WMCARES PRIDE SUMMARY

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WMCARES PRIDE SUMMARY

So it happened, the inaugural WMCARES PRIDE event! I have been told my aim (PYA and all) should to be succinct in all I do, (I have insight into my lack of ability to write in very short and concise sentences with the aim to project one’s aim precisely and accurately) therefore what follows is hopefully succinct.

It was quite simply a romp of awesomeness, first off we had the plenery session with Sharon Hudson speak about the rapid rise of Brumyodo a fellow acronymic explosion (Birmingham and ‘You-Only-Die-Once’), the lessons learnt and exciting projects and conversations happening, raising the public profile from a grass roots level. Have a nosey…

BrumYODO

Without any respite we rapidly munched into some serious multidisciplinary Haribo Star mix.

 

I have always wondered how does a CNS in palliative care working in a hospice setting manage DNA- CPR conversations with palliative/end of life patients and their families? And you know what, at that instant Jenny Hadley answers all there could be to know about said topic.

This was followed by ‘End of life prescriptions and wastage in patients’ homes – an audit by Dr Helena Lee (SWBH)’, whereby I felt a little guilty about all the omeprazole I have stockpiled in my house in case I eat another of my mates curries. This guilt however was abated by simply (in my opinion) the game changer of the day.

The St Richard’s Bereavement Cookery Group. Matt Jackson and Kevin Ratcliffe spoke about the most incredibly brilliant bereavement work. I know, as a bloke (grr) with testosterone driven pride and rippling musculature I would find it unspeakably tough to talk to a councillor about those sensations (I have never had) which people call emotions.

But…

Add in a slightly competitive, side by side (not face to face) banterous cooking experience, I am there. Kicking and whipping some apricot suflay.

And this is important! How do we engage these lost to the system blokes. Especially since these folk are the most at risk population for many many psychological issues (including suicide). I encourage you all to take this model and start it everywhere! (and talk to St Richards)

After the coffee break it was time to re-enter the foray with the Registrar trilogy. First up was Dr Maddy Turley demonstrating a working document to aid consistency in guidance led therapeutic decisions for diabetic patients in the hospice setting. Concentrating on day to day practical pragmatic practice rather than getting lost in the Gliptins, SGLT-2 groups, LMPTP inhibitors, (oh my more acronyms) etc, she kept to a single page document. Boom!

Then came the central event, Dr Hazel Coop founder of WMCARES outlined the journey thus far, the present projects and the future to behold (which is green coloured with a kinda splodge where there should be an ‘A’) She handed the baton on to Dr Mike Macfarlane a future leader of the Palliative movement as a whole, but now the lead of WMCARES. He outlined the DNA-CPR project and Electronic future planning projects,  showing us all the incredible output being created.

This lead onto wee ol’ me, explaining my incredible concept of horizontal traffic lights (see above) and levetiracetam. It was a whirl wind of powerpoint, family pictures and some science thrown in.
With many thanks to St Mary’s Hospice who provided the grub for lunch, we perused the posters which simply changed the landscape of research forever (above is Gemma Bennion’s work on GSF at New Cross Hospital).
Invigorated we dived back into our seats for the final trio of the day.
Next up was Maria Kavanagh with; ‘Gateway – a portal to the right care at the right time and place’, we all felt we were definitely in the right place and right time. Up nest was Dr Rebecca Benbow’s Audit of admission process at Compton Hospice Inpatient Unit showed us quantifiable data about what good work we are actually doing, and the (long) time it takes to do an admission.
The final chat of the day was in Compassionate Leadership in Palliative and End of Life Care – A focus group, by Alistair Hewison, which provoked fruity discussion about leadership. (What about followship?)
After the intense shotgun effect of information, the feeling of caffeine waning, all of the full heads in the room were contented, but understandably fatigued. Brimming with ideas for the future everyone agreed the event has instilled a PRIDE in the West Midlands Research and the direction has been charted, course set and sails freed for the coming year.

Itching to go to WMCARES PRIDE!

