal of palliating dyspnea without caus-ing adverse effects (agreement ).

Asking patients to report the severity and/ordistress of their breathlessness is recommend-

ed in order to assess its impact on an individu-als health status and to provide a baseline valuein order to evaluate the response to therapy. 812 Tis approach is analogous to the assessment ofpain that is mandated in healthcare encountersto guide pain awareness and management.

Although dyspnea is multidimensional and in-cludes both sensory and affective components,an initial strategy is to ask the patient to reportthe intensity or severity of breathlessness. 1013 Te scale, 14 the visual analog scale, 15,16 andthe numerical rating scale 17 have all been used toassess breathlessness in patients with advanceddisease. However, none of these instruments hasbeen shown to be superior in managing dyspneain this patient population. 1720

d mai : x g h ap7 Supplemental oxygen can provide relief ofdyspnea for patients who are hypoxemic at rest(agreement ).8 Supplemental oxygen can provide relief ofdyspnea for patients who are hypoxemic duringminimal activity (agreement ).

Oxygen therapy is standard of care for

the treatment of patients with hypoxemia. How-ever, only limited information is available aboutthe short-term effects of supplemental oxygentherapy on breathlessness at rest in patients withadvanced lung disease. wo studies reported sig-nicant improvement in dyspnea with oxygentherapy, 21,22 while other studies found no ben-et. 23,24 No randomized controlled trials wereidentied that evaluated the effects of oxygenin reducing breathlessness in patients with ad-vanced heart disease. For patients with advancedlung or heart disease who were not hypoxemicat rest, the literature search did not identify anystudies evaluating the effects of supplementaloxygen for the relief of dyspnea.

d mai : h pha ma l gi al h api9 Pursed-lips breathing (PLB) can be an effectivestrategy for relief of dyspnea (agreement ).10 Relaxation can be an effective strategy forrelief of dyspnea (agreement ).11 Noninvasive positive pressure ventilation canprovide relief of dyspnea (agreement ).

PLB is a breathing strategy often employedspontaneously by patients with COPD to relieve

breathlessness. By promoting a slower and deep-er breathing pattern, PLB improves physio logicalpara meters increases oxygen saturation anddecreases carbon dioxide levels that may affect

dyspnea during exercise were excluded becausethe expert panel believed the target patient pop-ulation would have difficulty performing exercisetesting because of dyspnea at rest or during min-imum activity. Five domains were identied thatrelate to the management of dyspnea in patientswith advanced lung or heart disease ( tAbLe 2 ).

d lphi m h For the rst round of evaluation, of the panel members ( ) completed

the survey. For the second round of evaluation, of individuals ( ) completed the sur-

vey. Te statements that achieved at least agreement are reported below. Tree statementsdid not achieve agreement ( tAbLe 3 ).

d ai : a f pa i pp a

1 Patients should be asked to routinely and reg-ularly rate the intensity of their breathlessnessas part of a comprehensive care plan (agreement

).2 Te patient-reported rating of breathlessnessshould be routinely documented in the medicalrecord to guide management and inter disciplinary

care (agreement ).3 Te assessment of dyspnea should includeinquiry into the distress, meaning, and unmetneeds that accompany breathlessness (agree-ment ).4 Te use of any particular instrument over an-other for the measurement of dyspnea is not sug-gested at the present time (agreement ).5 Healthcare professionals are ethically obligat-ed to treat dyspnea, and that patients and their

tAbLe 2 Five domains identified from the literaturesearch that related to the management of dyspneain patients with advanced lung or heart disease

1 measurement of patientreported dyspnea

2 oxygen therapy

3 other nonpharmaco logical treatment

4 opioid medications

5 ethical issues

tAbLe 3 Statements that did not achieve consensus

Number Consensus statement Agreement(%)

Range ofresponses

21 For patients with advanced lung or heartdisease who are nonhypoxemic at restor with minimal activity, supplementaloxygen can provide relief of dyspneaand improve exercise endurance.

47 15

22 For patients with advanced lung or heartdisease, nebulized opioids do notprovide equivocal or additional relief ofdyspnea beyond that achieved withparenteral or oral opioids.

59 15

23 For patients with advanced lung or heartdisease, fresh air or cool air movementwith a fan directed toward the face canbe an effective strategy for relief ofdyspnea.

61 15

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orIGInAL ArtIcLe Management of dyspnea in patients with advanced lung or heart disease 163

morphine was no better than nebulized saline forrelieving dyspnea. 42,43 Furthermore, Jenningset al. 39 concluded that nebulized opioids did notrelieve breathlessness.

