“…Box 1 shows the joint BTS/ACPRC guidance for relieving breathlessness. Joint British Thoracic Society and Association of Chartered Physiotherapists in Respiratory Care (BTS/ACPRC) guidance on positioning to relieve breathlessness33 35Passive fixation of the shoulder girdle by bracing the upper limbs, for example, placing hands on hips, to assist ventilatory muscle efficiency.Forward lean sitting which domes the diaphragm leading to improved force generation and ventilator capacity.Adaptation of forward lean for standing or lying if sitting is not possible.…”
Section: Non-pharmacologicalmentioning
confidence: 99%
“…Activity pacing and energy conservation 35. Patients should ensure that all available energy is not being expended unnecessarily on basic every day tasks, or on trying to complete tasks too quickly, leaving no energy to engage in other activities or exercise 35.…”
Section: Non-pharmacologicalmentioning
confidence: 99%
“…Patients should ensure that all available energy is not being expended unnecessarily on basic every day tasks, or on trying to complete tasks too quickly, leaving no energy to engage in other activities or exercise 35. Using an analogy such as a jug or battery full of energy for each day, which needs to be replenished by rest, can help patients think about how they want to expend their limited amount of energy.…”
Section: Non-pharmacologicalmentioning
confidence: 99%
“…More than 90% of patients responded to 20 mg or less daily 41. CBIS prefers to use a slow up-titration regimen (figure 4) and aims to find the lowest effective opioid dose 35. This approach develops the patient's confidence by minimising side effects and reassures other clinicians involved in the patient's care who may be less accustomed to prescribing opioids in this situation.…”
Section: Pharmacologicalmentioning
confidence: 99%
“…There may be a role for oxygen in certain subgroups of patients once other approaches have been optimised, and in these cases individual clinical assessment is warranted, but certainly routine use of oxygen for palliation of breathlessness is not indicated (box 2). Patients with breathlessness in their last days of life35Involvement of specialist palliative care team (community/inpatient) and close liaison with primary care services to ensure best quality care.Syringe pump containing:Diamorphine 5–10 mg/24 h (if opioid naïve). Consider 2.5 mg in elderly/frail.…”
Breathlessness is an important and common symptom globally, affecting patients with a variety of malignant and non-malignant diseases. It causes considerable suffering to patients and also their families, and is a significant cost to healthcare systems. Optimal management of the symptom should therefore be of interest and importance to a wide range of clinicians. Best practice in the management of breathlessness consists of both non-pharmacological and pharmacological interventions as evidenced by recent randomised controlled trials of multidisciplinary breathlessness support services. As well as providing evidence for integration of early palliative care into respiratory services, these revealed that patient distress due to breathlessness can be significantly reduced and better outcomes can be achieved at lower cost than standard care.
“…Box 1 shows the joint BTS/ACPRC guidance for relieving breathlessness. Joint British Thoracic Society and Association of Chartered Physiotherapists in Respiratory Care (BTS/ACPRC) guidance on positioning to relieve breathlessness33 35Passive fixation of the shoulder girdle by bracing the upper limbs, for example, placing hands on hips, to assist ventilatory muscle efficiency.Forward lean sitting which domes the diaphragm leading to improved force generation and ventilator capacity.Adaptation of forward lean for standing or lying if sitting is not possible.…”
Section: Non-pharmacologicalmentioning
confidence: 99%
“…Activity pacing and energy conservation 35. Patients should ensure that all available energy is not being expended unnecessarily on basic every day tasks, or on trying to complete tasks too quickly, leaving no energy to engage in other activities or exercise 35.…”
Section: Non-pharmacologicalmentioning
confidence: 99%
“…Patients should ensure that all available energy is not being expended unnecessarily on basic every day tasks, or on trying to complete tasks too quickly, leaving no energy to engage in other activities or exercise 35. Using an analogy such as a jug or battery full of energy for each day, which needs to be replenished by rest, can help patients think about how they want to expend their limited amount of energy.…”
Section: Non-pharmacologicalmentioning
confidence: 99%
“…More than 90% of patients responded to 20 mg or less daily 41. CBIS prefers to use a slow up-titration regimen (figure 4) and aims to find the lowest effective opioid dose 35. This approach develops the patient's confidence by minimising side effects and reassures other clinicians involved in the patient's care who may be less accustomed to prescribing opioids in this situation.…”
Section: Pharmacologicalmentioning
confidence: 99%
“…There may be a role for oxygen in certain subgroups of patients once other approaches have been optimised, and in these cases individual clinical assessment is warranted, but certainly routine use of oxygen for palliation of breathlessness is not indicated (box 2). Patients with breathlessness in their last days of life35Involvement of specialist palliative care team (community/inpatient) and close liaison with primary care services to ensure best quality care.Syringe pump containing:Diamorphine 5–10 mg/24 h (if opioid naïve). Consider 2.5 mg in elderly/frail.…”
Breathlessness is an important and common symptom globally, affecting patients with a variety of malignant and non-malignant diseases. It causes considerable suffering to patients and also their families, and is a significant cost to healthcare systems. Optimal management of the symptom should therefore be of interest and importance to a wide range of clinicians. Best practice in the management of breathlessness consists of both non-pharmacological and pharmacological interventions as evidenced by recent randomised controlled trials of multidisciplinary breathlessness support services. As well as providing evidence for integration of early palliative care into respiratory services, these revealed that patient distress due to breathlessness can be significantly reduced and better outcomes can be achieved at lower cost than standard care.
BackgroundBreathlessness is a common, distressing symptom in people with advanced disease and a marker of deterioration. Holistic services that draw on integrated palliative care have been developed for this group. This systematic review aimed to examine the outcomes, experiences and therapeutic components of these services.MethodsSystematic review searching nine databases to June 2017 for experimental, qualitative and observational studies. Eligibility and quality were independently assessed by two authors. Data on service models, health and cost outcomes were synthesised, using meta-analyses as indicated. Data on recipient experiences were synthesised thematically and integrated at the level of interpretation and reporting.ResultsFrom 3239 records identified, 37 articles were included representing 18 different services. Most services enrolled people with thoracic cancer, involved palliative care staff and comprised 4–6 contacts over 4–6 weeks. Commonly used interventions included breathing techniques, psychological support and relaxation techniques. Meta-analyses demonstrated reductions in Numeric Rating Scale distress due to breathlessness (n=324; mean difference (MD) −2.30, 95% CI −4.43 to −0.16, p=0.03) and Hospital Anxiety and Depression Scale (HADS) depression scores (n=408, MD −1.67, 95% CI −2.52 to −0.81, p<0.001) favouring the intervention. Statistically non-significant effects were observed for Chronic Respiratory Questionnaire (CRQ) mastery (n=259, MD 0.23, 95% CI −0.10 to 0.55, p=0.17) and HADS anxiety scores (n=552, MD −1.59, 95% CI −3.22 to 0.05, p=0.06). Patients and carers valued tailored education, self-management interventions and expert staff providing person-centred, dignified care. However, there was no observable effect on health status or quality of life, and mixed evidence around physical function.ConclusionHolistic services for chronic breathlessness can reduce distress in patients with advanced disease and may improve psychological outcomes of anxiety and depression. Therapeutic components of these services should be shared and integrated into clinical practice.Registration numberCRD42017057508.
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