Acute respiratory failure is a frequent cause of hospitalizations among seriously ill older adults at or near the end of life. These terminal hospitalizations are often complicated by distressful respiratory symptoms and chaotic transitions that result in high-intensity, high-risk interventions such as invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV), which delivers positive pressure ventilation through a mask. In this issue of JAMA Internal Medicine, Sullivan and colleagues studied trends in IMV and NIV use among older decedents hospitalized at the end of life. The authors found a substantial increase in NIV use and a slight increase in IMV use in the past 2 decades, potentially signifying a major shift in the way that clinicians provide ventilatory support at the end of life. Although use of NIV in older adults with terminal respiratory failure may seem appealing, high-quality evidence supporting its use across serious illnesses remains elusive.
BACKGROUND: The mortality rate of pulmonary tuberculosis (TB) patients with respiratory failure remains high. This study aimed to identify factors contributing to death in these patients, and develop a mortality prediction model for pulmonary TB patients with respiratory failure.
METHODS: A retrospective study of patients admitted consecutively to the medical ICU of Beijing Chest Hospital, (Beijing, China), Chaoyang Fourth Hospital (Liaoning, China) and Hebi Third People's Hospital (Henan, China) from May 2018 to May 2019 was conducted. 153 patients with pulmonary TB accompanied by respiratory failure were enrolled. A multivariate analysis was performed to identify risk factors for death. A predictive fatality score was determined. The utility of the score for predicting death was evaluated using receiver operating characteristic (ROC) curve analysis.
RESULTS: The patients' median age was 57.82±19.42 years (17.0-87.0 years) and there were 106 males (69.28%). The mortality rate was 39.22% (60 of 153). Independent predictive factors of mortality included the PaO2 (hazard ratio 0.928, 95% CI: 0.882 - 0.976, P=0.004), Albumin (hazard ratio 0.881, 95% CI: 0.792- 0.980, P=0.019), Apache II score (hazard ratio 1.120, 95% CI: 1.017-1.234, P=0.022) and C-reactive protein (hazard ratio 1.012, 95% CI: 1.004-1.019, P=0.003). Establishing a logistic model of the death risk grade of pulmonary TB with respiratory failure was Y=1.710 - 0.068*PaO2-0.163* albumin + 0.215* Apache II +0.012* C-reactive protein. The value was Y=-0.494. If the Y value was greater than or equal to -0.494, the patients belonged to the deceased group, and if less than -0.494 the patients belonged to the survival group. AUC=0.818, The sensitivity was 83.3%; specificity was 73.1%.
CONCLUSIONS: Pulmonary TB patients with respiratory failure have a high mortality rate and poor prognosis, particularly those with high Apache II scores, high C-reactive protein levels, low PaO2 admission to ICU and low albumin level. The prediction model will help assess the risk of death in patients with TB and respiratory failure.
BACKGROUND AND OBJECTIVES: High-flow nasal cannula (HFNC) oxygen may provide tailored benefits in patients with preset treatment limitations. The objective of this study was to assess the effectiveness of HFNC oxygen in patients with do-not-intubate (DNI) and/or do-not-resuscitate (DNR) orders.
METHODS: We conducted a systematic review of interventional and observational studies. A search was performed using MEDLINE, EMBASE, CINAHL, Scopus, and Web of Science, from inception to October 15, 2018.
RESULTS: We included six studies evaluating 293 patients. All studies had a high risk of bias. The hospital mortality rates of patients with DNI and/or DNR orders receiving HFNC oxygen were variable and ranged from 40% to 87%. In two before and after studies, the initiation of HFNC oxygen was associated with improved oxygenation and reduced respiratory rates. One comparative study found no difference in dyspnea reduction or morphine doses between patients using HFNC oxygen versus conventional oxygen. No studies evaluated quality of life in survivors or quality of death in nonsurvivors. HFNC was generally well tolerated with few adverse events identified.
CONCLUSIONS: While HFNC oxygen remains a viable treatment option for hospitalized patients who have acute respiratory failure and a DNI and/or DNR order, there is a paucity of high-quality, comparative, effectiveness data to guide the usage of HFNC oxygen compared with other treatments, such as noninvasive ventilation, conventional oxygen, and palliative opioids.
AIMS: to review current guidelines and studies available to health professionals in the UK and explore the literature to identify reasons for the prescription of palliative oxygen therapy in non-hypoxaemic patients.
BACKGROUND: oxygen therapy is often associated with the palliative treatment for breathlessness. Although prescription guidelines are available and the risks of oxygen therapy are known, the therapy is still prescribed for non-hypoxaemic patients.
DESIGN: a literature search was conducted using relevant databases. Cited evidence from published guidelines was also consulted.
