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Respiratory Medicine Nov 2023Dyspnea is a commonly described symptom in various chronic and acute conditions. Despite its frequency, relatively little is known about the prevalence and assessment of... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Dyspnea is a commonly described symptom in various chronic and acute conditions. Despite its frequency, relatively little is known about the prevalence and assessment of dyspnea in general populations. The aims of this review were: 1) to estimate the prevalence of dyspnea in general adult populations; 2) to identify associated factors; and 3) to identify used methods for dyspnea assessment.
METHODS
A systematic literature search was conducted using MEDLINE/PubMed, Embase, CINAHL and JAMA network. Records were screened by two independent reviewers and quality was assessed by using the Joanna Briggs Institute checklist for risk of bias in prevalence studies. Multi-level meta-analysis was performed to estimate pooled prevalence. The protocol was registered on PROSPERO (CRD42021275499).
RESULTS
Twenty original articles, all from studies in high-income countries, met the criteria for inclusion. Overall, their quality was good. Pooled prevalence of dyspnea in general adult populations based on 11 studies was 10% (95% CI 7, 15), but heterogeneity across studies was high. The most frequently reported risk factors were increasing age, female sex, higher BMI and respiratory or cardiac disease. The MRC or the modified MRC scale was the most used tool to assess dyspnea in general populations.
CONCLUSIONS
Dyspnea is a common symptom in adults in high-income countries. However, the high heterogeneity across studies and the lack of data from low- and middle-income countries limit the generalizability of our findings. Therefore, more research is needed to unveil the prevalence of dyspnea and its main risk factors in general populations around the world.
Topics: Humans; Adult; Female; Prevalence; Dyspnea; Risk Factors; Cross-Sectional Studies; Income
PubMed: 37595674
DOI: 10.1016/j.rmed.2023.107379 -
The Cochrane Database of Systematic... Jan 2015Terminally ill people experience a variety of symptoms in the last hours and days of life, including delirium, agitation, anxiety, terminal restlessness, dyspnoea, pain,... (Review)
Review
BACKGROUND
Terminally ill people experience a variety of symptoms in the last hours and days of life, including delirium, agitation, anxiety, terminal restlessness, dyspnoea, pain, vomiting, and psychological and physical distress. In the terminal phase of life, these symptoms may become refractory, and unable to be controlled by supportive and palliative therapies specifically targeted to these symptoms. Palliative sedation therapy is one potential solution to providing relief from these refractory symptoms. Sedation in terminally ill people is intended to provide relief from refractory symptoms that are not controlled by other methods. Sedative drugs such as benzodiazepines are titrated to achieve the desired level of sedation; the level of sedation can be easily maintained and the effect is reversible.
OBJECTIVES
To assess the evidence for the benefit of palliative pharmacological sedation on quality of life, survival, and specific refractory symptoms in terminally ill adults during their last few days of life.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 11), MEDLINE (1946 to November 2014), and EMBASE (1974 to December 2014), using search terms representing the sedative drug names and classes, disease stage, and study designs.
SELECTION CRITERIA
We included randomised controlled trials (RCTs), quasi-RCTs, non-RCTs, and observational studies (e.g. before-and-after, interrupted-time-series) with quantitative outcomes. We excluded studies with only qualitative outcomes or that had no comparison (i.e. no control group or no within-group comparison) (e.g. single arm case series).
DATA COLLECTION AND ANALYSIS
Two review authors independently screened titles and abstracts of citations, and full text of potentially eligible studies. Two review authors independently carried out data extraction using standard data extraction forms. A third review author acted as arbiter for both stages. We carried out no meta-analyses due to insufficient data for pooling on any outcome; therefore, we reported outcomes narratively.
MAIN RESULTS
The searches resulted in 14 included studies, involving 4167 adults, of whom 1137 received palliative sedation. More than 95% of people had cancer. No studies were randomised or quasi-randomised. All were consecutive case series, with only three having prospective data collection. Risk of bias was high, due to lack of randomisation. No studies measured quality of life or participant well-being, which was the primary outcome of the review. Five studies measured symptom control, using four different methods, so pooling was not possible. The results demonstrated that despite sedation, delirium and dyspnoea were still troublesome symptoms in these people in the last few days of life. Control of other symptoms appeared to be similar in sedated and non-sedated people. Only one study measured unintended adverse effects of sedative drugs and found no major events; however, four of 70 participants appeared to have drug-induced delirium. The study noticed no respiratory suppression. Thirteen of the 14 studies measured survival time from admission or referral to death, and all demonstrated no statistically significant difference between sedated and non-sedated groups.
AUTHORS' CONCLUSIONS
There was insufficient evidence about the efficacy of palliative sedation in terms of a person's quality of life or symptom control. There was evidence that palliative sedation did not hasten death, which has been a concern of physicians and families in prescribing this treatment. However, this evidence comes from low quality studies, so should be interpreted with caution. Further studies that specifically measure the efficacy and quality of life in sedated people, compared with non-sedated people, and quantify adverse effects are required.
Topics: Adult; Conscious Sedation; Deep Sedation; Humans; Hypnotics and Sedatives; Palliative Care; Selection Bias; Terminal Care; Terminally Ill
PubMed: 25879099
DOI: 10.1002/14651858.CD010206.pub2 -
JAMA Aug 2017Pneumonia is a leading cause of morbidity and mortality in children. It is important to identify the clinical symptoms and physical examination findings associated with... (Review)
Review
IMPORTANCE
Pneumonia is a leading cause of morbidity and mortality in children. It is important to identify the clinical symptoms and physical examination findings associated with pneumonia to improve timely diagnosis, prevent significant morbidity, and limit antibiotic overuse.
OBJECTIVE
To systematically review the accuracy of symptoms and physical examination findings in identifying children with radiographic pneumonia.
DATA SOURCES AND STUDY SELECTION
MEDLINE and Embase (1956 to May 2017) were searched, along with reference lists from retrieved articles, to identify diagnostic studies of pediatric pneumonia across a broad age range that had to include children younger than age 5 years (although some studies enrolled children up to age 19 years); 3644 unique articles were identified, of which 23 met inclusion criteria.
DATA EXTRACTION AND SYNTHESIS
Two authors independently abstracted raw data and assessed methodological quality. A third author resolved disputes.
MAIN OUTCOMES AND MEASURES
Likelihood ratios (LRs), sensitivity, and specificity were calculated for individual symptoms and physical examination findings for the diagnosis of pneumonia. An infiltrate on chest radiograph was considered the reference standard for the diagnosis of pneumonia.
RESULTS
Twenty-three prospective cohort studies of children (N = 13 833) with possible pneumonia were included (8 from North America), with a range of 78 to 2829 patients per study. The prevalence of radiographic pneumonia in North American studies was 19% (95% CI, 11%-31%) and 37% (95% CI, 26%-50%) outside of North America. No single symptom was strongly associated with pneumonia; however, the presence of chest pain in 2 studies that included adolescents was associated with pneumonia (LR, 1.5-5.5; sensitivity, 8%-14%; specificity, 94%-97%). Vital sign abnormalities such as fever (temperature >37.5°C [LR range, 1.7-1.8]; sensitivity, 80%-92%; specificity, 47%-54%) and tachypnea (respiratory rate >40 breaths/min; LR, 1.5 [95% CI, 1.3-1.7]; sensitivity, 79%; specificity, 51%) were not strongly associated with pneumonia diagnosis. Similarly, auscultatory findings were not associated with pneumonia diagnosis. The presence of moderate hypoxemia (oxygen saturation ≤96%; LR, 2.8 [95% CI, 2.1-3.6]; sensitivity, 64%; specificity, 77%) and increased work of breathing (grunting, flaring, and retractions; positive LR, 2.1 [95% CI, 1.6-2.7]) were signs most associated with pneumonia. The presence of normal oxygenation (oxygen saturation >96%) decreased the likelihood of pneumonia (LR, 0.47 [95% CI, 0.32-0.67]).
CONCLUSIONS AND RELEVANCE
Although no single finding reliably differentiates pneumonia from other causes of childhood respiratory illness, hypoxia and increased work of breathing are more important than tachypnea and auscultatory findings.
Topics: Adolescent; Chest Pain; Child; Child, Preschool; Cough; Diagnosis, Differential; Dyspnea; Female; Fever; Humans; Hypoxia; Lung; Male; Pneumonia; Radiography; Symptom Assessment; Vital Signs
PubMed: 28763554
DOI: 10.1001/jama.2017.9039 -
European Respiratory Review : An... Sep 2023A proportion of coronavirus disease 2019 (COVID-19) survivors experience persistent dyspnoea without measurable impairments in lung function. We performed a systematic... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
A proportion of coronavirus disease 2019 (COVID-19) survivors experience persistent dyspnoea without measurable impairments in lung function. We performed a systematic review and meta-analysis to determine relationships between dyspnoea and imaging abnormalities over time in post-COVID-19 patients.
METHODS
Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we analysed studies published prior to 15 September 2022 and indexed by Google Scholar, PubMed and LitCOVID which assessed chest imaging in adults ≥3 months after COVID-19. Demographic, chest imaging, spirometric and post-COVID-19 symptom data were extracted. The relationships between imaging abnormalities and dyspnoea, sex and age were determined using a random effects model and meta-regression.
RESULTS
47 studies were included in the meta-analysis (n=3557). The most prevalent computed tomography (CT) imaging abnormality was ground-glass opacities (GGOs) (44.9% (95% CI 37.0-52.9%) at any follow-up time-point). Occurrence of reticulations significantly decreased between early and late follow-up (p=0.01). The prevalence of imaging abnormalities was related to the proportion of patients with dyspnoea (p=0.012). The proportion of females was negatively correlated with the presence of reticulations (p=0.001), bronchiectasis (p=0.001) and consolidations (p=0.025). Age was positively correlated with imaging abnormalities across all modalities (p=0.002) and imaging abnormalities present only on CT (p=0.001) (GGOs (p=0.004) and reticulations (p=0.001)). Spirometric values improved during follow-up but remained within the normal range at all time-points.
CONCLUSIONS
Imaging abnormalities were common 3 months after COVID-19 and their occurrence was significantly related to the presence of dyspnoea. This suggests that CT imaging is a sensitive tool for detecting pulmonary abnormalities in patients with dyspnoea, even in the presence of normal spirometric measurements.
Topics: Adult; Female; Humans; COVID-19; SARS-CoV-2; Lung; Dyspnea; Lung Diseases
PubMed: 37558261
DOI: 10.1183/16000617.0253-2022 -
Japanese Journal of Clinical Oncology Mar 2023the role of benzodiazepines in relieving dyspnea in patients with cancer has not yet been established. This systematic review and meta-analysis aimed to determine the... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
the role of benzodiazepines in relieving dyspnea in patients with cancer has not yet been established. This systematic review and meta-analysis aimed to determine the efficacy and safety of benzodiazepines alone or in combination with opioids for dyspnea in patients with cancer.
METHODS
Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE and Ichushi-Web were searched for articles published from database inception to 23 September 2019. Studies of benzodiazepines alone or in combination with opioids for dyspnea were included. The primary outcome measure was the relief of dyspnea. The secondary outcome measures were anxiety, somnolence and severe adverse events.
RESULTS
of 505 publications initially identified, two trials and one trial were included in the meta-analysis of midazolam alone and in combination with morphine, respectively. With regard to the relief of dyspnea, midazolam alone showed no significant difference compared with morphine alone, with a relative risk of 0.95 (95% confidence interval: 0.47-1.89). Meanwhile, midazolam plus morphine was significantly more effective than morphine alone, with a relative risk of 1.33 (95% confidence interval: 1.02-1.75). For anxiety relief, a meta-analysis could not be performed because of insufficient data. The incidence of somnolence and severe adverse events was not significantly different between the experimental and control groups for either midazolam alone or in combination with morphine.
CONCLUSIONS
benzodiazepines alone do not significantly improve dyspnea compared with opioids alone, but a combination of benzodiazepines and opioids may be more effective. Evidence from randomized controlled trials focusing on patients with cancer has not been generated in recent years. Further appropriately designed randomized controlled trials are required.
Topics: Humans; Benzodiazepines; Midazolam; Sleepiness; Dyspnea; Neoplasms; Morphine; Analgesics, Opioid
PubMed: 36636762
DOI: 10.1093/jjco/hyac206 -
European Journal of Physical and... Dec 2023Until the last update in February 2022, the Cochrane Rehabilitation COVID-19 Evidence-based Response (REH-COVER) action identified an increasing volume of evidence for...
