Current opinion in supportive and palliative care
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Curr Opin Support Palliat Care · Sep 2014
ReviewInhaled nebulized and intranasal opioids for the relief of breathlessness.
Inhaled nebulized and intranasal opioid administration is available with a proven short onset of action for the relief of pain. As breathlessness episodes are short, these routes of administration seem to be attractive for breathlessness management. This review describes the recent studies evaluating the effectiveness of inhaled nebulized and intranasal application of opioids for patients suffering from refractory breathlessness. ⋯ There is currently not enough evidence to support the use of inhaled application of opioids for the relief of breathlessness. There are no controlled trials assessing the efficacy and effectiveness of intranasal opioid application, but a pilot trial is underway to provide preliminary data.
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Our review focuses on recent developments across many settings regarding the diagnosis, screening and management of delirium, so as to inform these aspects in the context of palliative and supportive care. ⋯ Although formal systematic delirium screening with brief but sensitive tools is strongly advocated for patients in palliative and supportive care, it requires critical evaluation in terms of clinical outcomes, including patient comfort. Randomized controlled trials are needed to inform the development of guidelines for the management of delirium in this setting.
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Curr Opin Support Palliat Care · Sep 2014
ReviewOpioid management of pain: the impact of the prescription opioid abuse epidemic.
The greater emphasis on pain control over the last decade has been accompanied by increased opioid prescriptions and an epidemic of opioid abuse. This review examines the financial, regulatory, and clinical practice impact of the epidemic, the factors contributing to its growth, and strategies that may counter this public health crisis. ⋯ The opioid prescription abuse epidemic has precipitated calls for increased regulation. Clinicians can improve patient care and diminish opioid abuse by identifying patient risk factors, increasing vigilance and structure for those at risk, and providing interdisciplinary care for any patients coping in a maladaptive manner.
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Dyspnea is a distressing consequence of many unremitting diseases. This review discusses the therapeutic use of noninvasive ventilation (NIV) in advanced illness. ⋯ NIV is an important adjunct to medications for patients with intractable dyspnea. Future research should attempt to clarify the effectiveness of NIV at controlling dyspnea within and outside the hospital. Barriers to its domiciliary application are largely unknown. Processes should be developed to optimize communication among clinicians, patients, and their caregivers around the issues of when to start NIV and how to withdraw it at the end of life.
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Curr Opin Support Palliat Care · Sep 2014
ReviewCorrelates between basic science and therapeutic interventions: the theory and the practice.
To review the science of breathlessness and demonstrate how current therapeutic interventions for breathlessness target the known underlying mechanisms. ⋯ Therapies which aim to reduce the neural respiratory drive include oxygen, exercise and opioids. Interventions which aim to improve ventilation include breathing retraining and positioning. Modulation of respiratory afferent feedback may be achieved using chest wall vibration and fan therapy. Cognitive and behavioural therapies aim to modify the emotional response to breathlessness. Opioids have been shown to modulate breathlessness at the level of the corticolimbic system, as well as the brainstem. Further work is needed to identify other relevant neurotransmitter systems in order to explore new therapies.