Natasha Smallwood

Management of refractory breathlessness with morphine in patients with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is a progressive, incurable illness, which leads to significant morbidity over long periods of time and mortality. Treatment aims to reduce symptoms, improve exercise capacity and quality of life, reduce exacerbations, slow disease progression and reduce mortality. However, breathlessness is common in patients with advanced COPD and remains undertreated. As all reversible causes of breathlessness are being optimally managed, consideration should be given to specific non‐pharmacological and pharmacological treatment strategies for breathlessness. Low dose morphine has been shown to reduce safely and effectively breathlessness in patients with severe COPD and refractory dyspnoea. However, despite numerous guidelines recommending opioids in this clinical setting, many barriers limit their uptake by clinicians. Integration of palliative care earlier in the disease course can help to improve symptom control for people with severe COPD and refractory breathlessness. A multidisciplinary approach involving both respiratory and palliative care teams offers a new model of care for these patients.

Junior doctors’ attitudes to opioids for refractory breathlessness in patients with advanced chronic obstructive pulmonary disease

Refractory breathlessness is a common, distressing symptom in patients with advanced chronic obstructive pulmonary disease (COPD). The judicious, off‐licence prescription of opioids, together with other management strategies, can improve breathlessness, however, internationally there is profound reluctance to prescribe opioids for breathlessness in COPD.

Respiratory depression secondary to morphine use in a patient with COPD and refractory breathlessness

Chronic obstructive pulmonary disease (COPD) is characterised by airflow obstruction and progressive respiratory failure. Patients develop increasing breathlessness, which can persist despite optimal medical management (refractory chronic breathlessness) [1]. Various studies suggests that low-dose morphine may safely reduce refractory breathlessness in patients with advanced respiratory disease [2–6]; however, the recent population cohort study by Vozoris et al. [7] in the European Respiratory Journal suggests opioids may be associated with increased adverse respiratory outcomes, including death in older COPD patients. We report a case of respiratory depression secondary to opioid use for refractory breathlessness. Respiratory depression secondary to morphine use in COPD patients with refractory breathlessness http://ow.ly/8NVw30aLZXv

Integrated respiratory and palliative care may improve outcomes in advanced lung disease

The unaddressed palliative care needs of patients with advanced, nonmalignant, lung disease highlight the urgent requirement for new models of care. This study describes a new integrated respiratory and palliative care service and examines outcomes from this service. The Advanced Lung Disease Service (ALDS) is a long-term, multidisciplinary, integrated service. In this single-group cohort study, demographic and prospective outcome data were collected over 4 years, with retrospective evaluation of unscheduled healthcare usage. Of 171 patients included, 97 (56.7%) were male with mean age 75.9 years and 142 (83.0%) had chronic obstructive pulmonary disease. ALDS patients had severely reduced pulmonary function (median (interquartile range (IQR)) forced expiratory volume in 1 s 0.8 (0.6–1.1) L and diffusing capacity of the lung for carbon monoxide 37.5 (29.0–48.0) % pred) and severe breathlessness. All patients received nonpharmacological breathlessness management education and 74 (43.3%) were prescribed morphine for breathlessness (median dose 9 mg·day−1). There was a 52.4% reduction in the mean number of emergency department respiratory presentations in the year after ALDS care commenced (p=0.007). 145 patients (84.8%) discussed and/or completed an advance care plan. 61 patients died, of whom only 15 (24.6%) died in an acute hospital bed. While this was a single-group cohort study, integrated respiratory and palliative care was associated with improved end-of-life care and reduced unscheduled healthcare usage. Integrated respiratory and palliative care is associated with better end-of-life care for patients with advanced lung disease http://ow.ly/mgkn30hlPXV

Individualized breathlessness interventions may improve outcomes in patients with advanced COPD: Individualized dyspnoea plans in COPD

Many patients with advanced COPD experience refractory breathlessness and individualized breathlessness interventions may improve management of this complex symptom. The aims of this study were to develop, implement and assess the efficacy of a breathlessness intervention for patients with COPD and refractory breathlessness and to evaluate patient acceptability.

Differing Approaches to Managing the Chronic Breathlessness Syndrome in Advanced COPD: A Multi-National Survey of Specialists

Abstract This study explored the approaches of respiratory and palliative medicine specialists to managing the chronic breathlessness syndrome in patients with severe chronic obstructive pulmonary disease. A voluntary, online survey was emailed to all specialists and trainees in respiratory medicine in Australia and New Zealand (ANZ), and to all palliative medicine specialists and trainees in ANZ and the United Kingdom (UK). Five hundred and seventy-seven (33.0%) responses were received from 1,749 specialists, with 440 (25.2%) complete questionnaires included from 177 respiratory and 263 palliative medicine doctors. Palliative medicine doctors in ANZ and the UK had similar approaches to managing chronic breathlessness, whereas respiratory and palliative medicine doctors had significantly different approaches (p < 0.0001). Both specialties most commonly recommended a combination of non-pharmacological and pharmacological breathlessness management strategies. Respiratory doctors focussed more on pulmonary rehabilitation, whereas palliative medicine doctors recommended breathing techniques, anxiety management and the handheld fan. Palliative medicine doctors (197 (74.9%)) recommended short acting oral morphine for breathlessness, as compared with 73 (41.2%) respiratory doctors (p < 0.0001). Respiratory doctors cited opioid concerns related to respiratory depression and lack of knowledge. Nineteen (10.7%) respiratory doctors made no specific recommendations for managing chronic breathlessness. Both specialties reported actively managing chronic breathlessness, albeit with differing approaches. Integrated services, which combine the complementary knowledge and approaches of both specialities, may overcome current gaps in care and improve the management of distressing, chronic breathlessness.

Antimicrobial prescription in patients dying from Chronic Obstructive Pulmonary Disease: Antimicrobials in deaths from COPD

Despite rising antimicrobial resistance, treatment guidelines for chronic obstructive pulmonary disease (COPD) exacerbations are frequently ignored. Patients with terminal conditions are often prescribed antimicrobials despite the goal of care to reduce burdensome treatments. The appropriate use of antimicrobials in patients who die from an exacerbation of COPD is unknown.

Breathlessness and palliative oxygen therapy in advanced chronic obstructive pulmonary disease: Letters to the Editor

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Predictable adverse events such as respiratory depression highlight the need for caution when prescribing morphine for refractory breathlessness

“A scientists aim in a discussion with his colleagues is not to persuade, but to clarify” [1]. We therefore thank D.C. Currow and co-workers for both their comments and the opportunity to continue the discussion regarding the risks and benefits of using opioids to treat refractory chronic breathlessness. The purpose of our recent case report [2] is not to persuade clinicians to prescribe or not prescribe opioids for the off-licence indication of refractory breathlessness, but to highlight and clarify risks of prescribing opioids in this clinical setting and when practising real life medicine, which is so different from the carefully controlled and managed environment of clinical trials. Caution is needed when prescribing morphine for refractory breathlessness in the real world http://ow.ly/DPxD30eabIJ

Prescription opioid use in advanced COPD: benefits, perils and controversies

We thank N.T. Vozoris for his comments and interest in the case report that we presented in the European Respiratory Journal of a patient with chronic obstructive pulmonary disease (COPD) who experienced respiratory depression after inadvertent opioid overdose while using opioids to manage refractory breathlessness [1]. The use of opioids to treat refractory breathlessness requires careful evaluation of risks and benefits http://ow.ly/ylHT30bPzfu