Background: Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome.Purpose: The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea.Methods: An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members.Results: Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consist...

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An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea

Efforts to reduce delays in lung cancer management should not cease even though they may not affect the prognosis

It is universally acknowledged that the prognosis of lung cancer is very poor, with overall 5 year survival figures of about 5–10% worldwide.1 What is less well recognised is that the picture has changed very little over the last 20 years, and that this is in sharp distinction to other solid tumours where not only are survival rates better—in the order of 60–90%—but they have been increasing (improving) fairly rapidly and continue to do so over a comparable time. For example, in our region of the UK, comprehensive population based registry data for 2 year survival of the 5000 patients diagnosed with lung cancer in 1999 was 13% compared with 60%, 79%, 87% and 92% for colorectal, cervix, prostate, and breast cancer, respectively.2 There is merit therefore in considering what might influence and be responsible for this poor outcome.

The factors which affect the prognosis in lung cancer are principally the stage and related performance status at presentation, histology (that is, the biological activity of the tumour), co-morbidity, age, sex, and the time interval between first symptom and treatment.

Some of these factors are not modifiable. In theory, however, reducing intervals between presentation and treatment might downstage patients and allow an improvement in survival. There are excellent data to show that early stage disease has better survival;3 there is less good but nevertheless fairly convincing evidence that very early stage disease (that is, small asymptomatic lesions) have an even better prognosis.

There are, of course, other ways of reducing lung cancer mortality. In the very long term, over a period of decades, prevention is clearly key. In the longer term, over a 5–10 year time span, the identification …

https://thorax.bmj.com/content/thoraxjnl/59/1/1.1.full.pdf

Delays in managing lung cancer

This systematic evidence review supports the American College of Physicians guideline on palliative care at the end of life. Strong to moderate evidence supports use of various treatments for cance...

Evidence for Improving Palliative Care at the End of Life: A Systematic Review

Respiratory depression limits the use of opioid analgesia. Although well described clinically, the specific mechanisms of opioid action on respiratory control centres in the brain have, until recently, been less well understood. This article reviews the mechanisms of opioid-induced respiratory depression, from the cellular to the systems level, to highlight gaps in our current understanding, and to suggest avenues for further research. The ultimate aim of combating opioid-induced respiratory depression would benefit patients in pain and potentially reduce deaths from opioid overdose. By integrating recent findings from animal studies with those from human volunteer and clinical studies, further avenues for investigation are proposed, which may eventually lead to safer opioid analgesia.

Opioids and the control of respiration

2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure.

Objective To determine the efficacy of oral morphine in relieving the sensation of breathlessness in patients in whom the underlying aetiology is maximally treated. Design Randomised, double blind, placebo controlled crossover study. Setting Four outpatient clinics at a hospital in South Australia. Participants 48 participants who had not previously been treated with opioids (mean age 76, SD 5) with predominantly chronic obstructive pulmonary disease (42, 88%) were randomised to four days of 20 mg oral morphine with sustained release followed by four days of identically formulated placebo, or vice versa. Laxatives were provided as needed. Main outcome measures Dyspnoea in the morning and evening as shown on a 100 mm visual analogue scale, quality of sleep, wellbeing, performance on physical exertion, and side effects as measured at the end of the four day treatment period. Results 38 participants completed the study; three withdrew because of definite and two because of possible side effects of morphine (nausea, vomiting, and sedation). Participants reported significantly different dyspnoea scores when treated with morphine: an improvement of 6.6 mm (95% confidence interval 1.6 mm to 11.6 mm) in the morning and of 9.5 mm (3.0 mm to 16.1 mm) in the evening (P = 0.011 and P = 0.006, respectively). During the period in which they were taking morphine participants also reported better sleep (P = 0.039). More participants reported distressing constipation while taking morphine (9 v 1, P = 0.021) in spite of using laxatives. All other side effects were not significantly worse with morphine, although the study was not powered to address side effects. Conclusions Sustained release, oral morphine at low dosage provides significant symptomatic improvement in refractory dyspnoea in the community setting.

https://www.bmj.com/content/bmj/327/7414/523.full.pdf

Annie McHugh

Papers

Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea