Managing dyspnea in patients with advanced chronic obstructive pulmonary disease. A Canadian Thoracic Society clinical practice guideline (2011)

Transcription

1 Managing dyspnea in patients with advanced chronic obstructive pulmonary disease A Canadian Thoracic Society clinical practice guideline (2011)

2 2011 Canadian Thoracic Society and its licensors All rights reserved. No parts of this publication may be modified, posted on-line or used for any commercial purposes without the prior written permission of the Canadian Thoracic Society (CTS). If you use this publication as a teaching tool in non-profit professional development or educational activities, please reference CTS as the source. Please contact kcurren@lung.ca or jsutherland@lung.ca for permission to use these slides for any other purpose. These slides can not be altered, and must be used as presented in the CTS template.

3 Citation: Marciniuk D et al. (2011). Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: A Canadian Thoracic Society clinical practice guideline. Canadian Respiratory Journal, 18(2),

4 Target Users The document is intended for all health care professionals involved in the care of patients experiencing dyspnea associated with advanced COPD (including Respirologists, Family Physicians, Internists, Nurses, Respiratory Therapists, Physiotherapists), and health care administrators and systems.

5 Background Dyspnea is a cardinal symptom of COPD; Its severity and magnitude increases as the disease progresses, leading to significant disability and a negative effect on health-related quality of life (HRQOL). Refractory dyspnea is a common and difficult symptom to treat in patients with advanced COPD. This document was compiled to address these important clinical issues using an evidence-based, systematic review process led by a representative inter-professional panel of experts.

6 Patient Population For this guideline, patients with advanced COPD are defined as those with either a forced expiratory volume in 1 second (FEV 1 ) of lower than 50% predicted, or a Medical Research Council dyspnea score of 4 or 5 out of 5. The specific management goal is to reduce persistent dyspnea occurring at rest or with minimal activity despite optimal COPD therapy that is distressing and negatively impacting on healthrelated quality of life.

7 Comprehensive Management of COPD O Donnell et al. Can Respir J 2008; 15(Suppl A):1A-8A..

8 Literature Search Results Section Topic Studies Informing Recommendations I II III IV Do anxiolytic and antidepressant medications reduce dyspnea and improve quality of life in stable patients with advanced COPD compared with usual care (control population)? Do opioids reduce dyspnea and improve quality of life in stable patients with advanced COPD when used as an adjunct to optimal conventional treatment? Do nonpharmacological interventions (use of a fan, chest vibration techniques, pursed-lip breathing, meditation, relaxation therapy or behavioral techniques) reduce dyspnea and improve quality of life in stable patients with advanced COPD compared with usual care (control population)? Does supplemental oxygen reduce dyspnea and improve quality of life in stable patients with advanced COPD compared with usual care (control population) in patients with hypoxemia, and in patients without hypoxemia? 13 (18-30) 10 (34-43) 38 (45-82) 12 (93-104)

9 Strength of Evidence and Grading of Recommendations Quality of Evidence Grade A Grade B Grade C Strength of evidence and grading of recommendations Randomized trials with limitations including inconsistent results or major methodological weaknesses Observational studies, and from generalization from randomized trials in one group of patients to a different group of patients Strength of Recommendations Grade 1 Grade 2 Strong recommendation, with desirable effects clearly outweighing undesirable effects (or vice versa) Weak recommendation, with desirable effects closely balanced with undesirable effects

10 SECTION I Question: Do anxiolytic and antidepressant medications reduce dyspnea and improve quality of life in stable patients with advanced COPD compared with usual care (control population)? The following recommendation is based on evidence from 13 studies and expert consensus of the CTS COPD expert panel: Recommendation #1 We recommend that anxiolytic and antidepressant medications not be routinely used for the management of dyspnea in patients with advanced COPD. (Grade of recommendation 2B)

11 Exercise Performance and Dyspnea Anxiolytics Alprazolam (baseline) Alprazolam (1-week) Placebo (baseline) Placebo (1-week) Age (yrs) 65.4 (2.9) 65.4 (2.4) FEV1 (L) 1.26 (0.16) 1.72 (0.29) 12 Minute Walk Distance (m) (302.6) 880 (269.3) (323.8) (331.7) Dyspnea (MRC 1-5) 3.0 (0.8) 3.0 (0.8) 3.2 (0.9) 3.0 (0.8) Man et al. CHEST 1986; 90:832-6.

