Download PDF
Geriatrie up2date 2021; 3(02): 95-103
DOI: 10.1055/a-1370-3963
Atmungsorgane

Refraktäre Dyspnoe bei fortgeschrittener COPD: Palliative Therapie mit Opioiden

Joachim H. Ficker
,
Wolfgang M. Brückl
› Further Information
    Permissions and Reprints All articles of this category

Vor allem in sehr fortgeschrittenen Krankheitsstadien der COPD mit „refraktärer Dyspnoe“ können neben einer Therapie der Grunderkrankung palliative Therapiemaßnahmen wie eine medikamentöse Therapie mit Opioiden zur Linderung der Dyspnoe erforderlich sein. Es gibt deutliche Hinweise darauf, dass diese wirksame Therapie bislang nur bei einem geringen Teil derjenigen COPD-Patienten eingesetzt wird, die davon profitieren könnten.
Kernaussagen

  • Dyspnoe ist letztlich die bewusste unangenehme Wahrnehmung eines vermehrten Atemantriebs. Sie korreliert wenig mit körperlichen Untersuchungsbefunden, Laborwerten oder den Ergebnissen apparativer Untersuchungen.

  • Dyspnoe ist ein multidimensionales Symptom, das aus dem Zusammenwirken von physiologischen und affektiven Mechanismen resultiert. Insbesondere Angst, Panik oder Depression können das Dyspnoe-Empfinden verstärken.

  • Die Basis jeder Therapie von Dyspnoe ist eine möglichst optimale Behandlung der Ursachen bzw. der Grund- und Begleiterkrankungen. Die palliative Therapie von Dyspnoe ergänzt diese kausale Therapie.

  • Die am besten etablierte medikamentöse Therapie der Dyspnoe ist die Behandlung mit niedrigdosierten systemischen Opioiden.

  • In der Regel sollte eine palliative Opioidtherapie bei stabiler refraktärer Dyspnoe im Rahmen einer COPD mit 1,0 – 2,5 mg unretardiertem oralem Morphin begonnen werden. Die Dosis wird unter sorgfältiger klinischer Überwachung titriert. Mögliche Nebenwirkungen wie Obstipation, Müdigkeit oder Übelkeit müssen beachtet werden.

  • Bis heute finden sich in der wissenschaftlichen Literatur keine eindeutigen Belege für eine erhöhte Mortalität durch Atemdepression beim Einsatz derart niedrigdosierter Opioide zur Therapie von refraktärer Dyspnoe bei fortgeschrittener COPD.

  • Die palliative Therapie der refraktären Dyspnoe bei fortgeschrittener COPD ist integraler Bestandteil der ärztlichen Versorgung dieser Patientengruppe.

