Management of Dyspnea in Advanced Cancer: ASCO Guideline

PURPOSE To provide guidance on the clinical management of dyspnea in adult patients with advanced cancer. METHODS ASCO convened an Expert Panel to review the evidence and formulate recommendations. An Agency for Healthcare Research and Quality (AHRQ) systematic review provided the evidence base for nonpharmacologic and pharmacologic interventions to alleviate dyspnea. The review included randomized controlled trials (RCTs) and observational studies with a concurrent comparison group published through early May 2020. The ASCO Expert Panel also wished to address dyspnea assessment, management of underlying conditions, and palliative care referrals, and for these questions, an additional systematic review identified RCTs, systematic reviews, and guidelines published through July 2020. RESULTS The AHRQ systematic review included 48 RCTs and two retrospective cohort studies. Lung cancer and mesothelioma were the most commonly addressed types of cancer. Nonpharmacologic interventions such as fans provided some relief from breathlessness. Support for pharmacologic interventions was limited. A meta-analysis of specialty breathlessness services reported improvements in distress because of dyspnea. RECOMMENDATIONS A hierarchical approach to dyspnea management is recommended, beginning with dyspnea assessment, ascertainment and management of potentially reversible causes, and referral to an interdisciplinary palliative care team. Nonpharmacologic interventions that may be offered to relieve dyspnea include airflow interventions (eg, a fan directed at the cheek), standard supplemental oxygen for patients with hypoxemia, and other psychoeducational, self-management, or complementary approaches. For patients who derive inadequate relief from nonpharmacologic interventions, systemic opioids should be offered. Other pharmacologic interventions, such as corticosteroids and benzodiazepines, are also discussed. Additional information is available at www.asco.org/supportive-care-guidelines .

Optimal Nutritional Factors Influencing the Duration of Mechanical Ventilation among Critically ill Adults in the Intensive Care Unit

Background: Malnutrition is associated with a complication problem affecting critically ill patients throughout the trajectory of their illness and which may increase the duration of hospitalization and mechanical ventilation and mortality. To explore nutritional factors impact on the duration of mechanical ventilation in critically ill patients. Methods: In this single-center, prospective observational study in a critical care unit. The sample of the study consisting of a total of 100 critically ill patients who were included in the regression analyzed by purposive sampling, performed to address the research objectives. The data were collected for each patient who participated in the study for 2 consecutive days with SGA, Dyspnea assessment form, APACHE II, and time to initial EN on the 24 hours of hospital admitted and the daily calories target requirement on the seven days. Results: At the end of monitoring, the nutrition status, time to initial EN, and calories, target requirements were moderate positive statistically significant related to the duration of mechanical ventilation (R = 0.54, R = 0.30, R= 0.40, p < 0.05). However, age, the severity of illness, and dyspnea scales were not related to the duration of mechanical ventilation (p> 0.05). Therefore, nutrition status and calory target requirements could be a predictor of the duration of mechanical ventilation. The predictive power was 28.0 percent of variance (R2 = 0.28, p< 0.01). Conclusion: The finding supports which assessment of the nutritional status and calory target requirement within 7 days revealed with reducing the duration of mechanical ventilation in critically ill patients.

Approach to decongestion therapy in patients with acute decompensated heart failure: the echocardiography guided strategy

Goal The E / (Ea×Sa) index is an echocardiographic parameter to determine a patient’s left ventricular filling pressure. This study aims to determine the safety and efficacy of the echocardiographic E / (Ea×Sa) index guided diuretic therapy compared to urine output (conventional) guided diuretic treatment.Material and Methods In this cross-sectional study, patients with heart failure with reduced ejection fraction (HFrEF) who were hospitalized due to acute decompensation episode were consecutively allocated in a 1:1 ratio to monitoring arms. The diuretic dose, which provided 20 % reduction in the E / (Ea×Sa) index value compared to initial value, was determined as adequate dose in echocardiography guided monitoring group. The estimated glomerular filtration rate (eGFR), change in weight, NT pro-BNP level and dyspnea assessment on visual analogue scale (VAS) were analyzed at the end of the monitoring.Results Although the similar doses of diuretics were used in both groups, the patients with E / (Ea×Sa) index guided strategy had the substantial lower NT pro-BNP level within 72 hours after diuretic administration (2172 vs.2514 pg / mL, p= 0.036). VAS score on dyspnea assessment was significantly better in the patients with E / (Ea×Sa) index guided strategy (52 vs. 65; p= 0.04). And, in term of body weight loss (4.93 vs.5.21 kg, p=0.87) and e-GFR (54.58±8.6 vs. 52.65±9.1 mL / min / 1.73 m2p=0.74) in both groups are associated with similar outcomes. In both groups, there was no worsening renal function and electrolyte imbalance that required stopping or decreasing loop diuretic dosing.Conclusions The E / (Ea×Sa) index guidance might be a safe strategy for more effective diuretic response that deserves consideration for selected a subgroup of acute decomposed HFrEF patients.

Intensive Care Nurses’ Perceptions of Routine Dyspnea Assessment

Background Dyspnea (breathing discomfort) is commonly experienced by critically ill patients and at this time is not routinely assessed and documented. Intensive care unit nurses at the study institution recently instituted routine assessment and documentation of dyspnea in all patients able to report using a numeric scale ranging from 0 to 10. Objective To assess nurses’ perceptions of the utility of routine dyspnea measurement, patients’ comprehension of assessment questions, and the impact on nursing practice and to gather nurses’ suggestions for improvement. Methods Data were obtained from interviews with intensive care unit nurses in small focus groups and an anonymous online survey randomly distributed to nurses representing all intensive care units. Results Intensive care unit nurses affirmed the importance of routine dyspnea assessment and documentation. Before implementing the measurement tool, nurses often assessed for breathing discomfort in patients by using observed signs. Most nurses agreed that routine assessment can be used to predict patients’ outcomes and improve patient-centered care. Nurses found the assessment tool easy to use and reported that it did not interfere with workflow. Nurses felt that patients were able to provide meaningful ratings of dyspnea, similar to ratings of pain, and often used patients’ ratings in conjunction with observed physical signs to optimize patient care. Conclusion Our study shows that nurses understand the importance of routine dyspnea assessment and that the addition of a simple patient report scale can improve care delivery and does not add to the burden of work-flow.