Recurrent respiratory infections can result in permanent loss of lung function for patients with cystic fibrosis, yet few studies show optimal approaches to exacerbation management. Researchers at Johns Hopkins University, Baltimore, looked at how treatment setting and treatment duration influenced CF patients’ outcomes.1
“Currently, there are no guidelines as to whether a patient should be treated with intravenous antibiotic therapy in the home or in the hospital and for how long,” said J. Michael Collaco, MD, assistant professor at Johns Hopkins. Consequently, practices at CF centers vary across the country. For example, some provide treatment for as few as five days, while others treat for as long as 21 days.
“Are we not giving patients adequate therapy with a very short course that could result in increased antibiotic resistance, or are we treating too long, resulting in increased health care costs and decreased quality of life for families?” Dr. Collaco asked. To determine the answers, Dr. Collaco and colleagues used retrospective data from 1,535 individuals in 755 families from the multi-center U.S. Cystic Fibrosis Twin-Sibling Study to compare baseline lung function levels to lung function at the end of treatment and also over the year after treatment.
They learned that there were no significant differences one year after the exacerbation in patients’ lung function when therapy was provided either in the home or in the hospital. This finding has the potential to change current practice for CF centers that lean toward hospital stays to treat CF respiratory exacerbations, said Peter Mogayzel, MD, director of the Cystic Fibrosis Center at John Hopkins Children’s Center.
“For carefully chosen patients, being treated at home is an option that can lead to similar outcomes as being in the hospital,” he said.
Dr. Mogayzel summed up the advantages for families who are well trained and have adequate resources to provide outpatient intravenous antibiotic therapy: less disruption to family life, fewer absences from work and school, and lower health care costs. The disadvantage is that a three-times-a-day antibiotic regimen can add stress for families already stretched by daily airway clearance and inhalational therapy routines.
“It’s a tremendous amount of work, and some patients find it preferable to be treated in the hospital,” Dr. Mogayzel said. Additionally, hospitalization provides an opportunity to provide more intensive therapy than what may be available in the home.
When the researchers looked at when lung function began to improve during the course of therapy, they found that optimal duration may be seven to 10 days. Their findings also imply that for a typical CF patient, extending therapy beyond 10 days may not offer any additional benefit.
However, Dr. Collaco emphasized that every CF patient responds to antibiotic therapy differently and requires an individualized care plan. “What the results indicate is that we need to do more research to determine which factors are important for determining an optimal approach to the treatment of pulmonary exacerbations,” Dr. Collaco said.
Management of dyspnea
Shortness of breath is a foreboding issue for patients with advanced lung diseases such as chronic obstructive pulmonary disease and advanced pulmonary fibrosis. Yet many physicians remain unsure of how to treat dyspnea, especially at the end of life. In order to fill this gap in knowledge, the American College of Chest Physicians convened a panel of experts who issued a consensus statement last year that explains how to achieve dyspnea relief consistently and effectively.2
Joshua O. Benditt, MD, FCCP, helped to write the consensus statement and said one of the key points is that physicians should not focus on a singular approach. “You have to think in an organized way about a bunch of different treatments,” Dr. Benditt said. Supplemental oxygen therapy, pursed lip breathing, relaxation techniques, and noninvasive positive pressure ventilation all should be considered to reduce dyspnea.
Some respiratory therapists previously may not have thought of using NPPV in the palliative care setting. The rationale for NPPV is that by unloading the respiratory muscles, the decreased work of breathing might provide relief of dyspnea, according to the consensus statement. In his own practice as director of respiratory care services at the University of Washington School of Medicine, Seattle, Dr. Benditt often uses NPPV for patients with a neuromuscular cause of breathing failure.
In addition to looking at new methods, the consensus statement addresses an older controversy of using opioid medications at the end of life. It supports using oral or parenteral opioids to relieve dyspnea. “It is very clear that opioids do help in palliative care,” Dr. Benditt said.
But he acknowledges that patients and families often worry that using opioids or sedatives might hasten death. This is an opportunity for clinicians to follow another consensus statement recommendation: Do a better job at communicating with patients and families about quality palliative care. By explaining how increased doses of opioids can relieve dyspnea symptoms and lessen anxiety over breathing difficulty, a clinician can help to put their fears into perspective.
Optimal duration of PR
Pulmonary rehabilitation program coordinators see their patients’ exercise tolerance, symptoms, and quality of life improve from day to day. But what they don’t know is exactly how many days their patients should participate in PR to reach their full potential and maintain those benefits.
While guidelines from the ACCP recommend PR programs of longer than 12 weeks, there is no consensus among physicians regarding the optimal duration. Hoping to shed light on a standardized length of time for PR, Marla K. Beauchamp, MScPT, and colleagues at the University of Toronto, Ontario, searched the literature and found that the length of programs varies from a few weeks to three years.3
Although a meta-analysis of their results wasn’t possible due to the large heterogeneity in program duration and outcomes, the researchers took a close look at five randomized controlled studies that compared different lengths of PR programs in patients with COPD. In three of the RCTs, longer duration PR programs showed more favorable effects on health-related quality of life. In two of the RCTs, longer duration PR programs demonstrated more benefits in terms of exercise capacity. The improvements in both areas were moderate, but they suggest to clinicians and patients that slow and steady wins the race.
“While shorter programs are capable of producing training effects, longer programs are likely needed in order to maintain benefits over time and to facilitate behavioral changes, which is an important goal for pulmonary rehabilitation,” Beauchamp said.
She encouraged PR program coordinators to look for ways to provide some elements of their intervention over extended periods, perhaps by implementing a graduated discharge program or helping patients to partner with nearby community fitness centers. “We need to look at more cost-effective strategies to help support patients to exercise for longer,” Beauchamp said.
The scarcity of literature available for review also demonstrates a need for more RCTs comparing different PR program lengths, she added.
Contact Sharlene George at firstname.lastname@example.org.