Schlüsselwörter

COPD - Dyspnoe - Palliativtherapie - Opioide - Opiate


Publication History

Article published online:
16 April 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and Prevention of COPD. 2017. Im Internet (Stand: 22.02.2021): http://goldcopd.org
    Google Scholar
  • 2 Goodridge D. Factors associated with opioid dispensation for patients with COPD and lung cancer in the last year of life: A retrospective analysis. Int J Chronic Obstr 2010; 5: 99-105
    Google Scholar
  • 3 Parshall MB, Shwartzstein R, Adams L. et al. on behalf of the American Thoracic Society Committee on Dyspnea. An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea. Am J Respir Crit Care Med 2012; 185: 435-452
    CrossrefPubMedGoogle Scholar
  • 4 Mahler D, OʼDonnel D. Dyspnea: Mechanisms, Measurement and Management. London: CRC Press; 2014
    CrossrefGoogle Scholar
  • 5 Mahler DA, Selecky PA, Harrod CG. et al. American College of Chest Physicians Consensus Statement on the Management of Dyspnea in Patients With Advanced Lung or Heart Disease. Chest 2010; 137: 674-691
    CrossrefPubMedGoogle Scholar
  • 6 OʼDonnell DE, Banzett RB, Carrieri-Kohlman V. et al. Pathophysiology of Dyspnea in Chronic Obstructive Pulmonary Disease. Proc Am Thorac Soc 2007; 4: 145-168
    CrossrefPubMedGoogle Scholar
  • 7 von Leupoldt A. Treating anxious expectations can improve dyspnoea in patients with COPD. Eur Respir J 2017; 50: 1701352
    CrossrefPubMedGoogle Scholar
  • 8 von Leupoldt A, Ambruzsova R, Nordmeyer S. et al. Sensory and Affective Aspects of Dyspnea Contribute Differentially to the Borg Scaleís Measurement of Dyspnea. Respiration 2006; 73: 762-768
    CrossrefPubMedGoogle Scholar
  • 9 Donesky D, Nguyen HQ, Paul SM. et al. The Affective Dimension of Dyspnea Improves in a Dyspnea Self-Management Program With Exercise Training. J Pain Symptom Manage 2014; 47: 757-771
    CrossrefPubMedGoogle Scholar
  • 10 Shin JA, Kosiba JD, Traeger L. et al. Dyspnea and Panic Among Patients With Newly Diagnosed Non-Small Cell Lung Cancer. J Pain Symptom Manage 2014; 48: 465-470
    CrossrefPubMedGoogle Scholar
  • 11 Gifford AH, Mahler DA, Waterman LA. et al. Neuromodulatory Effect of Endogenous Opioids on the Intensity and Unpleasantness of Breathlessness during Resistive Load Breathing in COPD. COPD Dis 2011; 8: 160-166
    CrossrefPubMedGoogle Scholar
  • 12 Mahler D, Murray J, Waterman L. et al. Endogenous opioids modify dyspnoea during treadmill exercise in patients with COPD. Eur Respir J 2009; 33: 771-777
    CrossrefPubMedGoogle Scholar
  • 13 Mahler DA, Gifford AH, Waterman LA. et al. Effect of Increased Blood Levels of β-Endorphin on Perception of Breathlessness. Chest 2013; 143: 1378-1385
    CrossrefPubMedGoogle Scholar
  • 14 Gagnon P, Bussières JS, Ribeiro F. et al. Influences of Spinal Anesthesia on Exercise Tolerance in Patients with Chronic Obstructive Pulmonary Disease. Am J Resp Crit Care 2012; 186: 606-615
    CrossrefPubMedGoogle Scholar
  • 15 Watanabe SM, Nekolaichuk C, Beaumont C. et al. A Multicenter Study Comparing Two Numerical Versions of the Edmonton Symptom Assessment System in Palliative Care Patients. J Pain Symptom Manage 2011; 41: 456-468
    CrossrefPubMedGoogle Scholar
  • 16 Mahler DA, Weinberg DH, Wells CK. et al. The Measurement of Dyspnea Contents, Interobserver Agreement, and Physiologic Correlates of Two New Clinical Indexes. Chest 1984; 85: 751-758
    CrossrefPubMedGoogle Scholar
  • 17 Witek TJ, Mahler DA. Minimal important difference of the transition dyspnoea index in a multinational clinical trial. Eur Respir J 2003; 21: 267-272
    CrossrefPubMedGoogle Scholar
  • 18 Simon PM, Weiss WJ, Weinberger SE. et al. Classifying Types of Dyspnea: Reply. Am Rev Respir Dis 1991; 143: 1201