RESULTS: the findings suggest that oxygen is no more effective than room air for treating dyspnoea for non-hypoxaemic patients, although two small studies of self-reported benefits from patients and carers indicate different perceptions of need.
CONCLUSION: the findings suggest that there is a knowledge gap with regards understanding the reasons for the prescription of oxygen therapy for non-hypoxaemic patients.
BACKGROUND: Driving cessation is associated with poor health-related outcomes. People with chronic diseases are often prescribed long-term opioid agonists that have the potential to impair driving. Studies evaluating the impact of opioids on driving-related psychomotor skills report contradictory results likely due to heterogeneous designs, assessment tools and study populations. A better understanding of the effects of regular therapeutic opioid agonists on driving can help to inform the balance between individual's independence and community safety.
AIM: To identify the literature assessing the impact of regular therapeutic opioid agonists on driving-related psychomotor skills for people with chronic pain or chronic breathlessness.
DESIGN: Systematic review reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-analysis statement; PROSPERO Registration CRD42017055909.
DATA SOURCES: Six electronic databases and grey literature were systematically searched up to January, 2017. Inclusion criteria were as follows: (1) empirical studies reporting data on driving simulation, on-the-road driving tasks or driving outcomes; (2) people with chronic pain or chronic breathlessness; and (3) taking regular therapeutic opioid agonists. Critical appraisal used the National Institutes of Health's quality assessment tools.
RESULTS: From 3809 records screened, three studies matched the inclusion criteria. All reported data on people with chronic non-malignant pain. No significant impact of regular therapeutic opioid agonists on people's driving-related psychomotor skills was reported. One study reported more intense pain significantly worsened driving performance.
CONCLUSION: This systematic review does not identify impaired simulated driving performance when people take regular therapeutic opioid agonists for symptom control, although more prospective studies are needed.
BACKGROUND: The use of noninvasive ventilation (NIV) in the emergency setting to reverse hypercapnic coma in frail patients with end-stage chronic respiratory failure and do-not-intubate orders remains a questionable issue given the poor outcome of this vulnerable population. We aimed to answer this issue by assessing not only subjects' outcome with NIV but also subjects' point of view regarding NIV for this indication.
METHODS: A prospective observational case-control study was conducted in 3 French tertiary care hospitals during a 2-y period. Forty-three individuals who were comatose (with pH < 7.25 and PaCO2 > 100 mm Hg at admission) were compared with 43 subjects who were not comatose and who were treated with NIV for acute hypercapnic respiratory failure. NIV was applied by using the same protocol in both groups. They all had a do-not-intubate order and were considered vulnerable individuals with end-stage chronic respiratory failure according to well-validated scores.
RESULTS: NIV yielded similar outcomes in the 2 groups regarding in-hospital mortality (n = 12 [28%] vs n = 12 [28%] in the noncomatose controls, P > .99) and 6-month survival (n = 28 [65%] vs n = 22 [51%] in the noncomatose controls, P = .31). Despite poor quality of life scores (21.5 ± 10 vs 31 ± 6 in the awakened controls, P = .056) as assessed by using the VQ11 questionnaire 6 months to 1 y after hospital discharge, a large majority of the survivors (n = 23 [85%]) would be willing to receive NIV again if a new episode of acute hypercapnic respiratory failure occurs.
CONCLUSION: In the frailest subjects with supposed end-stage chronic respiratory failure that justifies treatment limitation decisions, it is worth trying NIV when acute hypercapnic respiratory failure occurs, even in the case of extreme respiratory acidosis with hypercapnic coma at admission.
INTRODUCTION: Non-invasive ventilation(NIV) is commonly used to manage acute respiratory failure due to decompensated cardiorespiratory disease. We describe symptom burden in this population.
METHODS: Fifty, consecutive, consenting, English speaking, cognitively intact patients, admitted to wards other than the intensive care unit (ICU) in a tertiary teaching hospital and treated with NIV for hypercapnic respiratory failure, were recruited. The 14-item Condensed Memorial Symptom Assessment Scale was used to assess physical and psychological symptoms within 36 hours of commencing NIV. Breathlessness (using Borg score), pain location and intensity using a numerical rating scale, and four symptoms potentially prevalent in patients undergoing NIV (cough, sputum, gastric bloating and dry eyes) were also assessed.
RESULTS: Patients reported a median of 10 symptoms (IQR 9-13). A median of 5 symptoms (IQR 3-7) were rated as severe. Breathlessness was the most prevalent and most distressing symptom, with participants reporting a mean maximum Borg score of 7.55 over the 24 hours prior to admission. Dry mouth, lack of energy, cough, sputum, difficulty sleeping and psychological symptoms were prevalent. Pain, when reported, was of moderate intensity and contributed to distress.
CONCLUSIONS: This study describes the patient-reported symptoms occurring during an episode of acute respiratory failure. Understanding the symptom profile of patients in this setting may allow clinicians to target symptom relief while simultaneously managing respiratory failure, enhancing care.
OBJECTIVE: To evaluate the outcomes of tracheobronchial stenting in patients with malignant central airway obstruction and assist practitioners in palliative settings in understanding the indications, contraindications and management of tracheobronchial stents.
METHODS: This retrospective study involved a consecutive case series of palliative patients with central airway obstruction secondary to inoperable cancers who underwent tracheobronchial stenting at a single institution. The European Cooperative Oncology Group (ECOG) scale was used to evaluate patient functional status before and after tracheobronchial stenting.
RESULTS: Twenty-three patients underwent tracheobronchial stenting for malignant central airway obstruction. The majority of patients presented with symptoms of worsening dyspnoea (21 of 23; 91%). Postoperatively, there was a significant improvement in mean ECOG performance status from 2.88±0.34 to 1.58±0.50 (p<0.01). There was no intraoperative mortality resulting from tracheobronchial stenting. Five patients (21.74%) re-presented to hospital due to worsening symptoms and required emergency bronchoscopy. Two patients had stent migration, requiring stent replacement. One patient restenosed from tumour granulation, requiring microdebrider to debulk the mass. Two patients had stent failure secondary to external tumour compression, leading to death.
CONCLUSION: Tracheobronchial stenting is a safe and effective procedure that offers rapid palliation of symptoms and improvement in patient functional status.
BACKGROUND: Symptom management is an essential aspect of palliative and end-of-life care, but evidence suggests that patients' symptoms may not always be relieved, causing significant harm to patients and magnifying their relatives' distress. A growing body of evidence focuses on symptom management at the end-of-life, but research funding for palliative care remains disproportionately low. It is therefore crucial that research funding is targeted at areas of importance to patients and relatives. The Palliative and end-of-life care Priority Setting Partnership (PeolcPSP) undertook a UK-wide free-text survey to establish research priorities within palliative and end-of-life care and disseminated its results in 2015. Much of the data were related more broadly to personal perceptions and experiences rather than specific research questions. The aim of this article is to report on a supplementary analysis exploring the experiences and questions of PeolcPSP survey respondents regarding symptoms, hydration and nutrition.
METHODS: The PeolcPSP data (n = 1403) were coded by a team of qualitative researchers in a supplementary analysis. There were 190 responses that related to symptoms, nutrition and hydration. The data were analysed thematically using Braun and Clarke's approach.
RESULTS: Five themes were identified: pain, breathlessness, agitation, nutrition and hydration. The majority of responses related to symptoms that were sub-optimally managed, in particular pain. Nutrition and hydration were of significant concern, particularly for carers. Overall, respondents consistently asked about the most effective, evidence-based methods for managing symptoms and suggested areas where further research is necessary.
CONCLUSIONS: This study highlights the perceptions and experiences of patients, families and professionals within palliative care, highlighting the need for improved care, communication and further research to establish which treatments are most effective within a palliative care population. This is essential to reduce harm and distress for patients and families.
Background: The London Chest Activities of Daily Living Scale measures the impact of breathlessness on both activity and social functioning. However, the London Chest Activities of Daily Living Scale is not routinely used in patients with advanced disease.
Aim: To assess the psychometric properties of the London Chest Activities of Daily Living Scale in patients with refractory breathlessness due to advanced disease.
Design: A cross-sectional secondary analysis of data from a randomised controlled parallel-group, pragmatic, single-blind fast-track trial (randomised controlled trial) investigating the effectiveness of an integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness, known as the Breathlessness Support Service (NCT01165034). All patients completed the following questionnaires: the London Chest Activities of Daily Living Scale, Chronic Respiratory Questionnaire, the Palliative care Outcome Scale, Palliative care Outcome Scale-symptoms, the Hospital Anxiety and Depression Scale and breathlessness measured on a numerical rating scale. Data quality, scaling assumptions, acceptability, internal consistency and construct validity of the London Chest Activities of Daily Living Scale were determined using standard psychometric approaches.
Setting/participants: Breathless patients with advanced malignant and non-malignant disease.
Results: A total of 88 patients were studied, primary diagnosis included; chronic obstructive pulmonary disease = 53, interstitial lung disease = 17, cancer = 18. Median (range) London Chest Activities of Daily Living Scale total score was 46.5 (14?67). No floor or ceiling effect was observed for the London Chest Activities of Daily Living Scale total score. Internal consistency was good, and Cronbach's alpha for the London Chest Activities of Daily Living Scale total score was 0.90. Construct validity was good with 13 out of 15 a priori hypotheses met.
