Dyspnoea in Advanced Disease Oxford University Press Makes No Representation, Express Or Implied, That the Drug Dosages in This Book Are Correct
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OXFORD MEDICAL PUBLICATIONS Dyspnoea in advanced disease Oxford University Press makes no representation, express or implied, that the drug dosages in this book are correct. Readers must therefore always check the product information and clinical procedures with the most up to date published product information and data sheets provided by the manufacturers and the most recent codes of conduct and safety regulations. The authors and the publishers do not accept responsibility or legal liability for any errors in the text or for the misuse or misapplication of material in this work. Dyspnoea in advanced disease a guide to clinical management Edited by Sara Booth Macmillan Consultant in Palliative Medicine, Lead Clinician in Palliative Care Cambridge University Hospitals NHS Foundation Trust; Honorary Senior Lecturer, Department of Palliative Care and Policy Kings College, London Deborah Dudgeon W Ford Connell Professor of Palliative Care Medicine, Queen’s University, Kingston, Ontario, Canada 1 3 Great Clarendon Street, Oxford OX2 6DP Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide in Oxford New York Auckland Cape Town Dar es Salaam Hong Kong Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trade mark of Oxford University Press in the UK and in certain other countries Published in the United States by Oxford University Press Inc., New York ß Oxford University Press 2006 The moral rights of the author have been asserted Database right Oxford University Press (maker) First published 2006 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, or under terms agreed with the appropriate reprographics rights organization. Enquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above You must not circulate this book in any other binding or cover and you must impose this same condition on any acquirer A catalogue record for this title is available from the British Library Library of Congress Cataloging in Publication Data Dyspnoea in advanced disease: a guide to clinical management / edited by Sara Booth and Deborah Dudgeon. p.; cm. Includes bibliographical references and index. 1. Dyspnea. 2. Dyspnea–Palliative treatment. [DNLM: 1. Dyspnea–complications. 2. Dyspnea–therapy. 3. Palliative Care. WF 143 D9983 2005] I. Booth, Sara, Dr. II. Dudgeon, Deborah. RC776.D9D975 2005 616.2–dc22 2005016392 Typeset by SPI Publisher Services, Pondicherry, India Printed in Great Britain on acid-free paper by Biddles Ltd, Kings Lynn ISBN–0–19–853003–X (Pbk) 978–0–19–853003–9 (Pbk) 10987654321 Foreword The editors (Drs. Booth and Dudgeon), together with their contributors, have produced a major multi-author book on dyspnoea which will have real practical clinical significance, combining the modest pharmacological tools we have at present with other therapeutic strategies. The reader has been brought face to face with both the complexity and severity of the problems. Ameliorating dyspnoea is possible, but at the same time we learn how little we really understand of the genesis of this symptom. The size of the problem of effective therapeutics for dyspnoea is well summarized in the preface. The achievement of increased cooperation between those working in specialist palliative care, oncology, neurology, respiratory and cardiovascular medicine and paediatrics is clearly demonstrated by the contributions of individual authors knowledgeable in their own fields. The result for severely dyspnoeic patients is likely to be ‘‘shared care’’ between the super-specialist and the community practitioner, resulting in improved care. There remains an astonishing lack of precise information regarding the genesis of dyspnoea. Julius Comroe, a medically qualified physiologist and pharmacologist, wrote the equivalent of a ‘‘Foreword’’, Dyspnea; Modern Concepts of Cardiovascular Disease (1956), Vol. 25.9, 347–349. His advice to young investigators was to direct their attention to determining the neuro- biological basis of dyspnoea. There has been some advance along these lines and this is mentioned both in the preface and elsewhere in this book. We need to know where the perception of the symptom is taking place in the brain, so that appropriate medication can be discovered. The modern neuro-psych- iatrist is likely to be familiar with this type of question – even if not the answer! The association of Anxiety with Dyspnoea is striking and mentioned in more than one paper in this book. How does this come about? At present we do not understand this phenomenon. Imaging the brain in a functional as well as a structural manner is likely to demonstrate areas activated within the amyg- daloid complex in the anterior part of the temporal lobe – an area known to be concerned with anxiety perception in man. Minimising anxiety is likely to reduce the impact of dyspnoea. We need more specific drugs to reduce anxiety. vi j FOREWORD The editors should be congratulated on what has been achieved. As research is making progress, I suspect that a new edition will be needed within the next five years, to update us on all these matters. Meanwhile a word of warning is needed! Research in this area is very difficult. Let us neither castigate nor ignore research workers in this area for having only done few studies where the ‘‘n’’ is below an acceptable level of statistical ‘‘purity’’.We need to remember that no two patients are alike in their response to medication for dyspnoea. ‘‘Suck it and See’’ has historically done a great deal for the development of new therapeutics. Rushing to publish such studies is not necessarily a crime. Professor A. Guz August 2005 Preface Dyspnoea is a very common symptom in people with advanced cancer and cardiac, respiratory, and certain neurological diseases. Its prevalence varies according to the stage and the type of the underlying disorder. Breathlessness may be reversible early in the course of the illness but becomes intractable as the disease progresses. Once it is irreversible, in spite of the best medical care dyspnoea can profoundly impair the quality of life not only of the person who suffers with it but also those closest to them. Patients almost universally respond to breathlessness by decreasing their activity to whatever degree will relieve their discomfort. This leads to social isolation, depression, fatigue, generalized dissatisfaction with life and significant emotional distress. Some studies have found that many patients receive little or no medical or nursing assistance with their dyspnoea, leaving them to cope with this debilitating symptom in isolation. Many doctors and nurses, even amongst those who treat the diseases commonly associated with dyspnoea, find it hard to manage chronic intractable breathlessness and this can lead to a sense of nihilism which is often perceived by the patient and family, and possibly further exacerbates any feelings of helplessness and isolation. Unfortunately, even with the inter- ventions of expert teams, dyspnoea is often not as well controlled as pain. Specialists in palliative care are more practiced in managing the dyspnoea associated with advanced cancer (which invariably has a short prognosis when it becomes intractable) than managing patients who live with breathless- ness for many months or years. It is heartening that more attention is being paid to improving the quality of life (as well as understanding the medical care) of patients with non-malignant diseases such as heart failure and chronic obstructive airways disease (www.NICE.org.uk). There is also increasing co- operation between those working in specialist palliative care, oncology, neurol- ogy, respiratory medicine and cardiology so that patients can receive shared care both in hospital and in the community. There are also exciting advances in imaging of breathlessness with functional MRI and PETscanning beginning to illuminate the way the sensation is processed by the central nervous system. viii j PREFACE This synthesis of ideas should lead to a better understanding of the pathophy- siology and management of dyspnoea, with an improvement in the quality of life for patients with breathlessness. This book builds on this shared knowledge to provide clinicians with a practical guide to the management of breathlessness in patients with different common advanced diseases. It provides the latest scientific advances in the understanding of the pathophysiology, assessment and clinical management of this complex symptom. The increasing understanding of the wide-ranging effects on the patient’s quality of life is underlined. The book has been organized to address generalized aspects of breathless- ness in advanced illness and more specific underlying aetiologies and man- agements relevant to particular underlying diseases. The earlier chapters are concerned with the science and aetiology of breath- lessness (as it is presently understood) in specific diseases; others follow which consider