Chest
Volume 137, Issue 3, March 2010, Pages 674-691
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Consensus Statement
American College of Chest Physicians Consensus Statement on the Management of Dyspnea in Patients With Advanced Lung or Heart Disease

https://doi.org/10.1378/chest.09-1543Get rights and content

Background

This consensus statement was developed based on the understanding that patients with advanced lung or heart disease are not being treated consistently and effectively for relief of dyspnea.

Methods

A panel of experts was convened. After a literature review, the panel developed 23 statements covering five domains that were considered relevant to the topic condition. Endorsement of these statements was assessed by levels of agreement or disagreement on a five-point Likert scale using two rounds of the Delphi method.

Results

The panel defined the topic condition as “dyspnea that persists at rest or with minimal activity and is distressful despite optimal therapy of advanced lung or heart disease.” The five domains were: measurement of patient-reported dyspnea, oxygen therapy, other therapies, opioid medications, and ethical issues. In the second round of the Delphi method, 34 of 56 individuals (61%) responded, and agreement of at least 70% was achieved for 20 of the 23 statements.

Conclusions

For patients with advanced lung or heart disease, we suggest that: health-care professionals are ethically obligated to treat dyspnea, patients should be asked to rate the intensity of their breathlessness as part of a comprehensive care plan, opioids should be dosed and titrated for relief of dyspnea in the individual patient, both the patient and clinician should reassess whether specific treatments are serving the goal of palliating dyspnea without causing adverse effects, and it is important for clinicians to communicate about palliative and end-of-life care with their patients.

Section snippets

Executive Summary

This consensus statement was initiated based on the understanding that patients with advanced lung or heart disease are not currently being treated consistently and effectively for relief of dyspnea. The purpose is to summarize available evidence in order to improve the care and treatment of dyspnea in this population. An expert panel of specialists in pulmonary medicine, cardiology, nursing, and palliative care developed our findings. Selection of the expert panel and the development of the

Literature Search

The ACCP research methodologist performed a MEDLINE literature search of English language articles on human subjects for the period of 1966 to 2008. The purpose of the literature search was to evaluate published studies on this topic condition and to identify topic domains that would form the basis of the consensus survey. The following search strategy and key terms were used to capture studies relevant to the topic:

  • Patient population: advanced, severe, end-stage, end-of-life lung or

Results

The results of the literature review are presented in tables located in the Appendices. The results of the Delphi survey are presented in Table 2, Table 3, Table 4, Table 5, Table 6, Table 7.

Discussion

Despite the high prevalence of dyspnea in patients with advanced lung or heart disease, the current literature review and previous reviews demonstrate the paucity of scientific data on the management of this symptom.1, 27, 76, 99, 100 The majority of RCTs on this topic have focused on patients with advanced COPD, whereas information addressing dyspnea management in patients with advanced heart disease is quite limited.

With the Delphi method, consensus was achieved on 20 of 23 statements.

Summary

This consensus statement was initiated based on the understanding that patients with advanced lung or heart disease are not currently being treated consistently and effectively for relief of dyspnea. The purpose was to provide suggestions to improve the treatment of dyspnea in this patient population. The results of the literature review demonstrated a paucity of scientific information on this topic. Using the Delphi method to develop consensus, acceptable agreement was achieved for 20 of 23

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Carrieri-Kohlman has received grant money covering a small portion of her salary from an NIH RO1 grant entitled “Dsypnea Self-Management: Internet or Face-to-Face.” The overall aim of this proposal is to compare the impact of a new Internet-based dyspnea self-management program (I-DSMP) with a face-to-face program (f-DSMP) and an Attention Control (AC) that has been shown to be

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Funding/Support: This project was commissioned by the American College of Chest Physicians (ACCP) and is considered an official project of this organization.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestpubs.org/site/misc/reprints.xhtml).

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