Simon, S.T., Koskeroglu, P., Gaertner, J., & Voltz, R. (2013). Fentanyl for the relief of refractory breathlessness: A systematic review. Journal of Pain and Symptom Management, 46, 874–886.

DOI Link

Purpose

PURPOSE: To evaluate current evidence for the use of fentanyl for the relief of breathlessness
 
TYPE OF STUDY: Systematic review

Search Strategy

DATABASES USED: MEDLINE, EMBASE, Cochrane Library, and International Pharmaceutical Abstracts
 
KEYWORDS: Fentanyl and dyspnea (and dyspnea synonyms) 
 
INCLUSION CRITERIA: All types of studies containing original information about fentanyl (including drugs belonging to the pharmacologic group of fentanyl) and breathlessness; studies including healthy volunteers as well as patients (irrespective of disease); studies including breathlessness as a secondary as well as a primary outcome  
EXCLUSION CRITERIA: Literature reviews 

Literature Evaluated

TOTAL REFERENCES RETRIEVED: 622
 
EVALUATION METHOD AND COMMENTS ON LITERATURE USED: The evaluation was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendation for systematic reviews. The search and study evaluation methods were transparent and valid.  

Sample Characteristics

  • FINAL NUMBER STUDIES INCLUDED = 13 
  • TOTAL PATIENTS INCLUDED IN REVIEW = 88
  • SAMPLE RANGE ACROSS STUDIES: 1–35 patients
  • KEY SAMPLE CHARACTERISTICS: Two randomized, controlled trials ([RCTs] one RCT only had a sample size of two patients), two nonrandomized before–after studies, and nine case studies; majority of patients were inpatients with lung cancer or chronic obstructive pulmonary disease and constant or episodic (four studies) breathlessness receiving fentanyl (oral, IV, or transdermal) 

Phase of Care and Clinical Applications

PHASE OF CARE: Multiple phases of care 

APPLICATIONS: Elder care, palliative care

Results

All studies reported the successful relief of breathlessness after fentanyl application, but the only RCT (N = 12) failed to demonstrate a statistically significant difference when fentanyl was compared to a placebo. The nature and incidence of fentanyl-related adverse events such as somnolence and dizziness were comparable to other opioids, and no respiratory depression was observed.

Conclusions

There is no conclusive evidence about use of fentanyl to relieve breathlessness because of the lack of sufficiently powered, controlled studies. The descriptive and quasi-experimental studies included in this review show promising results for the use of fentanyl for breathlessness. All studies reported an improvement in breathlessness, but a fully powered RCT to conclusively determine the effect of fentanyl on breathlessness is warranted.

Limitations

The descriptive and quasi-experimental studies included were at-risk for bias because of the lack of a control. The doses of fentanyl varied considerably, which limits conclusions about the appropriate dose. Missing data included the time of response after the administration of fentanyl, which is important when comparing fentanyl to other opioids.

Nursing Implications

The clinical experience of fentanyl for breathlessness is promising. Considering emerging data, which suggests that breathless episodes often last less than 10 minutes, the current standard (immediate-release morphine) has a longer onset of action than the symptom episode duration. Fentanyl's time of onset still is unknown, but it may better match the characteristics of breathlessness episodes, which is clinically important.

Legacy ID

5249