Wiese, C.H., Barrels, U.E., Graf, B.M., & Hanekop, G.G. (2009). Out-of-hospital opioid therapy of palliative care patients with \"acute dyspnoea\": A retrospective multicenter investigation. Journal of Opioid Management, 5(2), 115-122.

The objective was to investigate and compare emergency medical treatment of acute dyspnea in palliative care patients with advanced-stage cancer on the basis of several emergency medical therapy schemes.

The study consisted of a retrospective evaluation of emergency medical treatment initiated in response to palliative client complaints of “acute dyspnea” over a 24-month period. Data collected were based on the emergency service protocol of four different German emergency medical services. Patients were categorized into five groups based on the intervention utilized by emergency physicians in the management of their dyspnea. Group 1 used therapy with morphine IV and oxygen; Group 2 used morphine IV, bronchodilator-effective drugs (IV and per inhalation), and oxygen; Group 3 used bronchodilator therapy (IV and per inhalation); Group 4 used oxygen therapy only; and Group 5 utilized no therapy. The extent to which the symptom was relieved was measured by patients’ numeric rating of intensity of dyspnea compared to extent of “vital sign normalization” on the basis of patients’ arterial oxygen saturation and respiratory rate.

• The sample was comprised of 116 patients.
• Patients ranged in age from 49–91.
• The median patient age in Group 1 was 77 years, Group 2 was 69 years, Group 3 was 73 years, Group 4 was 74 years, and Group 5 was 71 years.
• Of the 116 patients, 47 were females and 69 were males.
• Only patients diagnosed with advanced stage of disease (i.e., palliative stage with no feasible curative therapy alternative) were included in the current study.
• Multiple cancer types were included.
• Patients with advanced non-cancer disease and non-cancer related dyspnea (e.g., COPD) were excluded.
• All 116 patients were pre-treated with opioids according to WHO III standards for symptomatic pain control. Fifty-six patients (48%) were also pre-treated with rescue opioid medication for breakthrough symptoms of acute dyspnea (estimated as 1/6 of pain opioid dose rate).

The study was conducted during multiple out-of-hospital emergency response/home visits by four emergency medical services in Germany.

This was a retrospective, descriptive study.

• Numeric Rating Scale (NRS) to subjectively measure intensity of dyspnea (0 = very bad, 6 = very good)
• Arterial oxygen saturation
• Respiratory rate
• Phone interview and directed survey of emergency physicians regarding expertise in emergency medical care and palliative medicine

Based on improvement in respiratory rate, arterial oxygen saturation, and patient’s numeric rating of dyspnea, 47 patients (41%) experienced relief of dyspnea from emergency medical treatment. Dyspnea was relieved in 14 Group 1 patients (67%), 15 Group 2 patients (52%), 8 Group 3 patients (22%), 5 Group 4 patients (18%), and 5 Group 5 patients (71%). Though no significant differences regarding relief of dyspnea were noted between Groups 1 and 2 and between Groups 3 and 4 (P > 0.05), a statistically significant difference was noted when Groups 1 and 2 were compared to Groups 3 and 4 (P <  0.001), indicating a higher success among the two groups that utilized opioid therapy in the management of dyspnea. Only Group 5 experienced a correlation between subjective dyspnea ratings and objective measurements (i.e., oxygen saturation and respiratory rate). The high success rate in dyspnea alleviation observed in Group 5 (no medical treatment) was achieved by the transfer of a tracheostomy tube, which was the noted cause of dyspnea in five patients. Morphine was the only medication used during opioid therapy, and no respiratory sedation was noted by emergency physicians.

Significant relief of acute dyspnea was observed when IV opioid therapy was used as opposed to oxygen and bronchodilator therapy alone.

The study was purely descriptive, with no structured study protocol with measures for comparison or randomization of subjects. Thoroughness and accuracy of each documented encounter analyzed is also questionable. The investigation was carried out on the basis of a German system of emergency/pre-hospital treatment options that are not wholly generalizable to the American paramedic emergency response system.

IV opioid therapy for the management of acute dyspnea in out-of-hospital encounters for palliative care patients appears to be more beneficial than use of oxygen therapy and bronchodilator (IV and per inhalation) alone. Integration of a palliative care team (preferably with 24-hour accessibility) in the subsequent alleviation of dyspnea in out-of-hospital emergency palliative encounters may prove beneficial. This study raises the question of how dyspnea among palliative care patients may be managed by pre-hospital services in the United States and pre-hospital service staff knowledge of symptom management for this group of patients.