INTRODUCTION
Until the last update in February 2022, the Cochrane Rehabilitation COVID-19 Evidence-based Response (REH-COVER) action identified an increasing volume of evidence for the rehabilitation management of COVID-19. Therefore, our aim was to identify the best available evidence on the effectiveness of interventions for rehabilitation for COVID-19-related limitations of functioning of rehabilitation interest in adults with COVID-19 or post COVID-19 condition (PCC).
EVIDENCE ACQUISITION
We ran the searches on February 17, 2023, in the following databases: PubMed, EMBASE, CENTRAL, CINHAL, and the Cochrane COVID-19 Study Register, applying a publication date restriction to retrieve only papers published in 2022. To retrieve papers published before 2022, we screened the reference lists of previous publications included in the REH-COVER action, covering papers from early 2020 to the end of 2022. This current review includes only randomised controlled trials and concludes the rapid living systematic reviews of the Cochrane Rehabilitation REH-COVER action. The risk of bias and certainty of evidence were evaluated in all studies using the Cochrane Risk of Bias tool and GRADE, respectively. We conducted a narrative synthesis of the evidence. PROSPERO registration number: CRD42022374244.
EVIDENCE SYNTHESIS
After duplicate removal, we identified 18,950 individual records and 53 RCTs met the inclusion criteria. Our findings suggest that the effect of breathing and strengthening exercise programs on dyspnea and physical exercise capacity compared to no treatment in non-severe COVID-19 patients is uncertain. Multicomponent telerehabilitation may slightly increase physical exercise capacity compared to educational intervention in adults with PCC. There is, however, uncertainty about its effect on lung function and physical exercise capacity when compared to no treatment. Finally, the effect of inspiratory muscle training on maximal inspiratory pressure compared to no treatment in adults with PCC is uncertain.
CONCLUSIONS
Interventions that are part of comprehensive pulmonary rehabilitation approaches may benefit dyspnea and exercise tolerance in adults with COVID-19 and PCC. The available evidence has several methodological limitations that limit the certainty of evidence and the clinical relevance of findings. Therefore, we cannot provide robust suggestions for practice. While high-quality RCTs are being conducted, clinicians should consider using high-quality evidence from other pulmonary conditions to rehabilitate patients with COVID-19 or PCC using context-specific interventions.
Topics: Humans; Chronic Disease; COVID-19; Dyspnea; Exercise; Physical Therapy Modalities
PubMed: 38214047
DOI: 10.23736/S1973-9087.23.08331-4 -
The European Respiratory Journal May 2020https://bit.ly/2XVwIsa
https://bit.ly/2XVwIsa
Topics: Administration, Inhalation; Adrenal Cortex Hormones; Betacoronavirus; COVID-19; Coronavirus; Coronavirus Infections; Dyspnea; Humans; Pandemics; Pneumonia, Viral; SARS-CoV-2; COVID-19 Drug Treatment
PubMed: 32341100
DOI: 10.1183/13993003.01009-2020 -
The Cochrane Database of Systematic... Aug 2021Chronic non-invasive ventilation (NIV) is increasingly being used to treat people with COPD who have respiratory failure, but the evidence supporting this treatment has... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Chronic non-invasive ventilation (NIV) is increasingly being used to treat people with COPD who have respiratory failure, but the evidence supporting this treatment has been conflicting.
OBJECTIVES
To assess the effects of chronic non-invasive ventilation at home via a facial mask in people with COPD, using a pooled analysis of IPD and meta-analysis.