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Itching to go to WMCARES PRIDE!

 

5 Days until the inaugural acronymic mash up that is WMCARES PRIDE. We have some serious shapes to make on the dance floor of research. To alleviate the pruritis and alloknesis of anticipation here is some medications to consider…

 

Itching Meds

 

(If an emollient alone does not provide adequate relief, consider a trial of an emollient with an active ingredient (for example menthol 0.5% or 1% in aqueous cream) or topical crotamiton (Eurax®).

 

Nalfurafine Kappa opioid receptor agonist Pruritic (uraemic)
Cromolyn sodium

 

Leukotriene receptor antagonist Pruritis (uraemic) (prevent Mast cell degranulation)
Gabapentin Interacts with GABA –  unclear. Maybe voltage gated calcium channels. Also interacts with NMDA, protein kinase C. and inflammatory cytokines Prurities (Uraemic) and everything else
Rifampicin Antibiotic (inhibits bacterial DNA-dependent RNA synthesis) Most powerful inducer of cP450 Hepatic Pruritis
flumecinol

Flumenizol

Selective benzodiazepine receptor antagonist Hepatic pruritis
Doxepin TCA with H1 antagonism Dialysis patients pruritis
Paroxetine

 

SSRI (more anticholinergic effects) Any pruritis
Any antihistamine (cetirizine, fexofenidine, piriton, loratadine) Anti histamines

No difference between them, ? fexofenadine dermatology choice

Type 1 Hypersensitivity and allergic, urticarial, dermatitis, ? eczematous
Cimetadine H2 antagonist Lymphoma
Ondansetron 5HT3 receptor antagonist Opioid induced Pruritis
Cholestyramine

 

Bile acid sequesterant Cholestasis Pruritus
Naltrexone 6βnaltrexol are antagonists at the μ-opioid receptor (MOR), the κ-opioid receptor (KOR)

 

Uraemic itch
Mirtazapine Atypical antidepressant, Mirtazapine has antihistamine α2-blocker and antiserotonergic activity

 

The drug which solves everything. Aka Vitamin M
Steroids Epigenetic nucleaolar effects Any itch, any symptom, have we tried steroids yet?

 

 

References:

 

  1. Low-dose doxepin for treatment of pruritus in patients on hemodialysis https://www.ncbi.nlm.nih.gov/pubmed/19357442
  2. Scottish Guidelines http://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/Pruritis.aspx
  3. Cochrane review http://www.cochrane.org/CD008320/SYMPT_drugs-itching-adult-palliative-care-patients
  4. The Leviticus of Pall https://www.palliativedrugs.com
  5. NICE https://cks.nice.org.uk/itch-widespread#!scenario
  6. This is one of the references I havnt actually really read http://www.pcds.org.uk/clinical-guidance/pruritus-without-a-rash

The eve of the Penultimate Year of Assessment (PYA)

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Tonight, is the eve of my Penultimate Year of Assessment (PYA)

 

I am ‘currently’ writing (procrastinating) my presentation for the PYA and ‘philosophising’ where I want to be when I am grown up.  And you know what, I have realized there is so much I want to do. Indeed, there is so much to do.

 

Par example:

  • National legislation wise, why don’t we make it a requirement for folk to have to complete a Will to gain, say, life insurance or a mortgage? As far as I can see, the only people who benefit from uncertainty is the solicitors and their fees.
  • Or regarding internationally, think of all the countries in which Palliative care isn’t even a concept yet, there are likely millions of folk dying without the care and compassion afforded to us. Maybe project ECHO? (1)

 

Back to earth, and I guess more pressingly, I am also rapidly realising the huge inadequacies in my eportfolio and trying to navigate the cavernous holes in my laissez-faire completion through the years. Does wearing matching socks count as (self) management experience?

 

Ok, back to philosophising, and my last thought…

Everyone experiences time at the same rate. Everyone experiences seconds, minutes and hours. No matter their age, they have seen and experienced a lot which I will never experience. Literally, their viewpoint is impossible for me to have experienced. Therefore, there is always something to learn from everyone no matter how young / old / stupid / confused / frustrating / bonkers they are. There is so much!

