Expert panel issues recommendations for 'Dyspnea Crisis'
An American Thoracic Society panel of experts is calling for better care for thousands of Americans who suffer severe shortness of breath as a result of advanced lung and heart disease. These episodes can be very frightening for patients and caregivers, and the increased anxiety often makes the symptoms worse. In the current issue of the Annals of the American Thoracic Society, the panel suggests that patients work with their providers to develop individualized actions plans that can keep these episodes from turning into emergencies.
"By the time paramedics arrive, the patients and their caregivers are usually panicked," said Richard Mularski, MD, a Kaiser Permanente pulmonologist who heads the panel that made the recommendations.
"The paramedics often rely on inserting breathing tubes as the only way to safely give patients opioid medications to ease the sensation of suffocating."
"For patients who don't want breathing tubes or other life-sustaining measures, there are alternative relaxation and breathing techniques and medications that can ease symptoms, but these alternatives only work if they are planned for and practiced before the patient experiences shortness of breath," added Dr. Mularski.
The panel refers to these episodes with a new term, "dyspnea crisis," which describes an acute worsening of a dyspnea (shortness of breath) experience, a heightened psycho-social-spiritual patient response, and a setting in which unprepared caregivers are too overwhelmed to respond in an optimal manner.
To help patients develop an individual action plan, the panel suggests a pneumonic, COMFORT, that encompasses the key tools: Call for help with calming voice; Observe closely and assess dyspnea for ways to respond; Medications, which may or may not include opioids; Fan the face, which may decrease shortness of breath; Oxygen therapy if it has been helpful in past; Reassure the patient and use relaxation techniques; and Timing the interventions.
Other recommendations include:
- Involve palliative care specialists and interdisciplinary care teams in developing the response plan.
- Create a simple checklist for providers and caregivers with key elements of the response plan.
- Share the checklist with all providers and post it at home where emergency responders can see it.
- Complete and post advanced directives and Physician Orders for Life-Sustaining Treatment (POLST forms).
- Revise response plans frequently to reflect the patient's disease state and care goals.
Chosen by the American Thoracic Society leadership, the panel is made up of 27 clinicians, researchers and administrators specializing in pulmonary medicine, critical care, geriatrics, emergency medicine, respiratory care, nursing, medicine and social work. Members first met in 2009 to review the medical literature and systematic reviews on the management of dyspnea, including studies from 1999-2009. They have met several times since to review updated literature and to come up with the consensus recommendations.
Richard A. Mularski, MD, MSHS, MCR, is a pulmonary and end-of-life specialist with Kaiser Permanente Northwest, where palliative care teams work in the hospital and with outpatients in a coordinated fashion to provide the best individualized care for patients with advanced illnesses.
Panel co-chairs are Lynn E. Reinke, PhD, ARNP, of the University of Washington Medical Center; Virginia Carrieri-Kohlman, RN, DNSc, of the University of California, San Francisco; and Mark D. Fischer, MD, of Olympic Medical Center in Port Angeles, Wash.
