PURPOSE: Consensus statements by ACCP and other organizations on dyspnea describe management of chronic and episodic dyspnea, but do not address acute crises of dyspnea that may result in intensive medical utilization, especially near the end of life. In 2009, a professional organization project began discourse on identification, management, and resource optimization for palliative care for such acute episodes of dyspnea.
METHODS: We conducted a comprehensive search in Medline, EMBASE, CINAHL, Cochrane, DARE, and NICE for published articles from 1990-2009. Four reviewers evaluated available evidence quality from systematic evidence-based reviews (SEBRs) using AMSTAR; syntheses of data aided the project participants in formulating a definition of dyspnea crisis.
RESULTS: Search identified 1291 references including 49 SEBRs - we reviewed the evidence and used an informal consensus process to specify a definition for dyspnea crisis. Project members define dyspnea crisis as “sustained and severe resting breathing discomfort that occurs in patients with advanced, often life-limiting illness and overwhelms the patient and caregivers’ ability to achieve symptom relief.”.
CONCLUSION: The project work concentrates on dyspnea crisis management for patients in whom the goals of care are focused on palliation and for whom mechanical ventilation is not consistent with treatment preferences. Interventions for dyspnea crisis presume disease-specific therapies are already in use when appropriate. We recognized that identification and assessment of dyspnea crisis should begin with first responders who may be lay or minimally trained. Especially when dyspnea crisis occurs in the home or a care facility away from more advanced medical resources, project members emphasize the importance of preparation and practice of individualized responses for patients.
CLINICAL IMPLICATIONS: Project members offer a consensus definition for the novel description of the clinical entity, dyspnea crisis. The project is engaged in developing a summary document concerning identification, risk assessment, and first response; ethical and professional considerations; efficient utilization, communication, and care coordination; clinical management of dyspnea crisis with algorithm components; development of patient education and provider aid products; and development of audit and quality enhancement tools.
DISCLOSURE: Richard Mularski, No Financial Disclosure Information; No Product/Research Disclosure Information