Anatomy and Neuroscience - Research Publications
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ItemJunior doctors' attitudes to opioids for refractory breathlessness in patients with advanced chronic obstructive pulmonary disease(WILEY, 2017-09)BACKGROUND: 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. AIMS: To understand Australian junior doctors' knowledge and attitudes regarding the management of refractory breathlessness and the role of opioids in COPD. METHODS: All junior doctors undertaking basic training in internal medicine in Victoria were invited to complete an online survey. Knowledge, willingness, and experience prescribing opioids to COPD patients with refractory breathlessness, were examined. RESULTS: Of the 243 responses received, most trainees (193, 86.5%) believed opioids have a role in treating refractory breathlessness in stable COPD outpatients, with 143 (64.1%) recommending morphine as first-line treatment for refractory breathlessness. One quarter (55, 24.7%) reported having themselves initiated an opioid and 102 (45.7%) had prescribed an opioid under senior supervision for management of breathlessness in COPD. Concern regarding adverse opioid effects was low, with 58 (26.0%) having no concerns prescribing an opioid to COPD patients. CONCLUSION: This is the first study of doctors to demonstrate high awareness, confidence, willingness and experience in prescribing opioids for the off-licence indication of refractory breathlessness in COPD. These findings differ significantly from attitudes reported overseas and are unexpected given the doctors surveyed were recently qualified. The low awareness of possible adverse events and limited insight regarding knowledge gaps is concerning and highlights the significant need for greater education in palliative care.
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ItemIndividualized breathlessness interventions may improve outcomes in patients with advanced COPD(WILEY, 2018-12)BACKGROUND AND OBJECTIVE: 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. METHODS: An individualized breathlessness plan, information leaflets, breathlessness education and a hand-held fan were offered to consecutive patients with severe COPD and refractory breathlessness attending a tertiary integrated respiratory and palliative care service. Validated dyspnoea, quality of life and anxiety/depression questionnaires were administered at baseline and after 6 weeks, with change in dyspnoea scores being the primary outcome measure. A subset of patients participated in a structured telephone interview to qualitatively assess the intervention. RESULTS: Twenty-six patients with severe COPD (mean forced expiratory volume in 1 s (FEV1 ) 38%) were included, with a mean age of 74 years. Mean modified Medical Research Council Breathlessness Scale score was 3.5. Anxiety and depression were common, being present in 38% and 35% of participants. At 6 weeks, there was a clinically significant improvement in breathlessness severity as measured by the Numerical Rating Scale. The subset of patients with anxiety/depression also saw significant improvement in all domains of the Self-Administered Standardized Chronic Respiratory Questionnaire (CRQ-SAS). Patients reported that the intervention was highly useful and acceptable. CONCLUSION: This feasibility study of individualized breathlessness interventions in patients with severe COPD and refractory breathlessness is the first to demonstrate a clinically significant reduction in dyspnoea scores, with high levels of patient acceptability.
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ItemIntegrated respiratory and palliative care may improve outcomes in advanced lung disease(EUROPEAN RESPIRATORY SOC JOURNALS LTD, 2018-01-01)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.