[Advance care planning in COPD]. / Proactieve zorgplanning bij COPD.

COPD (Chronic Obstructive Pulmonary Disease) affects an estimated 600,000 Dutch citizens. This chronic disease often has an unpredictable and sometimes a very invalidating course, despite various treatment options. It is important to timely initiate advance care planning in this patient population, to address any disease-related worries, needs and wishes the patient has. In this way patients (and their caregivers) can stay in the lead regarding their chronic condition, by making decisions for (future) medical, psychological, spiritual, and social needs based upon good information, their values, beliefs and experiences.

"This is What Lies Ahead". Perspectives of Oxygen-Naïve COPD Patients on Long-Term Oxygen Use. A Qualitative Study.

Purpose: Oxygen is commonly prescribed to patients with severe COPD. However, little is known about the perspectives COPD patients, who do not yet use oxygen, have on this treatment. Patients and Methods: A total of 14 oxygen-naïve patients with COPD Gold stages 3-4 and a high symptom burden participated in semi-structured interviews, in which their beliefs and expectations regarding oxygen therapy were explored. We used conventional content analysis to process our qualitative data. Results: Four main themes were identified: seeking information, expected impact on quality of life, expected social impact and stigma, and last phase of life. Conclusion: The message that home oxygen should be started, was regarded as bad news by most participants. The rationale behind the therapy and the way it is delivered were unknown to most participants. Some participants anticipated smoking-related stigma and social isolation. Misconceptions such as tank explosions, becoming housebound, full dependency on oxygen and an imminent death were common amongst interviewees. Clinicians should be aware of these fears and assumptions when communicating with patients on this subject.

"When I am breathless now, I don't have the fear that's linked to it": a case series on the potential of EMDR to break the dyspnea-anxiety cycle in COPD.

BACKGROUND: Expectations can enhance the intensity and the neural processing of breathlessness. Previous breathlessness episodes may influence the perception of subsequent episodes because of psycho-traumatic consequences. In post-traumatic stress disorder, eye movement desensitization and reprocessing (EMDR) is the therapy of choice. AIMS AND OBJECTIVES: We explored the hypothesis that EMDR in patients with chronic obstructive pulmonary disease (COPD) and previous severe breathlessness episodes, improves breathlessness mastery by decreasing the anxiety component. METHODS: As we found no literature on previous research on this subject, we undertook a qualitative case series on four patients with COPD GOLD 4/D and refractory breathlessness who wished to undergo EMDR for psychotraumatic breathlessness episodes. Amongst others, we used the Chronic Respiratory Disease Questionnaire (CRQ) before and after EMDR, and semi-structured, face-to-face, in-depth interviews. RESULTS: All patients had between three and five EMDR sessions. On CRQ, subset mastery, three patients had a large improvement and one patient a moderate improvement. On subset emotional functioning, three patients showed a large improvement and one showed no change. All patients made a distinction between 'regular' breathlessness and breathlessness intertwined with anxiety. They all stated that the anxiety component of their breathlessness diminished or disappeared. All four would recommend EMDR for other COPD patients. CONCLUSION: There is ground for a randomized controlled clinical trial to test the effects of EMDR on breathlessness mastery in a subset of COPD patients with previous severe breathlessness episodes and high levels of anxiety.

Filling the Gap: A Feasibility Study of a COPD-Specific Breathlessness Service.

Refractory breathlessness is a devastating symptom in chronic obstructive pulmonary disease (COPD). Symptom-focused breathlessness services, involving palliative care teams, offer individualized support but are not yet widely available for people with nonmalignant disease among which COPD. Our primary aim was to demonstrate the feasibility of setting up a breathlessness service specifically for COPD patients within a respiratory outpatient clinic. Our secondary aims were to assess how many sessions patients need to complete the intervention; to obtain an indication of effect size (on the Chronic Respiratory Questionnaire (CRQ), subset mastery domain); and to evaluate patient and professional satisfaction. We conducted a non-randomized single-center feasibility study. Participants had COPD and refractory breathlessness. During at least one session with a respiratory nurse and a pulmonologist, and one session with a physiotherapist, patients learned non-pharmacological interventions to manage breathlessness. Of 34 screened patients, 19 were included. All completed the intervention. A median of two clinical visits and two telephone calls were needed to complete the intervention. The mean improvement of 1.55 in CRQ, mastery domain, significantly exceeded the clinically important difference of 0.5. The service was rated as excellent by the eight patients who completed the survey. The health professional team gave positive feedback on the experience of delivering the intervention. Delivery of a breathlessness service for COPD outpatients with refractory breathlessness appears feasible, easy to implement in a respiratory outpatient clinic, and has the potential to be effective. A randomized controlled clinical trial is needed to test effectiveness and cost-effectiveness in this context.

