Simon Steffen T, Higginson Irene J, Bausewein Claudia, Jolley Caroline J, Bajwah Sabrina, Maddocks Matthew, Wilharm Carolin, Oluyase Adejoke O, Pralong Anne
University of Cologne, Faculty of Medicine and University Hospital, Department of Palliative Medicine, Cologne, Germany.
University of Cologne, Faculty of Medicine and University Hospital, Centre for Health Services Research (ZVFK), Cologne, Germany.
Palliat Med. 2024 Dec;38(10):1079-1087. doi: 10.1177/02692163241270945. Epub 2024 Sep 12.
Severe and refractory chronic breathlessness is a common and burdensome symptom in patients with advanced life-limiting disease. Its clinical management is challenging because of the lack of effective interventions.
To provide practice recommendations on the safe use of pharmacological therapies for severe chronic breathlessness.
Scoping review of (inter)national guidelines and systematic reviews. We additionally searched for primary studies where no systematic review could be identified. Consensus on the recommendations was reached by 75% approval within an international expert panel.
Searches in MEDLINE, Cochrane Library and Guideline International Network until March 2023. Inclusion of publications on the use of antidepressants, benzodiazepines, opioids or corticosteroids for chronic breathlessness in adults with cancer, chronic obstructive pulmonary disease, interstitial lung disease or chronic heart failure.
Overall, the evidence from eight guidelines, 14 systematic reviews and 3 randomised controlled trials (RCTs) on antidepressants is limited. There is low quality evidence favouring opioids in patients with chronic obstructive pulmonary disease, cancer and interstitial lung disease. For chronic heart failure, evidence is inconclusive. Benzodiazepines should only be considered for anxiety associated with severe breathlessness. Antidepressants and corticosteroids should not be used.
Management of breathlessness remains challenging with only few pharmacological options with limited and partially conflicting evidence. Therefore, pharmacological treatment should be reserved for patients with advanced disease under monitoring of side effects, after optimisation of the underlying condition and use of evidence-based non-pharmacological interventions as first-line treatment.
严重且难治的慢性呼吸困难是晚期危及生命疾病患者常见且负担沉重的症状。由于缺乏有效的干预措施，其临床管理具有挑战性。
为严重慢性呼吸困难的药物治疗安全使用提供实践建议。
对（国际）指南和系统评价进行范围综述。我们还搜索了无法找到系统评价的原始研究。国际专家小组中75%的批准达成了对这些建议的共识。
检索MEDLINE、Cochrane图书馆和指南国际网络直至2023年3月。纳入关于在患有癌症、慢性阻塞性肺疾病、间质性肺疾病或慢性心力衰竭的成年人中使用抗抑郁药、苯二氮䓬类药物、阿片类药物或皮质类固醇治疗慢性呼吸困难的出版物。
总体而言，来自八项指南、十四项系统评价和三项关于抗抑郁药的随机对照试验的证据有限。有低质量证据表明阿片类药物对慢性阻塞性肺疾病、癌症和间质性肺疾病患者有益。对于慢性心力衰竭，证据尚无定论。苯二氮䓬类药物仅应考虑用于与严重呼吸困难相关的焦虑。不应使用抗抑郁药和皮质类固醇。
呼吸困难的管理仍然具有挑战性，只有少数药物选择，证据有限且部分相互矛盾。因此，药物治疗应保留给晚期疾病患者，在监测副作用的情况下，在优化基础疾病并使用循证非药物干预作为一线治疗之后使用。
