Gomutbutra, P., O'Riordan, D.L., & Pantilat, S.Z. (2013). Management of moderate-to-severe dyspnea in hospitalized patients receiving palliative care. Journal of Pain and Symptom Management, 45, 885–891.

DOI Link

Study Purpose

To describe the management of moderate to severe dyspnea in patients receiving palliative care

Intervention Characteristics/Basic Study Process

A retrospective study was conducted using the records of patients who were consulted by a palliative care service over a five-year period. Information about medications prescribed was collected for patients who self-reported moderate to severe dyspnea at their initial evaluations by the palliative care service. Follow-up assessments of dyspnea were conducted by the palliative care service within 24 hours of the initial assessment. Data extraction was completed by a physician.

Sample Characteristics

  • N = 115  
  • MEAN AGE = 64 years (SD = 17 years)
  • MALES: 51% (n = 59), FEMALES: 49% (n = 56)
  • KEY DISEASE CHARACTERISTICS: Primary diagnoses were cancer (64%, n = 59), heart failure (8%, n = 9), and chronic obstructive pulmonary disease (5%, n = 6). 
  • OTHER KEY SAMPLE CHARACTERISTICS: Half of the sample was Caucasian (54%, n = 62). Pneumonia was diagnosed in 34% of patients (n = 39), and 30% of patients (n = 35) had a pleural or pericardial effusion. 

Setting

  • SITE: Single site  
  • SETTING TYPE: Inpatient  
  • LOCATION: Urban medical center

Phase of Care and Clinical Applications

  • APPLICATIONS: Palliative care

Study Design

Retrospective chart review of patients with moderate or severe dyspnea

Measurement Instruments/Methods

  • Charleston Comorbidity Index (CCI) to assess the severity of illness through the classification of comorbidities to predict short- and long-term mortality
  • Dosages of opioids were converted into milligrams of oral morphine per day by equianalgesic dosing.
  • Plonk’s equation was used to convert methadone to morphine. 
  • Dyspnea, pain, and anxiety were measured using a four-point categorical scale based on patient self-reports.
  • Data from the chart review included the frequency and dose of opioids and benzodiazepines, age, sex, race, comorbidities, the presence of pneumonia, and pleural or pericardial effusion. 

Results

At baseline, most patients reported moderate dyspnea (73%, n = 31) or severe dyspnea (27%). In addition, 48% of patients reported pain, and 57% reported anxiety. 15% of patients reported nausea. There was no association between the severity of dyspnea at baseline and patients' reports of pain (P = 0.8), anxiety (P = 0.08), or nausea (P = 0.8). At the 24 hour follow-up assessment, 74% (n = 85) of patients reported an improvement in their dyspnea. 44% (n = 51) of patients reported mild dyspnea, 29% (n = 33) moderate, 9% (n = 10) severe, and 18% (n = 21) reported no dyspnea. Of the 74% of patients who reported an improvement in their dyspnea, 42% (n = 36) received opioids alone, 37% (n = 31) had benzodiazepines concurrent with opioids, 2% (n = 2) had benzodiazepines alone, and 19% (n = 16) had not received either medication. 
 
Patients prescribed a medication were significantly associated with improvements in dyspnea (p = 0.05). Logistical regression identified that patients who received benzodiazepines and opioids had increased odds of improving dyspnea (odds ratio = 5.5, 95% CI = 1.4, 21.3) compared to those receiving no medications. 

Conclusions

Most patients reported an improvement in dyspnea within of 24 hours after palliative care service consultation. Most patients with dyspnea received opioids but only the combination of benzodiazepines and opioids was independently associated to improve dyspnea.

Limitations

  • Baseline sample/group differences of import
  • Risk of bias (no control group) 
  • Risk of bias (no random assignment) 
  • Risk of bias (no appropriate attentional control condition)  
  • Other limitations/explanation: The results were from a retrospective chart review. Conclusions cannot be drawn about the effectiveness of treatment or the causal relationships between medication and improvements in in dyspnea symptoms due to the study’s design. The study acknowledges potential confounding factors including patient factors, procedures, and psychological care that may impact the study’s findings. The results are reflective of the practices of one institution, which may limit generalizability. The population studied may not be generalizable to the broader palliative care population.
 

 

Nursing Implications

Because dyspnea is a common symptom in patients receiving palliative care, the authors conducted a study that reviewed the records of patients with moderate or severe dyspnea. The study found that opioids given with benzodiazepines were associated with improvements in dyspnea. Additional research to determine whether the use of benzodiazepines alone or in combination with opioids is more effective is necessary to to lead to improvements in dyspnea treatments.