Chest
Volume 154, Issue 4, October 2018, Pages 925-934
Journal home page for Chest

Recent Advances in Chest Medicine
Management of Dyspnea in the Terminally Ill

https://doi.org/10.1016/j.chest.2018.04.003Get rights and content

The genesis of dyspnea involves the activation of several mechanisms that are mediated and perceived depending on previous experiences, values, emotions, and beliefs. Breathlessness may become unbearable, especially in patients who are terminally ill, whether afflicted by respiratory-, cardiac-, or cancer-related disorders, because of a final stage of a chronic process, an acute event, or both. Compared with pain, palliation of dyspnea has received relatively little attention in clinical practice and the medical literature. This is particularly true when the breathlessness is associated with acute respiratory failure because most of the studies on pharmacologic and nonpharmacologic treatments of respiratory distress have excluded such patients. Assessments of the quality of dying for patients in an ICU consistently show that few patients are considered by family members to breathe comfortably at the end of their life. This review focuses on the management of dyspnea in patients with advanced terminal illness, summarizing clinical trial evidence on pharmacologic and nonpharmacologic interventions available for these patients.

Section snippets

Search Criteria

This is a narrative review of the literature based on searches of two main databases, namely PubMed and The Cochrane Database of Systematic Reviews, using the key words “dyspnea,” “palliative dyspnea,” “breathlessness,” “palliative breathlessness,” and “refractory breathlessness.” The search strategy using Medical Subject Headings was limited to human studies and articles in English or in any other language with an English abstract. The search was done on abstract, title, and key words fields.

Results

A total of 151 citations were retrieved using the Medical Subject Headings previously listed, including 134 citations on PubMed and 17 on The Cochrane Database of Systematic Reviews.

Conclusions

Dyspnea is a common symptom in patients with advanced terminal illness that compromises quality of life and causes distress in patients and family members. Because dyspnea is a multidimensional symptom resulting from multiple mechanisms, it may not respond equally to the different pharmacologic and nonpharmacologic treatments. Therefore, a comprehensive multidisciplinary approach, composed of physical, emotional, social, and spiritual aspects of refractory breathlessness, is recommended. In

Acknowledgments

Authors contributions: S. N. takes full responsibility for the content of the manuscript, including the data and analysis. L. P., N. S. H., A. M. G. P., M. P., and S. N. have made substantial contributions to the interpretation of the data and critically revised the manuscript for important intellectual content. L. P. and M. P. have made substantial contribution concerning literature search, writing, data analysis, and study design. N. S. H., A. M. G. P., and S. N. have made substantial

References (79)

  • C. Morélot-Panzini et al.

    Aerosol furosemide for dyspnea: controlled delivery does not improve effectiveness

    Respir Physiol Neurobiol

    (2018)
  • R.B. Banzett et al.

    Aerosol furosemide for dyspnea: high-dose controlled delivery does not improve effectiveness

    Respir Physiol Neurobiol

    (2018)
  • J.K. Stoller et al.

    Long-term Oxygen Treatment Trial Research Group. Oxygen therapy for patients with COPD: current evidence and the long-term oxygen treatment trial

    Chest

    (2010)
  • A.P. Abernethy et al.

    Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial

    Lancet

    (2010)
  • M.L. Campbell et al.

    Oxygen is nonbeneficial for most patients who are near death

    J Pain Symptom Manage

    (2013)
  • E. Bruera et al.

    Effects of oxygen on dyspnoea in hypoxaemic terminal-cancer patients

    Lancet

    (1993)
  • J. Philip et al.

    A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer

    J Pain Symptom Manage

    (2006)
  • S. Nava et al.

    Palliative use of non-invasive ventilation in end-of-life patients with solid tumours: a randomised feasibility trial

    Lancet Oncol

    (2013)
  • R. Tiruvoipati et al.

    High-flow nasal oxygen vs high-flow face mask: a randomized crossover trial in extubated patients

    J Crit Care

    (2010)
  • D. Hui et al.

    High-flow oxygen and bilevel positive airway pressure for persistent dyspnea in patients with advanced cancer: a phase II randomized trial

    J Pain Symptom Manage

    (2013)
  • S. Galbraith et al.

    Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial

    J Pain Symptom Manage

    (2010)
  • Dyspnea

    Mechanisms, assessment, and management: A consensus statement. American Thoracic Society

    Am J Respir Crit Care Med

    (1999)
  • C. Peiffer et al.

    Relief of dyspnea involves a characteristic brain activation and a specific quality of sensation

    Am J Respir Crit Care Med

    (2008)
  • C.M. Fletcher et al.

    The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population

    Br Med J

    (1959)
  • M.O. Delgado-Guay et al.

    Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team

    Cancer

    (2009)
  • M.F. Muers

    Opioids for dyspnoea

    Thorax

    (2002)
  • H. Barnes et al.

    Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness

    Cochrane Database Syst Rev

    (2016)
  • D.D. Marciniuk et al.

    Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline

    Can Respir J

    (2011)
  • A. Noseda et al.

    Disabling dyspnoea in patients with advanced disease: lack of effect of nebulized morphine

    Eur Respir J

    (1997)
  • P.N. Lanken 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)
  • M.B. Parshall et al.

    An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea

    Am J Respir Crit Care Med

    (2012)
  • D.A. Mahler

    Opioids for refractory dyspnea

    Expert Rev Respir Med

    (2013)
  • R. Wiseman et al.

    Chronic refractory dyspnoea–evidence based management

    Aust Fam Physician

    (2013)
  • K. Puntillo et al.

    Palliative care in the ICU: relief of pain, dyspnea, and thirst–a report from the IPAL-ICU Advisory Board

    Intensive Care Med

    (2014)
  • M.P. Ekström et al.

    Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study

    BMJ

    (2014)
  • D.J. Janssen et al.

    Attitudes toward opioids for refractory dyspnea in COPD among Dutch chest physicians

    Chron Respir Dis

    (2015)
  • R.B. Banzett et al.

    Using laboratory models to test treatment: morphine reduces dyspnea and hypercapnic ventilatory response

    Am J Respir Crit Care Med

    (2011)
  • R. Bernabeu-Mora et al.

    Rates and predictors of depression status among caregivers of patients with COPD hospitalized for acute exacerbations: a prospective study

    Int J Chron Obstruct Pulmon Dis

    (2016)
  • J. Yorke et al.

    Quantification of dyspnoea using descriptors: development of initial testing of Dyspnoea-12

    Thorax

    (2010)
  • Cited by (0)

    View full text