Fear of overdosing and the development ofrespiratory depression are common concerns incaring for patients with advanced lung or heartdisease who experience severe dyspnea. Howev-er, Chan et al. 44 reported that higher doses of opi-oids and benzodiazepines used in the withdraw-

al of life-sustaining treatment were not associ-ated with a decreased time from withdrawal oflife support to death. Of studies that provid-ed information on arterial blood gases or oxygensaturation, only study reported any signicantchanges in oxygenation after opioid administra-tion. 45 Although the arterial carbon dioxide par-tial pressure increased with opioid use, the val-ue did not exceed mmHg. 46 Other adverse ef-fects that may occur with opioids include con-stipation, confusion, drowsiness, hallucinations,nausea/vomiting, and psychosis.

d ai : i al i f li f f p aa li15 Concerns about contributing to addictionand/or physical dependence should never lim-it effective treatment or palliation of dyspnea(agreement ).16 Te principle of double effect providesa rationale for using opioids or sedatives thatmight hasten death, provided that the purposeof increasing doses is to relieve dyspnea (agree-ment ).17 Anxiety and depression frequently accom-

pany dyspnea and require evaluation (agreement).

18 Clinicians should understand that familymembers from some cultures may have differentperspectives on the role of the family and whoshould be involved in decisions about treatingdyspnea at the end of life (agreement ).19 Te clinician should anticipate differenc-es in family perspectives and/or spiritual be-liefs on the value of maintaining consciousnessat the end of life and the value of suffering, andbe prepared to apply principles of culturally ef-fective end-of-life care to these situations (agree-ment ).20 It is important for clinicians to communicateabout palliative and end-of-life care with their pa-tients (agreement ).

Major ethical issues include the obligation totreat or palliate dyspnea, appropriate opioid dos-ing, as well as associated concerns of addiction,cultural sensitivity, and effective communication. Many patients with advanced lung or heart dis-ease have a tremendous concern about the ex-perience of dying, and fear breathlessness anda suffocating feeling. 4749 Recent statements

and guidelines have emphasized the obligationof physicians and nurses to use available treat-ments to relieve dyspnea in this patient pop-ulation. 12,40,41 Te principle of double effect

the perception of dyspnea. 2527 In addition, PLBmay provide the patient with a sense of controlover her/his breathing.

Patients with respiratory disease often describethat movement of cool air with a fan or fresh airreduces breathlessness. 28 Laboratory studies haveshown that cold air directed on the cheek decreas-es dyspnea induced in healthy individuals. 29 How-ever, there are no randomized controlled studiesthat have examined the use of a fan and/or cool

air for the relief of dyspnea in patients with ad-vanced lung or heart disease.

wo studies measured the effects of relax-ation on perceived dyspnea at rest in patientswith COPD.30,31 Gift et al. 30 found that patientsreported less dyspnea after listening to a tape-

-recorded relaxation message compared with sit-ting quietly. Renfroe 31 reported that progres-sive muscle relaxation was effective in reducingdyspnea in patients with COPD after each of weekly sessions ( P = . ), but not at the end ofthe -week period.

Te rationale for noninvasive positive pressureventilation (NPPV) is that by unloading the re-spiratory muscles, the decreased work of breath-ing might provide relief of dyspnea. In system-atic reviews the authors concluded that use ofNPPV improved patients perception of dyspneain those with advanced COPD or acute respirato-ry failure. 3234 In randomized controlled trials,there was a modest to signicant improvementin patient-reported dyspnea with NPPV. 3538 Asrelief of dyspnea with NPPV may not relate tochanges in arterial blood gases, it is appropriateto reassess the breathlessness experienced by pa-

tients receiving such ventilatory support at fre-quent inter vals.

Te literature review did not nd sufficientinformation on anxiolytic medications, antide-pressants, phenothiazines, inhaled furosemide,inhaled lidocaine, music therapy, and acupunc-ture for relief of dyspnea in the target patientpopulation.

d mai : pi i m i a i12 Oral and/or parenteral opioids can providerelief of dyspnea (agreement ).13 Opioids should be dosed and titrated forthe individual patient with consideration of mul-tiple factors (e.g., renal, hepatic, pulmonary func-tion, and current and past opioid use) for reliefof dyspnea (agreement ).14 Respiratory depression is a widely held con-cern with the use of opioids for the relief of dys-pnea (agreement ).