[Treatment of anxiety in COPD with CBT]. / Angst bij COPD behandelen met CGT.

A major part of COPD patients suffers from anxiety. The presence of an anxiety or stress disorder compromises their quality of life. Anxiety and (posttraumatic) stress disorders may be treated with cognitive behavior therapy (CBT). CBT encompasses different treatment interventions and protocols. Some of these interventions have been investigated to treat anxiety in patients with COPD. Those that have been proven to be effective, should be offered to COPD patients with anxiety. Examples are: education about symptoms in COPD (mostly dyspnea) and the bodily anxiety response; education about the positive and negative anxiety and breathing circle; breathing, posture and relaxation exercises; identification and correction of catastrophic thoughts; setting goals and planning activities (behavior activation) and pacing.

Opioids in patients with COPD and refractory dyspnea: literature review and design of a multicenter double blind study of low dosed morphine and fentanyl (MoreFoRCOPD).

BACKGROUND: Refractory dyspnea or breathlessness is a common symptom in patients with advanced chronic obstructive pulmonary disease (COPD), with a high negative impact on quality of life (QoL). Low dosed opioids have been investigated for refractory dyspnea in COPD and other life-limiting conditions, and some positive effects were demonstrated. However, upon first assessment of the literature, the quality of evidence in COPD seemed low or inconclusive, and focused mainly on morphine which may have more side effects than other opioids such as fentanyl. For the current publication we performed a systematic literature search. We searched for placebo-controlled randomized clinical trials investigating opioids for refractory dyspnea caused by COPD. We included trials reporting on dyspnea, health status and/or QoL. Three of fifteen trials demonstrated a significant positive effect of opioids on dyspnea. Only one of four trials reporting on QoL or health status, demonstrated a significant positive effect. Two-thirds of included trials investigated morphine. We found no placebo-controlled RCT on transdermal fentanyl. Subsequently, we hypothesized that both fentanyl and morphine provide a greater reduction of dyspnea than placebo, and that fentanyl has less side effects than morphine. METHODS: We describe the design of a robust, multi-center, double blind, double-dummy, cross-over, randomized, placebo-controlled clinical trial with three study arms investigating transdermal fentanyl 12 mcg/h and morphine sustained-release 10 mg b.i.d. The primary endpoint is change in daily mean dyspnea sensation measured on a numeric rating scale. Secondary endpoints are change in daily worst dyspnea, QoL, anxiety, sleep quality, hypercapnia, side effects, patient preference, and continued opioid use. Sixty patients with severe stable COPD and refractory dyspnea (FEV1 < 50%, mMRC ≥ 3, on optimal standard therapy) will be included. DISCUSSION: Evidence for opioids for refractory dyspnea in COPD is not as robust as usually appreciated. We designed a study comparing both the more commonly used opioid morphine, and transdermal fentanyl to placebo. The cross-over design will help to get a better impression of patient preferences. We believe our study design to investigate both sustained-release morphine and transdermal fentanyl for refractory dyspnea will provide valuable information for better treatment of refractory dyspnea in COPD. Trial registration NCT03834363 (ClinicalTrials.gov), registred at 7 Feb 2019, https://clinicaltrials.gov/ct2/show/NCT03834363 .

Digital versus analogue chest drainage system in patients with primary spontaneous pneumothorax: a randomized controlled trial.