12 SECTION II Question: Do opioids reduce dyspnea and improve quality of life in stable patients with advanced COPD when used as an adjunct to optimal conventional treatment? The following recommendation is based on evidence from 10 studies and expert consensus of the CTS COPD expert panel: Recommendation #2 We recommend that oral (but not nebulized) opioids be used for the treatment of refractory dyspnea in the individual patient with advanced COPD. (Grade of recommendation 2C)

13 Dyspnea - Opioids Rocker et al. Thorax 2009; 64:

14 Dyspnea - Opioids Morphine (N=38) Placebo (N=38) Mean Diff. morphineplacebo 95% CI P value Morning 40.1 (24) 47.7 (26) Evening 40.3 (23) 49.9 (24) Dyspnea scores assessed using a VAS (0 = no breathlessness; 100 = worst possible breathlessness) at the end of 4-day treatment period. Abernethy AP, et al. BMJ 2003; 327:523-8.

15 HRQOL and Dyspnea - Opioids Poole et al. AJRCCM 1998; 157:

16 Suggested Protocol for Managing Dyspnea with Opioids in Advanced COPD Initiate opioid therapy with oral immediate release morphine syrup titrate slowly at weekly intervals over a 4 to 6 week period. Start therapy with morphine 0.5 mg orally twice daily for 2 days, and then increase to 0.5 mg orally every 4 hours while awake for remainder of week 1. If tolerated and indicated, increase to morphine 1.0 mg orally every 4 h while awake in week 2, increasing by 1.0 mg/week or 25% dosage increments/week until the lowest effective dose that appropriately relieves dyspnea is achieved. Once a stable dosage is achieved (i.e., no significant dose change for 2 weeks and dyspnea controlled), a sustained-release preparation at a comparable daily dose could be considered for substitution. If patients experience significant opioid-related side effects such as nausea or confusion, substitution of an equipotent dose of oral hydromorphine could be considered (1 mg hydromorphine = 5 mg morphine). Stool softeners and laxatives should be routinely offered to prevent opioidassociated constipation.

17 SECTION III Question: Do nonpharmacological interventions (use of a fan, chest vibration techniques, pursed-lip breathing, meditation, relaxation therapy or behavioral techniques) reduce dyspnea and improve quality of life in stable patients with advanced COPD compared with usual care (control population)? The following recommendations are based on evidence from 38 studies and expert consensus of the CTS COPD expert panel: Recommendation #3a NMES and chest wall vibration are helpful in reducing dyspnea in patients with COPD. We recommend that NMES and chest wall vibration, undertaken by knowledgeable providers, be used in the management of dyspnea in patients with advanced COPD. (Grade of recommendation 2B)

18 Neuromuscular Electrical Stimulation Image source:

19 Muscle Strength and Exercise Performance NMES Vivodtzev et al. CHEST 2006; 129:

20 Muscle Strength, Exercise Performance, and Dyspnea NMES NMES (baseline) NMES (6-weeks) Control (baseline) Age (yrs) 66.6 (7.7) 65.0 (5.4) Control (6-weeks) FEV1 (% pred) 38.0 (9.6) 39.5 (13.3) Peak Torque (Nm) Endurance time (min) Diff in CRDQ Dyspnea domain at 6 weeks between NMES & Control 1.2 ( ) Neder et al. Thorax 2002; 57:333-7.

21 SECTION III Question: Do nonpharmacological interventions (use of a fan, chest vibration techniques, pursed-lip breathing, meditation, relaxation therapy or behavioral techniques) reduce dyspnea and improve quality of life in stable patients with advanced COPD compared with usual care (control population)? The following recommendations are based on evidence from 38 studies and expert consensus of the CTS COPD expert panel: Recommendation #3b COPD patients with dyspnea benefit from the use of walking aids. It is recommended that patients with advanced COPD be informed of the potential benefits of walking aids and undergo professional assessment for choosing a suitable device. (Grade of recommendation 2B)

22 Exercise Performance Walking Aids Crisafulli et al. CHEST 2007; 131:

23 SECTION III Question: Do nonpharmacological interventions (use of a fan, chest vibration techniques, pursed-lip breathing, meditation, relaxation therapy or behavioral techniques) reduce dyspnea and improve quality of life in stable patients with advanced COPD compared with usual care (control population)? The following recommendations are based on evidence from 38 studies and expert consensus of the CTS COPD expert panel: Recommendation #3c Pursed-lip breathing can be an effective strategy for relief of dyspnea. It is recommended that patients with advanced COPD be informed of the potential benefits of pursed-lip breathing and be instructed in its use. (Grade of recommendation 2B)

24 Pursed-lip Breathing STEP ONE: With your mouth closed, breathe in a normal amount of air through your nose. STEP TWO: Purse your mouth as if you re whistling or making a candle flame flicker gently. STEP THREE: Keeping your lips pursed, slowly blow the air out through your mouth. Do not strain yourself to force the air out. Source: BreathWorks Factsheet. Breathlessness. The Lung Association. July 2008.