This isn’t a penultimate year of me knowing enough, and certainly not of a grander assessment, this is simply a new chapter, a fresh start where I know even less than before.

 

P.s. I have not disclosed this blog post in the PYA otherwise I feel I am doomed.

  1. Project ECHO https://echo.unm.edu also see Prof Max Watson TED talk https://www.youtube.com/watch?v=3OVVuFXoL0E

My Letter to the Pope

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My letter to the Pope

 

As from my previous post it is probably easy to ascertain I was struck by the precedence of the Charlie Gard case from multiple perspectives, least of all regarding my role as a palliative care physician. There was the completely understandable public support to ‘try’ and give this wee boy a chance. Emotional response is always going to trump an establishments logic, no matter how well and carefully explained.

 

One perspective which particularly caught me was the backing of the Vatican. I tried to read as much as I possibly could, regarding their stance, which represents Catholicism and indirectly doctrine, of which I unfortunately found relatively little. As a consequence, I wrote a letter, of which I have yet received no reply.

 

I put this here to raise debate and thought. I have upmost respect for the office of the Pope and the Vatican and Catholic Church as a whole, I do not intend for this to be in any way to be misconstrued for anything but trying to understand the rational and the direction of movement of both the Catholic Church and more generally, society. Likewise, I can only offer my most sincere condolences for the parents, family and friends of Charlie Gard for their loss and struggle.

Don’t chase dreams, chase reality

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Don’t chase dreams, chase reality

 

This generation, this society, this era, our ethical compass is hard to see clearly because we live in this culture, but I suspect we are in the age of choice. We weigh choice (autonomy) a wee bit higher than the other principles of medical ethics. We innately accept this trump card without really seeing it.

 

Needless-to-say it wasn’t always so, in the past non-maleficence held a higher waiting (such as in the Hippocratic oath), or I believe beneficence had a higher weighting in the 60s, 70s, 80s with multiple new treatments coming through, although over time there was a greater and greater emphasis on ‘respect for autonomy’. I find it very insightful autonomy is prefixed with ‘respect for’, which often lays absent and forgotten.

 

This movement overall has been a good thing, informed consent for an operation and involving the patient in decision making has been shown to increase compliance and outcomes. (1)  However there has also been issues with this shift, to cite examples; the vaccination of children, in which uptake has dropped to levels in which herd immunity is being effected and the resurgence of forgotten diseases occurs (2,3), or the level to which informed consent should extend without the patient becoming a qualified surgeon (4). It has likely been a factor (one of many) in the growth of unreasonable expectations, increasing demands (5) and the break down in doctor-patient relationships.

 

From a cultural perspective, choice means choice, freedom from constraint, as long as one’s behaviour does not hurt others it is ok. It is the liberalisation of society.

 

It however tends not to recognise the extent to which most actions, even the most apparently private ones, have an impact on others, and the more apparently private an activity is, the more liberal individual autonomy insists that it not be regulated.

 

By-the-way, there is problems with weight unproportionally placed upon any of the ethical principles. For example; who defines beneficence? Can we not be paralysed into inaction because of non-maleficence? Shouldn’t it be justice that NICE gives everyone proton beam radiotherapy?

 

There are other models of ethics, such as narrative bioethics, but none seem to capture the soul of medicine today as most understand it, which has grown out of a rich history from the Greeks through various centuries of religious influences and more recently to the declaration of Helsinki and Nuremberg code and Beauchamp/Childress’s textbook, Principles of biomedical ethics.

 

We are in the age of autonomy. In medicine as a whole paternalism is frowned upon and we have often lost all incentive for soft paternalism.

Why is this important?

It is important not as a vague theoretical topic, but as a real applied principle in medicine as a whole but acutely in palliative care.

