In 2009, the American Thoracic Society (ATS) funded an assembly project, Palliative Management of Dyspnea Crisis, to focus on identification, management, and optimal resource utilization for effective palliation of acute episodes of dyspnea. We conducted a comprehensive search of the medical literature and evaluated available evidence from systematic evidence-based reviews (SEBRs) using a modified AMSTAR approach and then summarized the palliative management knowledge base for participants to use in discourse at a 2009 ATS workshop. We used an informal consensus process to develop a working definition of this novel entity and established an Ad Hoc Committee on Palliative Management of Dyspnea Crisis to further develop an official ATS document on the topic. The Ad Hoc Committee members defined dyspnea crisis as "sustained and severe resting breathing discomfort that occurs in patients with advanced, often life-limiting illness and overwhelms the patient and caregivers' ability to achieve symptom relief." Dyspnea crisis can occur suddenly and is characteristically without a reversible etiology. The workshop participants focused on dyspnea crisis management for patients in whom the goals of care are focused on palliation and for whom endotracheal intubation and mechanical ventilation are not consistent with articulated preferences. However, approaches to dyspnea crisis may also be appropriate for patients electing life-sustaining treatment. The Ad Hoc Committee developed a Workshop Report concerning assessment of dyspnea crisis; ethical and professional considerations; efficient utilization, communication, and care coordination; clinical management of dyspnea crisis; development of patient education and provider aid products; and enhancing implementation with audit and quality improvement.

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Dietary salt restriction is the most common therapeutic recommendation given to hypertensives, but past studies have assessed the effect of salt restriction using resting blood pressure (BP) measurements not with the newer technique of 24-h ambulatory BP monitoring. We compared the effect of high (250 mEq Na/day) and low (10 mEq Na/day) salt diets on resting versus ambulatory BP in 12 normal and 15 hypertensive subjects. Each diet was given for 7 days. Ambulatory BP was monitored from day 6 to day 7 of each diet; resting supine BP was measured on the morning of day 8. In normal subjects, neither resting nor ambulatory BP changed with sodium restriction. In hypertensives, resting BP fell 14 +/- 3/6 +/- 2 mm Hg (systolic/diastolic; P less than .01 for both) with sodium restriction while ambulatory BP fell only 4 +/- 2/2 +/- 2 (P = NS). The resting BP fall was significantly greater than the ambulatory BP fall (P less than .05) for both systolic and diastolic pressure. Ambulatory heart rates were also significantly greater during sodium restriction, suggesting that the low salt diet activated the sympathetic nervous system. This may, in turn, have partially offset the hypotensive effect of sodium restriction. We conclude that using resting BP to assess the effect of sodium restriction may overestimate the efficacy of this therapy. Ambulatory BP monitoring should be employed in future studies of sodium restriction.

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