SEARCH METHODS
We searched the Cochrane Airways Register of Trials, MEDLINE, Embase, PsycINFO, CINAHL, AMED, proceedings of respiratory conferences, clinical trial registries and bibliographies of relevant studies. We conducted the latest search on 21 December 2020.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) comparing chronic NIV for at least five hours per night for three consecutive weeks or more (in addition to standard care) versus standard care alone, in people with COPD. Studies investigating people initiated on NIV in a stable phase and studies investigating NIV commenced after a severe COPD exacerbation were eligible, but we reported and analysed them separately. The primary outcomes were arterial blood gases, health-related quality of life (HRQL), exercise capacity (stable COPD) and admission-free survival (post-exacerbation COPD). Secondary outcomes for both populations were: lung function, COPD exacerbations and admissions, and all-cause mortality. For stable COPD, we also reported respiratory muscle strength, dyspnoea and sleep efficiency.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. After inclusion of a study, we requested the IPD. We analysed continuous and time-to-event data using linear- and cox-regression mixed-effect models with a random effect on study level. We analysed dichotomous IPD using generalised estimating equations. We adjusted all models for age and sex. We assessed changes in outcomes after three and 12 months. We also conducted a meta-analysis on aggregated trial data.
MAIN RESULTS
We included 14 new RCTs in this review update, in addition to the seven previously included. Seventeen studies investigated chronic NIV in stable COPD and four studies investigated chronic NIV commenced after a severe COPD exacerbation. Three studies compared NIV to sham continuous positive airway pressure (2 to 4 cmHO). Seven studies used a nasal mask, one study used an oronasal mask and eight studies used both interfaces. Five studies did not report the interface. The majority of trials (20/21) were at high risk of performance bias due to an unblinded design. We considered 11 studies to have a low risk of selection bias and 13 to have a low risk of attrition bias. We collected and analysed the IPD from 13 stable COPD studies (n = 778, 68% of the participants included) and from three post-exacerbation studies (n = 364, 96% of the participants included). In the stable COPD group, NIV probably results in a minor benefit on the arterial partial pressure of oxygen (PaO) after three months (adjusted mean difference (AMD) 0.27 kPa, 95% CI 0.04 to 0.49; 9 studies, 271 participants; moderate-certainty evidence), but there was little to no benefit at 12 months (AMD 0.09 kPa, 95% CI -0.23 to 0.42; 3 studies, 171 participants; low-certainty evidence). The arterial partial pressure of carbon dioxide (PaCO) was reduced in participants allocated to NIV after three months (AMD -0.61 kPa, 95% CI -0.77 to -0.45; 11 studies, 475 participants; high-certainty evidence) and persisted up to 12 months (AMD -0.42 kPa, 95% CI -0.68 to -0.16; 4 studies, 232 participants; high-certainty evidence). Exercise capacity was measured with the 6-minute walking distance (minimal clinical important difference: 26 m). There was no clinically relevant effect of NIV on exercise capacity (3 months: AMD 15.5 m, 95% CI -0.8 to 31.7; 8 studies, 330 participants; low-certainty evidence; 12 months: AMD 26.4 m, 95% CI -7.6 to 60.5; 3 studies, 134 participants; very low-certainty evidence). HRQL was measured with the Severe Respiratory Insufficiency and the St. Georges's Respiratory Questionnaire and may be improved by NIV, but only after three months (3 months: standardised mean difference (SMD) 0.39, 95% CI 0.15 to 0.62; 5 studies, 259 participants; very low-certainty evidence; 12 months: SMD 0.15, 95% CI -0.13 to 0.43; 4 studies, 200 participants; very low-certainty evidence). Lastly, the risk for all-cause mortality is likely reduced by NIV (adjusted hazard ratio (AHR) 0.75, 95% CI 0.58 to 0.97; 3 studies, 405 participants; moderate-certainty evidence). In the post-exacerbation COPD group, there was little to no benefit on the PaO after three months, but there may be a slight decrease after 12 months (3 months: AMD -0.10 kPa, 95% CI -0.65 to 0.45; 3 studies, 234 participants; low-certainty evidence; 12 months: -0.27 kPa, 95% CI -0.86 to 0.32, 3 studies; 170 participants; low-certainty evidence). The PaCO was reduced by NIV at both three months (AMD -0.40 kPa, 95% CI -0.70 to -0.09; 3 studies, 241 participants; moderate-certainty evidence) and 12 months (AMD -0.52 kPa, 95% CI -0.87 to -0.18; 3 studies, 175 participants; high-certainty evidence). NIV may have little to no benefit on HRQL (3 months: SMD 0.25, 95% CI -0.01 to 0.51; 2 studies, 219 participants; very low-certainty evidence; 12 months: SMD 0.25, 95% -0.06 to 0.55; 2 studies, 164 participants; very low-certainty evidence). Admission-free survival seems improved with NIV (AHR 0.71, 95% CI 0.54 to 0.94; 2 studies, 317 participants; low-certainty evidence), but the risk for all-cause mortality does not seem to improve (AHR 0.97, 95% CI 0.74 to 1.28; 2 studies, 317 participants; low-certainty evidence).
