Management of Dyspnea in Patients With Far-Advanced Lung Disease

Markowitz, Amy J.

doi:10.1001/jama.287.17.2261

Cited by 4 publications

(4 citation statements)

References 40 publications

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“…PAO is an important sign of AAD, and if present, it significantly increases the likelihood of AAD [ 25 ]. Absence of PAO was a risk factor for DD in the study of Harris et al [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room

et al. 2015

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BackgroundInitial diagnosis of acute aortic dissection (AAD) in the emergency room (ER) is sometimes difficult or delayed. The aim of this study is to define clinical predictors related to inappropriate or delayed diagnosis of Stanford type A AAD.MethodsWe conducted a retrospective analysis of 127 consecutive patients with type A AAD who presented to the ER within 12 h of symptom onset (age: 69.0 ± 15.4 years, male/female = 49/78). An inappropriate initial diagnosis (IID) was considered if AAD was not included in the differential diagnosis or if chest computed tomography or echocardiography was not performed as initial imaging tests. Clinical variables were compared between IID and appropriate diagnosis group. The time to final diagnosis (TFD) was also evaluated. Delayed diagnosis (DD) was defined as TFD > third quartile. Clinical factors predicting DD were evaluated in comparison with early diagnosis (defined as TFD within the third quartile). In addition, TFD was compared with respect to each clinical variable using a rank sum test.ResultsAn IID was determined for 37% of patients. Walk-in (WI) visit to the ER [odds ratio (OR) 2.6, 95% confidence interval (CI) = 1.01–6.72, P = 0.048] and coronary malperfusion (CM, OR = 6.48, 95% CI = 1.14–36.82, P = 0.035) were predictors for IID. Overall, the median TFD was 1.5 h (first/third quartiles = 0.5/4.0 h). DD (>4.5 h) was observed in 27 cases (21.3%). TFD was significantly longer in WI patients (median and first/third quartiles = 1.0 and 0.5/2.85 h for the ambulance group vs. 3.0 and 1.0/8.0 h for the WI group, respectively; P = 0.003). Multivariate analysis revealed that WI visit was the only predictor for DD (OR = 3.72, 95% CI = 1.39–9.9, P = 0.009). TFD was significantly shorter for appropriate diagnoses than for IIDs (1.0 vs. 6.0 h, respectively; P < 0.0001).ConclusionsWI visit to the ER and CM were predictors for IID, and WI was the only predictor for DD in acute type A AAD in the community hospital.

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“…PAO is an important sign of AAD, and if present, it significantly increases the likelihood of AAD [ 25 ]. Absence of PAO was a risk factor for DD in the study of Harris et al [ 9 ].…”

Section: Discussionmentioning

confidence: 99%

Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room

et al. 2015

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“…Several of these articles have direct relevance to the clinical management of respiratory patients such as Mr LV. [31][32][33][34][35][36][37][38][39][40][41][42][43][44][45][46] These articles have been updated with recent evidence as a book and published as Care at the close of life: Evidence and experience. 47 Its 42 chapters are rich with examples of words that clinicians can utilize.…”

Section: Our Recommendationsmentioning

confidence: 99%

Pulmonary rehabilitation and palliative care in COPD: Two sides of the same coin?

2012

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Pulmonary rehabilitation and palliative care are two important components of the integrated care of the patient with chronic respiratory disease such as chronic obstructive pulmonary disease (COPD). These two interventions are remarkably similar in many respects. Both utilize a multidisciplinary team that focuses on the specific needs of the individual patient. Care in both is goal defined and includes relief of symptoms and improvements in functional status and quality of life. Pulmonary rehabilitation is commonly given in a specific setting, such as a hospital-based outpatient setting, while palliative care is often hospital based, with its services extending into the home setting in the form of hospice. Components of pulmonary rehabilitation and palliative care should be administered as part of good medical care. Both pulmonary rehabilitation and palliative care are currently underutilized in the respiratory patient, and often provided relatively late in the patient's clinical course. The case provided illustrates the often-overwhelming symptom burden of advanced COPD and demonstrates opportunities for the application of these twin interventions.

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“…Nevertheless, others have suggested that opioids should be considered, not only in end-of-life situations, but also for stable patients with COPD whenever breathlessness is severe and continues despite maximal bronchodilator therapy 2 43 44. The potential for use of opioids in this setting demands further study.…”

Section: Barriers To Use Of Opioids In Advanced Copdmentioning

confidence: 99%

“…Case reports2 22 43 44 attest that, for some, the improvements in quality of life have been profound.…”

Section: Barriers To Use Of Opioids In Advanced Copdmentioning

confidence: 99%

Palliation of dyspnoea in advanced COPD: revisiting a role for opioids

Rocker

Horton²,

Currow³

et al. 2009

Thorax

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Chronic obstructive pulmonary disease (COPD) will be the third leading cause of death worldwide by 2020. The burdens of this increasingly prevalent illness borne by patients, their family caregivers and the healthcare system are substantial. Dyspnoea as the predominant symptom becomes increasingly difficult to palliate as COPD progresses through advanced stages and, for 50% of patients, can become refractory to conventional treatment. This narrative review focuses on the potential role for carefully initiated and titrated opioids in the management of dyspnoea for patients with advanced COPD who are not yet in a terminal stage, yet struggle with symptoms that reflect underlying mechanisms of dyspnoea that lend themselves to this approach. The many barriers that currently exist to the provision of opioids in this setting are addressed, and recommendations are provided for an approach that should engender confidence among patients, their caregivers and the physicians who treat them.Chronic obstructive pulmonary disease (COPD) will be the third leading cause of death worldwide by 2020.1 In recent years there has been a welcome increase in the focus on the care of advanced COPD in the pages of both specialist palliative care journals 2 3 and in the respiratory literature. [4][5][6] This long overdue change reflects the reality that COPD is unique among the major diseases in western society in that its prevalence, morbidity and attributable mortality continue to rise, 7 that for patients who have advanced COPD the symptom burden is substantial, 8 9 that dyspnoea as the predominant symptom is often poorly controlled and ultimately incapacitating, 10 and that palliative care services in hospital or at home and high quality symptom-focused interventional strategies in our current models of care are less accessible than they are for people with cancer.4 9 While palliative care in general is responding to calls to extend traditional boundaries to encompass patients with advanced non-malignant medical illness, we need innovative and effective approaches to symptom control in advanced stages of COPD 2 if we are to lessen the increasing burdens that advanced COPD places on the lives of patients and caregivers alike. 11The purpose of this narrative review is to (re)consider the role of opioids in the management of the patient who lives with advanced COPD and struggles with dyspnoea refractory to conventional treatment. We also set out to describe barriers to the provision of opioid therapy.The information for this narrative review was compiled from previous researches of MEDLINE, CINAHL and EMBASE since 31 December 2006 and a recent review through PUBMED to February 2009. Dyspnoea has been a research interest for the last 15 years for the senior authors, and articles from personal archives, the unpublished literature, work in progress from colleagues, text books, the searching of recent journals and references from papers have also been incorporated. Where possible, original studies are cited but, to limit references t...

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Management of Dyspnea in Patients With Far-Advanced Lung Disease

Cited by 4 publications

References 40 publications

Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room

Clinical Predictors for Delayed or Inappropriate Initial Diagnosis of Type A Acute Aortic Dissection in the Emergency Room

Pulmonary rehabilitation and palliative care in COPD: Two sides of the same coin?

Palliation of dyspnoea in advanced COPD: revisiting a role for opioids

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