Opioids are the primary pharmaco logic treat-ment for relief of dyspnea in patients with ad-vanced disease. 3941 Although oral morphine isthe most commonly prescribed opioid for the re-lief of dyspnea, other medications include diamor-

phine, dihydrocodeine, fentanyl, hydromorphone,and oxycodone . Although there is anecdotal sup-port for the use of nebulized opioids, data from randomized controlled trials found that nebulized

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54 Au DH, Udris EM, Fihn SD, et al. Differences in health care utilizationat the end of life among patients with chronic obstructive pulmonary disease and patients with lung cancer. Arch Intern Med. 2006; 166: 326331.

55 Gore JM, Brophy CJ, Greenstone MA. How well do we care for patients with end stage chronic obstructive pulmonary disease (COPD)?A comparison of palliative care and quality of life in COPD and lung cancer.Thorax. 2000; 55: 10001006.

56 Curtis JR, Engelberg RA, Nielsen EL, et al. Patientphysician communication about endoflife care for patients with severe COPD. Eur Respir J.2004; 24: 200205.

57 Heffner JE, Fahy B, Hilling L, Barbieri C. Attitudes regarding advancedirectives among patients in pulmonary rehabilitation. Am J Respir CritCare Med. 1996; 154: 17351740.

58 Heffner JE, Fahy B, Hilling L, Barbieri C. Outcomes of advance directive education of pulmonary rehabilitation patients. Am J Respir Crit CareMed. 1997; 155: 10551059.

59 Knauft E, Nielsen EL, Engelberg RA, et al. Barriers and facilitators toendoflife care communication for patients with COPD. Chest. 2005; 127:21882196.

60 Ahmedzai SH, Muers MF. Supportive Care in Respiratory Disease. In:Ahmedzai SH, Muers MF, eds. London: Oxford University Press; 2005.

61 Beattie J, Goodlin S. Supportive Care in Heart Failure. In: Beattie J,Goodlin S, eds. London: Oxford University Press; 2008.

62 Lorenz K, Lynn J, Morton SC, et al. Endoflife care and outcomes.Summary, Evidence Report/Technology Assessment. 2004; 110.

25 Breslin EH. The pattern of respiratory muscle recruitment duringpursedlip breathing. Chest. 1992; 101: 7578.

26 Mueller RE, Petty TL, Filley GF. Ventilation and arterial blood gas changes induced by pursed lips breathing. J A ppl Physiol. 1970; 28: 784789.

27 Tiep BL, Burns M, Kao D, et al. Pursed lips breathing training using earoximetry. Chest. 1986; 90: 218221.

28 JansonBjerklie S, Carrieri VK, Hudes M. The sensations of pulmonarydyspnea. Nurs Res. 1986; 35: 154159.

29 Schwartzstein RM, Lahive K, Pope A, et al. Cold facial stimulationreduces breathlessness induced in normal subjects. Am Rev Respir Dis.1987; 136: 5861.

30 Gift AG, Moore T, Soeken K. Relaxation to reduce dyspnea and anxietyin COPD patients. Nurs Res. 1992; 41: 242246.

31 Renfroe KL. Effect of progressive relaxation on dyspnea and state anxiety in patients with chronic obstructive pulmonary disease. Heart Lung.1988; 17: 408413.

32 Curtis JR, Cook DJ, Sinuff T, et al. Noninvasive positive pressure ventilation in critical and palliative care settings: understanding the goals oftherapy. Crit Care Med. 2007; 35: 932939.

33 Kolodziej MA, Jensen L, Rowe B, Sin D. Systematic review of noninvasive positive pressure ventilation in severe stable COPD. Eur Respir J.2007; 30: 293306.

34 Ries AL, Bauldoff GS, Carlin BW, et al. Pulmonary Rehabilitation: JointACCP/AACVPR EvidenceBased Clinical Practice Guidelines. Chest. 2007;131 (5 Suppl): 4S42S.

35 Casanova C, Celli BR, Tost L, et al. Longterm controlled trial of nocturnal nasal positive pressure ventilation in patients with severe COPD. Chest.2000; 118: 15821590.

36 Clini E, Sturani C, Rossi A, et al. The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease patients. EurRespir J. 2002; 20: 529538.

37 Jolliet P, Tassaux D, Thouret JM, Chevrolet JC. Beneficial effects ofhelium: oxygen versus air: oxygen noninvasive pressure support in patients with decompensated chronic obstructive pulmonary disease. CritCare Med. 1999; 27: 24222429.

38 Lien TC, Wang JH, Huang SH, Chen SD. Comparison of bilevel positive airway pressure and volume ventilation via nasal or facial masks inpatients with severe, stable COPD. Zhonghua Yi Xue Za Zhi (Taipei). 2000;63: 542551.