25 Exercise Performance Pursed-lip Breathing Garrod et al. Chronic Respiratory Disease 2005; 2:67-72.

26 Dyspnea Pursed-lip Breathing Spahija J et al. Chest 2005;128: PLB has a variable effect on dyspnea at rest and during exercise in COPD Relates to the combined changes that PLB promotes in: EELV VT Pressure generating capacity of respiratory muscles

27 SECTION III Question: Do nonpharmacological interventions (use of a fan, chest vibration techniques, pursed-lip breathing, meditation, relaxation therapy or behavioral techniques) reduce dyspnea and improve quality of life in stable patients with advanced COPD compared with usual care (control population)? The following recommendations are based on evidence from 38 studies and expert consensus of the CTS COPD expert panel: There is insufficient evidence to recommend the routine use of acupuncture, acupressure, distractive auditory stimuli (music), relaxation, handheld fans, counseling and support programs, and psychotherapy.

28 SECTION IV Question: Does supplemental oxygen reduce dyspnea and improve quality of life in stable patients with advanced COPD compared with usual care in patients with hypoxemia, and in patients without hypoxemia? The following recommendation is based on evidence from 10 studies and expert consensus of the CTS COPD expert panel: Continuous oxygen therapy for hypoxemic COPD patients reduces mortality, and may reduce dyspnea in some patients. The CTS has previously recommended that patients with advanced COPD who are hypoxemic at rest receive long-term continuous oxygen therapy because of a mortality benefit. Oxygen therapy may also provide symptomatic benefit by reducing dyspnea when administered at rest to hypoxemic patients with advanced COPD. (Grade of recommendation 2B)

29 Survival Long-term Continuous Oxygen

30 HRQOL and Exercise Performance Addition of Ambulatory Oxygen to Long-term Continuous Oxygen in Hypoxemic COPD Patients Lacasse et al. Eur Respir J 2005; 25(6):

31 SECTION IV Question: Does supplemental oxygen reduce dyspnea and improve quality of life in stable patients with advanced COPD compared with usual care in patients with hypoxemia, and in patients without hypoxemia? The following recommendation is based on evidence from 10 studies and expert consensus of the CTS COPD expert panel: There is no evidence to support the routine use of supplemental oxygen to reduce dyspnea in non-hypoxemic patients with advanced COPD. There appears to be little benefit from supplemental oxygen on quality of life in patients with advanced COPD.

32 Dyspnea Long-term Continuous Oxygen Moore et al. Thorax 2011; 66:32-37.

33 HRQOL Long-term Continuous Oxygen Nonoyama et al. AJRCCM 2007; 176:

34 Comprehensive Approach to Management of Refractory Dyspnea in Advanced COPD Initiate & Optimize Opioid Therapies: Short- and Long-Acting Agents Initiate & Optimize Non-Pharmacologic Therapies: Exercise, Pursed-Lip Breathing, Walking Aids, Chest Wall Vibration, NMES Initiate & Optimize Pharmacologic Therapies: SABD, LAAC, ICS/LABA, PDE 4 Inhibitors, Theophylline, O 2 in Hypoxemic Patients Magnitude of Dyspnea Exclude Contributing Causes Regular Follow-up And Reassessment V End of Life Care Marciniuk DD, et al. Can Resp J 2011; 18:69-78.

35 Discussion This guideline process was initiated with the belief, shared by many others, that many advanced COPD patients are not currently being treated consistently and effectively for relief of dyspnea. For these recommendations to be applied in the management of dyspnea in patients with advanced COPD, clinicians and clinical documentation must regularly and serially assess the patient experience of dyspnea.

36 Knowledge Transfer Publication in Canadian Respiratory Journal and available on-line at Slide kit available for viewing and download. Patient/family/caregiver and health care professional information sheets (two in total) will be posted for viewing and download, and also further disseminated by the Canadian and provincial lung associations. Other tools (e.g. slim jim, smart phone app) summarizing key recommendations and information from this clinical practice guideline will be forwarded to target Canadian audience (clinicians). These materials will also be distributed to provincial Ministries of Health, and selected provincial and regional health authorities.

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38 Closing Remarks Conflict of interest, policies and disclosures available on-line. Editorial independence and expert review. Clinical Practice Guidelines development process: Systematic literature reviews, PICO (Problem/ Intervention/Comparison/Outcome) questions, recommendations and grading. Significant Canadian expertise and leadership readily accessible to the CTS. Cost-sensitivity and containment. We have set the stage and are ready for the next steps.

39 For more information: Canadian Thoracic Society c/o The Lung Association National Office 1750 Courtwood Crescent, Suite 300 Ottawa, ON K2C 2B5 Kristen Curren (613) , ext