 

Putting aside assisted suicide/dying/euthanasia. We potentially restrict and make paternalistic decisions constantly in palliative care as the patient changes and deteriorates.

 

This is going against the grain, making paternalistic decisions when the patient is unable to. We often weigh beneficence (e.g. medication changes) and non-maleficence (e.g. not for hospital admission) above clear direct consent for whatever we are doing. Sure, they have consented to come into hospice / our involvement, but they do not (and no-one does) have the intricate understanding of what the future holds and challenges awaited, thus what may be done in all instances.

 

We of course try to be in-keeping with what we understand is the patient’s wishes or prior wishes. We take into account their character, preferences, advanced statements etc. We speak to family, NOK and colleagues. If there is a POA (medical), their view is considered the patients view.

 

This is a huge responsibility, in this age of autonomy, we often weigh other principles above the accepted norm, namely because we cannot know. Although seldom said, we truly ‘respect for’ autonomy.

 

I guess noticing this dichotomy in societal expectation of absolute autonomy and our role practicably managing it, is something to both understand for communication purposes, but also semi-predict that they will come into conflict at times.

 

I would suggest Charlie Gard was the high-profile end of this conflict. I suspect (as alot do) this scenario and similar is going to become increasingly more frequent as this dichotomy becomes more and more pronounced.

 

My question, without an answer, is how do we approach and manage this?

 

This is just a wee observation, and to any ethicist out there this thought process is probably unpalatably simplistic, and I would appreciate any corrections / additions / comments etc. These views are my own and do not represent WMCARES

References:

  1. Jin, J., Sklar, G. E., Min Sen Oh, V., & Chuen Li, S. (2008). Factors affecting therapeutic compliance: A review from the patient’s perspective. Therapeutics and Clinical Risk Management, 4(1), 269–286.
  2. Phadke VK, Bednarczyk RA, Salmon DA, et al. Association between vaccine refusal and vaccine-preventable diseases in the United States: a review of measles and pertussis. JAMA 2016 Mar 15;315(11):1149-58 http://www.cidrap.umn.edu/news-perspective/2016/03/study-relates-vaccine-refusal-rise-measles-pertussis
  3. Porteous GH, Hanson NA, Sueda LA, Hoaglan CD, Dahl AB, Ohlson BB, Schmidt BE, Wang CC, Fagley RE. Resurgence of Vaccine-Preventable Diseases in the United States: Anesthetic and Critical Care Implications. Anesth Analg. 2016 May;122(5):1450-73. doi: 10.1213/ANE.0000000000001196. Review. PubMed PMID: 27088999.
  4. Consent: Patients and Doctors making decisions together (2008) http://www.gmcuk.org/GMC_Consent_0513_Revised.pdf_52115235.pdf
  5. The Kings Fund Think Tank 2016 https://www.kingsfund.org.uk/press/press-releases/demand-nhs-services-soars-record-levels
  6. Just really interesting – http://www.bbc.co.uk/programmes/b091wf88

Put in my two penny worth and a penny for your thoughts…

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Put in my two penny worth and a penny for your thoughts…

 

The Spinal DOPS. This is an assessment most Palliative Medicine trainees get flustered and frustrated about, me included. If you are unaware it is a Direct Observational Procedure which needs to be signed off to complete the palliative curriculum and gain the converted consultanthood. It is frustrating become large swathes of the country do not do it, to be frank, the vast majority have little to no access to it. Needless-to-say it is there, looming, dipping and dopping away in the to do list.

In the process of trying to gain this ethereal mystical assessment I was at the pain clinic and you may be surprised that I began to learn one or two things. Namely Spinal analgesia is actually quite good, and just maybe we should be doing a wee bit more.