39 Jennings AL, Davies AN, Higgins JP, et al. A systematic review ofthe use of opioids in the management of dyspnoea. Thorax. 2002; 57:939944.

40 Lanken PN, Terry PB, Delisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med. 2008;177: 912927.

41 Qaseem A, Snow V, Shekelle P, et al. Evidencebased interventions toimprove the palliative care of pain, dyspnea, and depression at the end oflife: a clinical practice guideline from the American College of Physicians.Ann Intern Med. 2008; 148: 141146.

42 Eaton B, Hall J, MacDonald S. Does nebulized morphine offer symptom relief to patients with disabling dyspnea during endstage disease?Can Fam Physician. 1999; 45: 319320.

43 Noseda A, Carpiaux JP, Markstein C, et al. Disabling dyspnoea in patients with advanced disease: lack of effect of nebulized morphine. EurRespir J. 1997; 10: 10791083.

44 Chan JD, Treece PD, Engelberg RA, et al. Narcotic and benzodiazepineuse after withdrawal of life support: association with time to death? Chest.2004; 126: 286293.

45 Jennings AL, Davies AN, Higgins JP, Broadley K. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database Syst Rev.2001: CD002 066.46 BarOr D, Marx JA, Good J. Breathlessness, alcohol, and opiates.N Engl J Med. 1982; 306: 13631364.

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ArtyKu oryGInALny

Postpowanie w dusznoci u chorychz zaawansowanymi schorzeniami puc lub serca

Praktyczne wskazwki z uzgodnionego stanowiska American College of Physicians

Donald A. Mahler 1, Paul A. Selecky 2, Christopher G. Harrod 3

1 Dartmouth Medical School, Lebanon, New Hampshire, Stany Zjednoczone2 Hoag Hospital, Newport Beach, Kalifornia, Stany Zjednoczone3 American College of Chest Physicians, Northbrook, Illinois, Stany Zjednoczone

Adres do korespondencji:Donald A. Mahler, MD, FCCP,DartmouthHitchcock Medical Center,Pulmonary and Critical Care Medicine,One Medical Center Drive, Lebanon,NH 037560001, USAtel.: +16036505533,fax: +16036500580, email:donald.a.mahler@hitchcock.orgPraca wpyna: 30.03.2010.Przyjta do druku:30.03.2010.Nie zgoszono sprzecznoci

interesw.Pol Arch Med Wewn. 2010;120 (5): 160166Copyright by Medycyna Praktyczna,Krakw 2010

streszczenIe

wProwAdzenIe Chorzy na zaawansowane choroby puc i serca najczciej nie otrzymuj spjnegoi skutecznego leczenia zmniejszajcego duszno.ceLe Celem pracy by przegld dostpnego pimiennictwa i uzgodnienie metod delfick stanowiskadotyczcego omawianego tematu.PAcjencI I metody Zesp ekspertw American College of Chest Physicians (ACCP) zdefiniowaomawiany stan chorobowy jako duszno utrzymujc si w spoczynku lub przy minimalnym wysiku, ktra jest uciliwa mimo optymalnego leczenia zaawansowanych chorb puc lub serca. Podokonaniu przegldu pimiennictwa zesp ekspertw opracowa 23 stwierdzenia, ktre nastpniepoddano analizie zgody/niezgody za pomoc 5stopniowej skali Likerta z uwzgldnieniem 2 rundmetody delfickiej.wynIKI W 1. rundzie metody delfickiej ankiet wysano 15 czonkom zespou ekspertw. Niektrestwierdzenia zmodyfikowano, jeli uznano to za waciwe. W 2. rundzie 23 stwierdzenia wysano do56 lekarzy zasiadajcych w komitetach sterujcych 5 specjalistycznych grup (NetWork) ACCP. Zgodna poziomie 70% osignito dla 20 z 23 stwierdze.wnIosKI Uzgodniono, e: chorych z zaawansowan chorob puc lub serca naley pyta o nasilenie iuciliwo dusznoci; oddychanie przez zasznurowane usta, relaksacja, tlen u chorych z hipoksemi,nieinwazyjna wentylacja mechaniczna dodatnim cinieniem oraz opioidy doustnie lub poza jelitowo

mog przynie ulg w dusznoci; leczenie naley wdraa rozumiejc, e pacjent i lekarz oceni,czy dana metoda przynosi ulg w dusznoci bez powodowania dziaa niepodanych; wane jestmwienie o opiece paliatywnej i opiece u schyku ycia.

sowA KLuczowe

duszno w oceniechorego, lekiopioidowe, tlenoterapia, zagadnieniaetyczne