BACKGROUND: Patients with a primary spontaneous pneumothorax (PSP) who are treated with chest tube drainage are traditionally connected to an analogue chest drainage system, containing a water seal and using a visual method of monitoring air leakage. Electronic systems with continuous digital monitoring of air leakage provide better insight into actual air leakage and changes in leakage over time, which may lead to a shorter length of hospital stay. METHODS: We performed a randomized controlled trial comparing the digital with analogue system, with the aim of demonstrating that use of a digital drainage system in PSP leads to a shorter hospital stay. RESULTS: In 102 patients enrolled with PSP we found no differences in total duration of chest tube drainage and hospital stay between the groups. However, in a post-hoc analysis, excluding 19 patients needing surgery due to prolonged air leakage, hospital stay was significantly shorter in the digital group (median 1 days, IQR 1-5 days) compared to the analogue group (median 3 days, IQR 2-5 days) (p 0.014). Treatment failure occurred in 3 patients in both groups; the rate of recurrence within 12 weeks was not significantly different between groups (16% in the digital group versus 8% in the analogue group, p 0.339). CONCLUSION: Length of hospital stay was not shorter in patients with PSP when applying a digital drainage system compared to an analogue drainage system. However, in the large subgroup of uncomplicated PSP, a significant reduction in duration of drainage and hospital stay was demonstrated with digital drainage. These findings suggest that digital drainage may be a practical alternative to manual aspiration in the management of PSP. TRIAL REGISTRATION: Registered 22 September 2013 - Retrospectively registered, Trial NL4022 (NTR4195).

COPD patients in need of palliative care: Identification after hospitalization through the surprise question.

Currently, few patients suffering from chronic obstructive pulmonary disease (COPD) who might benefit from a palliative care approach are referred to a palliative care team. Tools to identify patients eligible for a palliative care approach have been found to be difficult to apply in daily practice. Therefore, there is need for a simple and easily applicable tool to identify those patients who would benefit from referral to a palliative care team. The aim of this study was to determine if the surprise question (SQ) "Would I be surprised if this patient dies within 12 months?" in a subset of recently hospitalized COPD patients identifies those subjects. Recently hospitalized COPD patients were included, and the answer to the SQ was provided by the treating pulmonologist. The gold standards framework (GSF) prognostic indicator guidance was regarded as the gold standard test and was assessed for each patient. Sensitivity, specificity, and negative and positive predictive values were calculated to determine the accuracy of the SQ plus recent hospitalization compared to the variables of the GSF. A total of 93 patients were analyzed. In 35 patients (38%), the answer to the SQ was "not surprised"; 78 patients (84%) met ≥1 criteria of the GSF (15 (16%) did not meet any criteria). Specificity and positive predictive value for the SQ were both 100% ((78.2-100) and (87.7-100), respectively). Sensitivity was 44.9% (33.7-56.5) and negative predictive value was 25.9% (22.2-29.9). The "not surprised" group fulfilled significantly more GSF criteria. The SQ after recent hospitalization for COPD has a very high specificity compared to a standardized tool and is therefore a useful tool for the quick identification of patients who are most likely to benefit from palliative care. However, this method doesn't identify all patients who are eligible for referral to palliative care.

Attitudes toward opioids for refractory dyspnea in COPD among Dutch chest physicians.

Dyspnea is the most frequently reported symptom of outpatients with advanced chronic obstructive pulmonary disease (COPD). Opioids are an effective treatment for dyspnea. Nevertheless, the prescription of opioids to patients with advanced COPD seems limited. The aims of this study are to explore the attitudes of Dutch chest physicians toward prescription of opioids for refractory dyspnea to outpatients with advanced COPD and to investigate the barriers experienced by chest physicians toward opioid prescription in these patients. All chest physicians (n = 492) and residents in respiratory medicine (n = 158) in the Netherlands were invited by e-mail to complete an online survey. A total of 146 physicians (response rate 22.5%) completed the online survey. Fifty percent of the physicians reported to prescribe opioids for refractory dyspnea in 20% or less of their outpatients with advanced COPD and 18.5% reported never to prescribe opioids in these patients. The most frequently reported barriers toward prescription of opioids were resistance of the patient, fear of possible adverse effects, and fear of respiratory depression. To conclude, Dutch chest physicians and residents in respiratory medicine rarely prescribe opioids for refractory dyspnea to outpatients with advanced COPD. This reluctance is caused by perceived resistance of the patient and fear of adverse effects, including respiratory adverse effects.