Symptoms and disease severity in lung transplant candidates co-managed with palliative care

Abstract

Background: Lung transplant (LTx) candidates experience significant respiratory symptoms often necessitating palliative care (PC) support. We aimed to describe symptoms experienced by interstitial lung disease (ILD) and chronic obstructive pulmonary disease (COPD) LTx candidates referred for PC using the Edmonton Symptom Assessment Scale (ESAS) and to assess the change in ESAS in relation to pre-LTx exercise capacity, oxygen requirements, and respiratory exacerbations. Understanding symptom trajectory of these two patient groups will help inform PC management. Methods: Single centre, retrospective cohort of 102 ILD and 24 COPD LTx candidates who were assessed in the Toronto Transplant PC Clinic (TPCC) from 2014-2017. Chi-square and t-tests were used to compare clinical characteristics, physiological parameters, and ESAS scores. Results:The most common symptom in ILD and COPD patients was dyspnea (median score of 8, cough 7, fatigue 6). ILD patients reported higher cough scores (7 vs. 4, P<0.001). There was no association between the change in ESAS domains and six-minute walk distance (6MWD), oxygen requirements, or respiratory exacerbations, despite increased oxygen requirements and a greater decline in 6MWD in ILD compared to COPD pre-LTx (−47 vs. −8 meters, P=0.01). ILD candidates who were delisted/died compared to those transplanted, experienced worse depression (median ESAS; 4.5 vs. 1), anxiety (5.5 vs. 2) and dyspnea (9.5 vs. 8); P<0.05.Conclusions: ILD patients had similar symptoms as COPD patients, despite increased oxygen requirements and decreasing 6MWD pre-LTx. This study highlights the importance of symptom management of LTx candidates co-managed with PC, independent of traditional measures of disease severity.

An update of palliative care in lung transplantation with a focus on symptoms, quality of life and functional outcomes

“…Several reviews have been published in support of managing symptoms while balancing both disease modifying and PC interventions in patients with advanced lung disease such as COPD [27], ILD [28], and pulmonary arterial hypertension [29]. Emerging evidence specifically focusing on the impact of PC on patients in LTx programs [20 ▪ ] is consistent with studies conducted in the broader context of PC for advanced lung disease. In a recent systematic review evaluating 8 studies (7 randomized control trials), Santos and Reis-Pina (2023) revealed that PC interventions improved breathlessness in patients with chronic respiratory disease [19 ▪▪ ].…”

“…Lung transplant candidates experience significant symptoms while awaiting transplantation. In a study from our center by Minuk et al [20 ▪ ] the most common symptoms were dyspnea, cough and fatigue observed in both COPD and ILD LTx candidates. ILD candidates had similar symptom scores compared to patients with COPD on all domains of the Edmonton Symptom Assessment Score (ESAS), apart from greater cough symptoms.…”

“…The ESAS is a scale that evaluates 12 common symptoms domains (i.e. cough, dyspnea, fatigue, etc) with each domain scored on a scale from 0 (no symptoms) to 10 (worse symptoms) [11 ▪▪ ,20 ▪ ], as shown in Table 1. Furthermore, symptoms assessed with the ESAS were not correlated with the trajectory of exercise capacity, oxygen requirements or respiratory exacerbations pre-LTx while participating in pulmonary rehabilitation [20 ▪ ].…”

“…cough, dyspnea, fatigue, etc) with each domain scored on a scale from 0 (no symptoms) to 10 (worse symptoms) [11 ▪▪ ,20 ▪ ], as shown in Table 1. Furthermore, symptoms assessed with the ESAS were not correlated with the trajectory of exercise capacity, oxygen requirements or respiratory exacerbations pre-LTx while participating in pulmonary rehabilitation [20 ▪ ]. This highlights the potential contribution of PC support in attenuating symptoms in the setting of disease progression while awaiting transplantation.…”

“…Thus, the literature on PC effects in the advanced lung disease and transplant populations has been mixed [17 ▪▪ ,18,19 ▪▪ ]. Further, evidence demonstrates that symptoms in LTx candidates can be heterogeneous and do not always reflect objective measures of illness severity [20 ▪ ], often a trigger for referral to PC, especially in those who are younger, more racially diverse, and have higher psychosocial risk factors [39 ▪ ].…”