Anesthesia and Intensive Care and Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Via San Lorenzo 312, 90145, Palermo, Italy.
Home Palliative Care Program, SAMO, Palermo, Italy.
Drugs. 2018 Apr;78(5):543-547. doi: 10.1007/s40265-018-0879-5.
The aim of this review is to present the way in which episodic breathlessness (EB) has been recognized over the years, with regard to definition, characteristics, and management of these acute episodes that have serious consequences for patients. EB is characterized by a sudden increase in intensity of dyspnea over a short duration of time, leading to high levels of anxiety. A significant aggravation of dyspnea may occur in patients with a background of dyspnea or intermittently even without basal breathlessness. Often, known precipitating factors may trigger EB. Flares of breathlessness are accompanied by degrees of psychological distress, although it is unclear whether psychological factors may precede or be induced by EB. In any case, there is a reinforcing circuit. The duration of EB ranges from 10-30 min. Given the specific temporal pattern, requiring rapid intervention, substances with a short onset of action are suitable to overlap this phenomenon. Short-onset opioids could provide a clinical effect overlapping the onset and duration of an episode, resembling what has been largely reported for breakthrough pain. Although data are still insufficient to suggest specific recommendations, strategies such as avoiding exertion, pacing or using devices, or keeping calm have been described. Few controlled studies have investigated the effects of different formulations of opioids. Some data were gathered from studies assessing the pre-emptive use of rapid onset opioids, such as transmucosal preparations of fentanyl, followed by a provocative test, while other studies attempted to reproduce real-life conditions, given as needed. All these trials were insufficiently powered to address the efficacy of fentanyl products over oral morphine or placebo, reflecting the difficulties in patient recruiting and finalizing the studies. Strategies to prevent the occurrence of EB should be taken into consideration, including optimization of the condition of persistent dyspnea or treating psychologic or environmental causes.
本文旨在介绍多年来人们对发作性呼吸困难（EB）的认识方式，包括其定义、特征以及这些急性发作的管理方法，这些急性发作对患者有严重的影响。EB 的特征是在短时间内呼吸困难强度突然增加，导致高度焦虑。在有呼吸困难背景或间歇性发作甚至没有基础呼吸困难的患者中，可能会出现显著加重的呼吸困难。通常，已知的诱发因素可能会引发 EB。呼吸困难发作伴随着不同程度的心理困扰，尽管尚不清楚心理因素是否先于 EB 发生或由 EB 引起。在任何情况下，都存在一个强化回路。EB 的持续时间从 10-30 分钟不等。鉴于其特定的时间模式，需要快速干预，因此适合使用起效快的药物来缓解这种情况。起效快的阿片类药物可以提供一种与发作和持续时间重叠的临床效果，类似于广泛报道的突破性疼痛。尽管数据仍不足以提出具体建议，但已经描述了一些策略，例如避免劳累、调整节奏或使用设备，或保持冷静。少数对照研究调查了不同阿片类药物制剂的效果。一些数据来自于评估快速起效阿片类药物（如芬太尼经黏膜制剂）预防性使用的研究，然后进行激发试验，而其他研究则试图模拟现实生活条件，按需给药。所有这些试验都没有足够的效力来确定芬太尼产品相对于口服吗啡或安慰剂的疗效，这反映了招募患者和完成研究的困难。应考虑采取预防 EB 发生的策略，包括优化持续性呼吸困难的状况或治疗心理或环境原因。