AUTHORS' CONCLUSIONS
Regardless of the timing of initiation, chronic NIV improves daytime hypercapnia. In addition, in stable COPD, survival seems to be improved and there might be a short term HRQL benefit. In people with persistent hypercapnia after a COPD exacerbation, chronic NIV might prolong admission-free survival without a beneficial effect on HRQL. In stable COPD, future RCTs comparing NIV to a control group receiving standard care might no longer be warranted, but research should focus on identifying participant characteristics that would define treatment success. Furthermore, the optimal timing for initiation of NIV after a severe COPD exacerbation is still unknown.
Topics: Disease Progression; Dyspnea; Humans; Noninvasive Ventilation; Pulmonary Disease, Chronic Obstructive; Quality of Life; Respiratory Insufficiency
PubMed: 34368950
DOI: 10.1002/14651858.CD002878.pub3 -
Integrated disease management interventions for patients with chronic obstructive pulmonary disease.The Cochrane Database of Systematic... Sep 2021People with chronic obstructive pulmonary disease (COPD) show considerable variation in symptoms, limitations, and well-being; this often complicates medical care. A... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
People with chronic obstructive pulmonary disease (COPD) show considerable variation in symptoms, limitations, and well-being; this often complicates medical care. A multi-disciplinary and multi-component programme that addresses different elements of care could improve quality of life (QoL) and exercise tolerance, while reducing the number of exacerbations.
OBJECTIVES
To compare the effectiveness of integrated disease management (IDM) programmes versus usual care for people with chronic obstructive pulmonary disease (COPD) in terms of health-related quality of life (QoL), exercise tolerance, and exacerbation-related outcomes.
SEARCH METHODS
We searched the Cochrane Airways Group Register of Trials, CENTRAL, MEDLINE, Embase, and CINAHL for potentially eligible studies. Searches were current as of September 2020.
SELECTION CRITERIA
Randomised controlled trials (RCTs) that compared IDM programmes for COPD versus usual care were included. Interventions consisted of multi-disciplinary (two or more healthcare providers) and multi-treatment (two or more components) IDM programmes of at least three months' duration.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed trial quality and extracted data. If required, we contacted study authors to request additional data. We performed meta-analyses using random-effects modelling. We carried out sensitivity analyses for the quality of included studies and performed subgroup analyses based on setting, study design, dominant intervention components, and region.
MAIN RESULTS
Along with 26 studies included in the 2013 Cochrane Review, we added 26 studies for this update, resulting in 52 studies involving 21,086 participants for inclusion in the meta-analysis. Follow-up periods ranged between 3 and 48 months and were classified as short-term (up to 6 months), medium-term (6 to 15 months), and long-term (longer than 15 months) follow-up. Studies were conducted in 19 different countries. The mean age of included participants was 67 years, and 66% were male. Participants were treated in all types of healthcare settings, including primary (n =15), secondary (n = 22), and tertiary care (n = 5), and combined primary and secondary care (n = 10). Overall, the level of certainty of evidence was moderate to high. We found that IDM probably improves health-related QoL as measured by St. George's Respiratory Questionnaire (SGRQ) total score at medium-term follow-up (mean difference (MD) -3.89, 95% confidence interval (CI) -6.16 to -1.63; 18 RCTs, 4321 participants; moderate-certainty evidence). A comparable effect was observed at short-term follow-up (MD -3.78, 95% CI -6.29 to -1.28; 16 RCTs, 1788 participants). However, the common effect did not exceed the minimum clinically important difference (MCID) of 4 points. There was no significant difference between IDM and control for long-term follow-up and for generic QoL. IDM probably also leads to a large improvement in maximum and functional exercise capacity, as measured by six-minute walking distance (6MWD), at medium-term follow-up (MD 44.69, 95% CI 24.01 to 65.37; 13 studies, 2071 participants; moderate-certainty evidence). The effect exceeded the MCID of 35 metres and was even greater at short-term (MD 52.26, 95% CI 32.39 to 72.74; 17 RCTs, 1390 participants) and long-term (MD 48.83, 95% CI 16.37 to 80.49; 6 RCTs, 7288 participants) follow-up. The number of participants with respiratory-related admissions was reduced from 324 per 1000 participants in the control group to 235 per 1000 participants in the IDM group (odds ratio (OR) 0.64, 95% CI 0.50 to 0.81; 15 RCTs, median follow-up 12 months, 4207 participants; high-certainty evidence). Likewise, IDM probably results in a reduction in emergency department (ED) visits (OR 0.69, 95%CI 0.50 to 0.93; 9 RCTs, median follow-up 12 months, 8791 participants; moderate-certainty evidence), a slight reduction in all-cause hospital admissions (OR 0.75, 95%CI 0.57 to 0.98; 10 RCTs, median follow-up 12 months, 9030 participants; moderate-certainty evidence), and fewer hospital days per person admitted (MD -2.27, 95% CI -3.98 to -0.56; 14 RCTs, median follow-up 12 months, 3563 participants; moderate-certainty evidence). Statistically significant improvement was noted on the Medical Research Council (MRC) Dyspnoea Scale at short- and medium-term follow-up but not at long-term follow-up. No differences between groups were reported for mortality, courses of antibiotics/prednisolone, dyspnoea, and depression and anxiety scores. Subgroup analysis of dominant intervention components and regions of study suggested context- and intervention-specific effects. However, some subgroup analyses were marked by considerable heterogeneity or included few studies. These results should therefore be interpreted with caution.
AUTHORS' CONCLUSIONS
This review shows that IDM probably results in improvement in disease-specific QoL, exercise capacity, hospital admissions, and hospital days per person. Future research should evaluate which combination of IDM components and which intervention duration are most effective for IDM programmes, and should consider contextual determinants of implementation and treatment effect, including process-related outcomes, long-term follow-up, and cost-effectiveness analyses.
Topics: Aged; Disease Management; Dyspnea; Exercise Tolerance; Humans; Male; Pulmonary Disease, Chronic Obstructive; Quality of Life
PubMed: 34495549
DOI: 10.1002/14651858.CD009437.pub3 -
Palliative & Supportive Care Oct 2022Cancer-related dyspnea is a common symptom in patients with cancer. It has also been reported to be a predictor of poorer prognosis, which can then change clinical... (Meta-Analysis)
Meta-Analysis Review
INTRODUCTION
Cancer-related dyspnea is a common symptom in patients with cancer. It has also been reported to be a predictor of poorer prognosis, which can then change clinical treatment and advance care planning. Currently, no definitive recommendation for pharmacologic agents for cancer-related dyspnea exists. The aim of this systematic review and network meta-analysis is to compare pharmacologic agents for the prophylaxis and treatment of cancer-related dyspnea.
METHODS
A search was conducted in the databases of PubMed, Embase, and Cochrane CENTRAL through May 2021. Standardized mean differences (SMDs), as reported by studies or calculated from baseline and follow-up dyspnea scores, were amalgamated into a summary SMD and 95% confidence interval (CI) using a restricted maximum likelihood multivariate network meta-analysis.
RESULTS
Twelve studies were included in this review; six reported on prophylaxis of exertional dyspnea, five on treatment of everyday dyspnea, and one on treatment of episodic dyspnea. Morphine sulfate was better at controlling everyday dyspnea than placebo (SMD 1.210; 95% CI: 0.415-2.005). Heterogeneity in study design and comparisons, however, led to some concerns with the underlying consistency assumption in network meta-analysis design.
CONCLUSION
Optimal pharmacologic interventions for cancer-related dyspnea could not be determined based on this analysis. Further trials are needed to report on the efficacy of pharmacologic interventions for the prophylaxis and treatment of cancer-related dyspnea.
Topics: Dyspnea; Humans; Morphine; Neoplasms; Network Meta-Analysis
PubMed: 36111729
DOI: 10.1017/S1478951521001656