I read the British Pain Society’s review (1, also web-link below) and this is truly excellent, so I won’t bore you with my placid attempt at summarising the literature, but I will say a few salient points. There are only really three indications for spinal / Intrathecal drug administration…

  1. Chronic non-malignant pain. – Of which there ain’t much evidence, One small RCT and numerous prospective studies supports the efficacy of intrathecal opioids. However there have been large scale RCTs with snail juice (ziconotide) which showed limited short term efficacy. (Snail talk for another post I think)
  2. Pain associated with Cancer. – There has only been one RCT (2), the results are glowing with everything better F.A.B. There is also evidence from Mr Cochrane indirectly (3) of which I learnt about intracerebroventricular drug administration (the oldest operation in the world with a twist) Overall evidence appears to supports the use of intrathecal opioid therapy for pain that has not been adequately controlled by our regular treatments.
  3. Spasticity – Of which there is cracking evidence with intrathecal baclofen in multiple sclerosis (MS), cerebral palsy, and spinal cord injury

So; if it works well, the remit defined, evidence is as sound as the rest of palliative care and the skills in place (lots of folk are putting in baclofen pumps for MS), why are we not doing it a wee bit more?

Maybe we don’t need it? Well, the landmark paper (4) looking at 10-year view of the effectiveness of the WHO analgesic ladder disagrees, suggesting there is a clear percentage (around 10%) of which the WHO elevator doesn’t fully cut the mustard. Folk have many suggestions (5,6,7) to modify the WHO staircase, all with putting interventional procedures in various positions on the WHO escalator. But all agree we need something.

Aww complications you say? What about granulomas, the intractable itch, the danger of dose conversions? What about the under reported endocrine effects including hypogonadotrophic hypogonadism, loss of libido and hypocortisism? Well, I say these are concerns, sure, but not as dangerous or harmful as we first perceive.

The rate of diagnosis of intrathecal granulomas in a UK centre was 7%, the equivalent to 0.009 events per patient year (8) and the recommendations are to be aware and avoid high dosages and high concentrations of opioids solutions. It seems more likely to occur the longer it is in for, and remember most of this info is from baclofen pumps. If the doses are reduced they have been shown to reduce the incidence of granuloma formation (9). A nifty chart has been made…

What about the procedure I hear you cry, well, in a multi-centre study with cancer and non-cancer pain patients, procedure related complications occurred at a rate of 0.29 events per patient year and catheter related complications at a rate of 0.05 events per patient year (10). The rate of complications / side-effects in a non-cancer study with a 13-year follow-up was 0.111 events per patient year. i.e. not much really. There appears less of a side effect profile than traditional opioid administration (less constipation etc.).

Now I know there are a lot of barriers to us using a relative unknown, both in our minds and practically, both within the medics and nurses having to learn and practice new skills, but surely if we truly want the best evidence based treatment for our patients should we not be intrathcaling Mrs Thrice opioid switch? Are we missing a trick here?

Folk often cite the paper “Patient-controlled spinal opiate analgesia in terminal cancer. Has its time really arrived?” (11) which states there is a multifactorial 30% failure rate with intrathecal pumps, but this was published in 1992, in which I was still in single fingers. Maybe, just maybe the time has now come?

As I continued to chat with the chronic pain (anaesthetic) consultant he reflected upon his past ways, which were very interventional and giving bonkers amounts of opioids for chronic pain, this has strongly fallen out of favour. The whole chronic pain profession has moved towards ‘softer’ less interventional foci such as psychology (ACT, CBT etc.), mindfulness and how to live with pain. He mirrors this thought with palliative care and the impression of it being ‘hand holding’ historically but is now moving slowly to be more interventional. “We both started the wrong way around.” He said.

He wishes palliative care just hurries up a little because this spinal intervention is just a good idea for our palliative patients.

Needless to say I’d better get my DOPS.

