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End of Life Online Curriculum

Overview

Assisted Suicide

 Palliative Sedation  
Communication

Opioid Conversion

Transition to Death

 
Home Hospice

Dyspnea

Bereavement

  
Prognostication

     
 

 

Dyspnea: How to Assess and Palliate Dyspnea (Air-Hunger)

  
 

Introduction & Learning Objectives
Overview

Normal Breathing
Prevalence

Patient Distress
Pathophysiology
Causes Flowchart

Assessment

Flowchart 1
Flowchart 2
Flowchart 3
Tools
Palliation

Specific Situations

Case 1: John Silver (a 67 year old man with dyspnea)

Pearls
Resources
Authors

Appendices

Prevalence of Dyspnea

Points to Ponder

  • Prevalence ranges from 20 to 60% of all cancer patients.
  • Dyspnea is much more prevalent in end stage heart (Anderson 2001) and lung diseases for patients in their final years.
  • Many HIV positive patients suffer from dyspnea (owing to comorbid conditions like Pneumocystis Carinii pneumonia, Kaposi's sarcoma with lung infiltration, tuberculosi etc.)
  • Dyspnea tends to become more severe and more frequent toward the end of life (Ripamonti 1999) (Higginson 1989) (Conill 1997).
  • Prevalence and intensity increase with lung, pleural and mediastinal involvements in cancer patients (Reuben 1986) (Dudgeon 2001).
  • Low functional status (Karnofsky Performance Scale) is associated with an increase in severity and incidence of dyspnea (Reuben 1986) (Chang 2000) (Mercadante 2000).
  • Dyspnea is often unreported by patients and unnoticed by healthcare professionals (Roberts 1993) (Kutner 2001).

Evidence of Dyspnea by Disease

Author

Setting

Patients#

Prevalence

Comments
Ripamonti Medline Search 1966-1999 -- 21-79%

10-63% moderate-severe increase frequency and severity when close to death, different causes may coexist.
Higginson Community 86 21% became the most severe symptom at death
Reuben National hospice study 1754 50% Incidence 70%, significantly associated with lung & pleura tumor involvement, low Karnofsky Performance Scale, and underlying lung disease. Lung, colorectal, and breast carcinomas are the most common tumor sites.
Grond Pain clinic 1635 24% Pain plus 3.3 symptoms on average.
Muers Specialist clinic 289

60%

 NSCLC, symptom worsened with time.
Donnelly Palliative care consult 1000 28% Advanced cancers, moderate to severe in 63%.
Chang VA In/outpatients 240 50% Median # of symptoms 8, # of intense symptoms increased as Karnofsky Performance Scale decreased. Disease free patients may still experience intense symptoms.
Dudgeon Outpatient 923 46% General cancer, 4% lung cancer, 5.4% lung mets.
Potter Palliative care referral 400 31% 95% of patients were with cancer.
Conill Home and inpatients 176 40% Increased to 46% in the last week of life.
Bruera Pain clinic 135 55%* Lung involvement and anxiety were independently correlated with intensity of dyspnea. (* Moderate).
Edmonds Post bereavement interview 449 78% Lung cancer.
Claessens Five academic centers 939 32%* NSCLC (* Severe).
COPD
Edmonds Post bereavement interview 87 94% Chronic lung disease, dyspnea increased in final year and final weeks.
Claessens Five academic centers 1008 56% * COPD (* Severe).
CHF
Nordgren Review of hospitalized 80 men 90%, women 86% Last 6 months of life CHF patients.
HIV/AIDS
Fantoni Inpatient and outpatients 266 68% Last 3 months of life.
Diaz Academic medical center 327 41% Positive HIV without AIDS.
General Home Hospice Population
Syrett St. Christopher’s home 470 43% Home hospice audit.
Elderly Population
Ho General patients at home 500 32% Community-based study in South Wales.
2006-05-01 Update
 
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Home | Project Website | ©End of Life Curriculum Project, a joint project of the US Veterans Administration and SUMMIT, Stanford University Medical School. Funded by a grant to the Veterans Administration Nationwide Palliative Care Network by the National Library of Medicine. VJ Periyakoil, Principal Investigator.