Conclusion: Psychometric analyses suggest that the London Chest Activities of Daily Living Scale is acceptable, reliable and valid in patients with advanced disease and refractory breathlessness.
Purpose: The acute-on-chronic exacerbations of end-stage respiratory diseases often result in prolonged hospital stays, relating these events to ethical conflicts in the fields of medical futility and distributive justice. This study aimed to understand patients’ preferences for life-sustaining treatments when clinically stable and during regular follow-up visits, and to determine the factors that can influence these preferences.
Procedure: This was a prospective, observational, exploratory study using convenience sampling. Over a three-year period, the study enrolled 106 adult outpatients with end-stage pulmonary disease on long-term oxygen treatment with/without noninvasive mechanical ventilation with dyspnoea scores of 6 or more in the modified Borg dyspnoea scale and one of the following: Gold (chronic obstructive pulmonary disease classification) stage IV, diffusing capacity (DLCO) <40%, heart failure (New York Heart Association functional classification (NYHA)) stage III/IV, or systolic pulmonary artery pressure =40 mm Hg.
Results: Factors that were influential in preferences were age, gender, household status, NYHA class, and previous exposure to mechanical ventilation.
Conclusions: There was no consensus on life-sustaining treatment preferences. Demographic factors, such as age group, gender, household status, severity of disease, and previous treatment with mechanical ventilation, seemed to affect patients’ preferences.
Cet article présente les résultats d'un projet pilote mené au NHS Greater Glasgow and Clyde concernant l'utilisation d'un dossier tenu par le patient intégrant un plan anticipé des soins. Il a été testé sur neuf patients avec une maladie pulmonaire obstructive chronique sévère pendant six mois.
L'insuffisance respiratoire est un symptôme très commun en phase avancée de cancer des poumons. Il est difficile à évaluer et à prendre en charge et nécessite une approche multidisciplinaire. Les objectifs de la prise en charge sont le soulagement de la dyspnée et l'amélioration de la qualité de vie.
L'insuffisance cardiaque est une maladie chronique commune, en augmentation sachant la population vieillissante. Quand la maladie est avancée, les patients peuvent bénéficier d'une approche des soins palliatifs dans un cadre de modèle intégré des soins. Des similitudes existent entre les soins palliatifs pour des patients en insuffisance cardiaque avancée et les soins palliatifs pour des patients atteints de cancer.
L'assistance ventilatoire au cours de la sclérose latérale amyotrophique (SLA) est une modalité thérapeutique dont le statut est hybride et varie au cours de l'évolution de la maladie. Elle peut prolonger la vie, mais elle a aussi et peut-être surtout pour effet de soulager la dyspnée. Elle doit ainsi être inscrite dans un projet palliatif qui ne saurait s'y limiter. Comme pour de nombreuses pathologies chroniques de pronostic fatal, la prise en charge palliative de la SLA ne peut qu'être le fait de la réflexion commune et de l'action concertée d'intervenants multiples, dont le médecin et le patient ne sont que deux des représentants.
Introduction. The transition from paternalistic medicine to a healthcare culture centred on the patient's decision making autonomy presents problems of communication and understanding. Chronic respiratory failure challenges patients, their families and caregivers with important choices, such as invasive and non-invasive mechanical ventilation and tracheostomy, which, especially in the case of neuromuscular diseases, can significantly postpone the end of life. Material and Methods. A 7-item questionnaire was administered to 100 patients with advanced COPD, neuromuscular diseases and pulmonary fibrosis, all of them on oxygen therapy and receiving day-hospital treatment for respiratory failure. The objective was to find out whether or not patients, if faced with a deterioration of their health condition, would want to take part in the decision making process and, if so, how and with whom. Results. Results showed that : 90% of patients wanted to be interviewed, 10% preferred not to be interviewed, 82% wanted to be regularly updated on their clinical situation, 75% wanted to be intubated, if necessary, and 56% would also agree to have a tracheostomy. These choices have been confirmed one year later, with 93% of respondents accepting the questionnaire and considering it useful. Conclusions. It is possible to conclude that a simple questionnaire can be a useful tool contributing to therapeutic decision making in respiratory failure.
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Les unités de soins palliatifs sont souvent amenées à soigner des patients souffrant de maladies bénignes. Les infirmières doivent alors assurer la liaison avec d'autres services spécialisés. Cette étude de cas décrit les problèmes qui se sont posés pour mettre en place une ventilation non invasive chez un patient atteint d'une maladie neurologique à un stade avancé. Des solutions sont suggérées qui auraient pu éviter ces problèmes.