 

References:

  1. Intrathecal drug delivery for the management of pain and spasticity in adults; recommendations for best clinical practice, British Pain Society, Dec 2015 https://www.britishpainsociety.org/static/uploads/resources/files/itdd_2015_pro_v3.pdf
  2. Smith TJ, Staats PS, Deer T, Stearns LJ, Rauck RL, Boortz-Marx RL, Buchser E, Catala E, Bryce DA, Coyne PJ, Pool GE, Implantable Drug Delivery Systems Study Group. Randomized clinical trial of an implantable drug delivery system compared with comprehensive medical management for refractory cancer pain: impact on pain, drug-related toxicity, and survival. J Clin Oncol 2002; 20(19):4040-4049.
  3. Ballantyne JC, Carwood CM. Comparative e cacy of epidural, subarachnoid and intracerebroventricular opioids in patients with pain due to cancer. Cochrane Database Syst Rev 2005; (1):CD005178. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005178/abstract
  4. Zech DF, Grond S, Lynch J, Hertel D, Lehmann KA.. Validation of the World Health Organisation guidelines for cancer pain relief: a 10 year prospective study. Pain 1995; 63(1): 65-7
  5. Natoli S, Lazzari M, Dauri M. Open questions in the treatment of cancer pain: time for strong evidence-based approach? Expert Opin Pharmacother. 2015;16(1):1–4.
  6. Pergolizzi JV, Raffa RB. The WHO pain ladder: do we need another step? Pract Pain Manage. 2014;14(1):1–16.
  7. Vargas-Schaffer G. Is the WHO analgesic ladder still valid? Can Fam Physician. 2010;56(6):514–517.
  8. Duarte RV, Raphael JH, Southall JL, Baker C, Hanu-Cernat D. Intrathecal in ammatory masses: is the yearly opioid dose increase an early indicator? Neuromodulation 2010; 13(2):109-113.
  9. McMillan MR, Doud T, Nugent W. Catheter-associated masses in patients receiving intrathecal analgesic therapy. Anesth Analg 2003; 96(1):186-190.
  10. Follett KA, Naumann CP. A prospective study of catheter-related complications of intrathecal drug delivery systems. J Pain Symptom Manage 2000; 19: 209-215.
  11. Duarte RV, Raphael JH, Sparkes E, Southall JL, LeMarchand K, Ashford RL. Long-term intrathecal drug administration for chronic non- malignant pain. J Neurosurg Anesthesiol 2012; 24(1):63-70.
  12. Chrubasik J, Chrubasik S, Martin E. Patient-controlled spinal opiate analgesia in terminal cancer. Has its time really arrived? Drugs 1992; 43 (6): 799-804.

How the West (Midlands) was won and where it got us…

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How the West (Midlands) was won and where it got us…

 

As of today there are only 15 spaces left for the inaugural WM CARES PRIDE!

Please email “westmidlandcares@gmail.com” asap if you want a space

As well as the WM CARES PRIDE on the horizon, we are pleased to announce 3 posters have been accepted to HospiceUK conference in Liverpool 22-24th Nov, these are…

  1. Do we prepare our patients for their digital legacy?
  2. How the West Midlands CARES about and prioritises research
  3. A retrospective study exploring subcutaneous Levetiracetam use and practice within the West Midlands

With awesome amounts of modesty, WM CARES is awesome!

“I’ve given up asking rhetorical questions. What’s the point?” – Alexei Sayle

References:

  1. How the West was won and where it got us, REM (https://www.youtube.com/watch?v=9BC07l2_zKU)
  2. Hospice UK conference (https://www.hospiceuk.org/what-we-offer/courses-conferences-and-learning-events/hospice-uk-annual-conf)
  3. BBC News Scotland – http://www.bbc.co.uk/news/uk-scotland-40999000

Waterboarding for breathlessness?

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Waterboarding for breathlessness?

 

I love that we have some evidence supporting the use of a handheld fan in breathlessness. It is quirky, lateral thinking that appeals to me and I believe is part of the ethos of palliative care, holistically trying to resolve an issue by using all methodological routes available to us.

It’s largely part of standard practice and although further research is recommended, it seems effective in select patients and has no side effect profile (1,2,3). In Galbraith’s study there was a significant difference in the visual analogue scale (VAS) for breathlessness (P=0.003).

However, there is not a completely clear picture!

In Bausewain’s study (1) the paper reads, “This study does not allow a conclusion about the effectiveness of a HHF (Hand Held Fan) to relieve breathlessness.” Also, I note Mr Cochrane, which states there is not enough evidence to judge (4) (2008, updated 2013, now awaiting further update). The sad news doesn’t stop there, unfortunately, it looks like there will not be another trial regarding our beloved hand held fan, because it has been deemed the value of information for changing practice or policy is unlikely to justify the expense (5).

Anyway, the above was done on the back of previous research that cold facial stimulation reduced breathlessness (6) and exercise induced dyspnoea in COPD was reduced using a fan (7).

All of this research doesn’t seem to have a clear mechanism by which blowing on someone’s face works!

 

Sure, there have been proposals, such as; the diving response, which causes ventilator depression when the trigeminal area of the face is cooled, or by the cooling of nasal / oral mucosal receptors, or via a decreased central respiratory drive (8).

Basically, we don’t know how it is working, but have a pretty strong inclination it is.

 

The beauty in good palliative care (and indeed all of medicine) is simplicity, and that is what appeals to me about the fan. Given one of the mechanism we propose is cooling the face down, the question becomes … why don’t we try that by other methods?

Stick a flannel on their forehead, spray them with cool water spray, what about a cooling pillow? Bung them in the fridge.

I want the stormy Atlantic ocean on my face.

 

Indeed, if as we believe mindfulness also helps breathlessness, stick a virtual reality helmet on my eyes. Virtually put me on a fishing trawler in the stormy north seas. Or more likely on a calm beach with a gentle breeze, or moving in an open top fancy car. All the while fanning and spraying me cool. If nothing else the sensory overload would distract.

I have witnessed patients who are short of breath ask for a cold drink, and what do they do instinctivly but raise their cold glass to their forehead to cool them down.

Anywhichway, why don’t we empty the Cif spray bottle, give it a clean, fill it with water, put in a fridge and when we have a panic attack / feel breathless, soak the face with a fine mist! Or stick a cold flannel on the forehead. Just an idea, easy trial, could even cross over (or double) trial of n of 1. We could use the validated VAS score and even compare with existing trials. A negative result would even suggest an alternative mechanism.

 

References

  1. Bausewein, C., Booth, S., Gysels, M., Kuhnbach, R., and Higginson, I.J. Effectiveness of a hand-held fan for breathlessness: a randomised phase II trial. BMC Palliat Care. 2010; 9: 22
  2. Galbraith, S., Fagan, P., Perkins, P., Lynch, A., and Booth, S. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage. 2010; 39: 831–838
  3. Ekstrom, M.P., Abernethy, A.P., and Currow, D.C. The management of chronic breathlessness in patients with advanced and terminal illness. BMJ. 2015; 349: g7617
  4. Bausewein, C., Booth, S., Gysels, M., and Higginson, I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev. 2008; : CD005623
  5. Johnson MJ, Booth S, Currow DC, Lam LT, Phillips JL. A Mixed-Methods, Randomized, Controlled Feasibility Trial to Inform the Design of a Phase III Trial to Test the Effect of the Handheld Fan on Physical Activity and Carer Anxiety in Patients With Refractory Breathlessness. J Pain Symptom Manage. 2016 May;51(5):807-15. Doi 10.1016/j.jpainsymman.2015.11.026. Epub 2016 Feb 12. PubMed PMID: 26880253.
  6. Schwartzstein RM, Lahive K, Pope A, Weinberger SE, Weiss JW. Cold facial stimulation reduces breathlessness induced in normal subjects. American Review of Respiratory Disease. 1987;136(1):58–61.
  7. Baltzan M. Fan to palliate exercise-induced dyspnea with severe COPD [abstract] American Journal of Respiratory and Critical Care Medicine. 2000;161(3 Suppl):A59.
  8. Marchetti, N., Travaline, J.M., and Criner, G.L. Air current applied to the face of COPD patients enhances leg ergometry performance. ([abstract])Am J Respir Crit Care Med. 2004; 169: A773