    CrossrefPubMedGoogle Scholar
  • 19 Simon PM, Schwartzstein RM, Weiss WJ. et al. Distinguishable Types of Dyspnea in Patients with Shortness of Breath. Am Rev Respir Dis 1990; 142: 1009-1014
    CrossrefPubMedGoogle Scholar
  • 20 Simon ST, Higginson IJ, Benalia H. et al. Episodes of breathlessness: types and patterns – a qualitative study exploring experiences of patients with advanced diseases. Palliative Med 2013; 27: 524-532
    CrossrefPubMedGoogle Scholar
  • 21 Simon ST, Higginson IJ, Benalia H. et al. Episodic and Continuous Breathlessness: A New Categorization of Breathlessness. J Pain Symptom Manag 2013; 45: 1019-1029
    CrossrefPubMedGoogle Scholar
  • 22 Lansing RW, Gracely RH, Banzett RB. The multiple dimensions of dyspnea: review and hypotheses. Respir Physiol Neurobiol 2009; 167: 53-60
    CrossrefPubMedGoogle Scholar
  • 23 Banzett RB, Dempsey JA, OʼDonnell DE. et al. Symptom Perception and Respiratory Sensation in Asthma. Am J Resp Crit Care 2000; 162: 1178-1182
    CrossrefPubMedGoogle Scholar
  • 24 McGavin C, Artvinli M, Naoe H. et al. Dyspnoea, disability, and distance walked: comparison of estimates of exercise performance in respiratory disease. Br Med J 1978; 2: 241-243
    CrossrefPubMedGoogle Scholar
  • 25 Yorke J, Moosavi S, Shuldham C. et al. Quantification of dyspnoea using descriptors: development and initial testing of the Dyspnoea-12. Thorax 2010; 65: 21-26
    CrossrefPubMedGoogle Scholar
  • 26 Borg GA. Psychophysical bases of perceived exertion. Medicine Sci Sports Exerc 1982; 14: 377
    CrossrefGoogle Scholar
  • 27 Mahler DA, Wells CK. Evaluation of Clinical Methods for Rating Dyspnea. Chest 1988; 93: 580-586
    CrossrefPubMedGoogle Scholar
  • 28 Stefan MS, Priya A, Martin B. et al. How well do patients and providers agree on the severity of dyspnea?. J Hosp Med 2016; 11: 701-707
    CrossrefPubMedGoogle Scholar
  • 29 Giacomini M, DeJean D, Simeonov D. et al. Experiences of living and dying with COPD: a systematic review and synthesis of the qualitative empirical literature. Ont Heal Technology Assess Ser 2012; 12: 1-47
    Google Scholar
  • 30 Kessler R, Partridge MR, Miravitlles M. et al. Symptom variability in patients with severe COPD: a pan-European crosssectional study. Eur Respir J 2011; 37: 264-272
    CrossrefPubMedGoogle Scholar
  • 31 Qaseem A, Snow V, Shekelle P. et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008; 148: 141-146
    CrossrefPubMedGoogle Scholar
  • 32 Lanken PN, Terry PB, DeLisser HM. et al. An Official American Thoracic Society Clinical Policy Statement: Palliative Care for Patients with Respiratory Diseases and Critical Illnesses. Am J Resp Crit Care 2008; 177: 912-927
    CrossrefPubMedGoogle Scholar
  • 33 Marciniuk DD, Goodridge D, Hernandez P. et al. Managing Dyspnea in Patients with Advanced Chronic Obstructive Pulmonary Disease: A Canadian Thoracic Society Clinical Practice Guideline. Can Respir J 2011; 18: 69-78
    CrossrefPubMedGoogle Scholar
  • 34 AWMF. Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): Palliativmedizin für Patienten mit einer nicht heilbaren Krebserkrankung. Langversion 1.1, 2015, AWMF-Registernummer: 128/001OL.
    Google Scholar
  • 35 Abernethy AP, Currow DC, Frith P. et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ 2003; 327: 523-528
    CrossrefPubMedGoogle Scholar
  • 36 Ekström M, Bajwah S, Bland MJ. et al. One evidence base; three stories: do opioids relieve chronic breathlessness?. Thorax 2018; 73: 88-90
    CrossrefPubMedGoogle Scholar
  • 37 Ekström M, Nilsson F, Abernethy AA. et al. Effects of Opioids on Breathlessness and Exercise Capacity in Chronic Obstructive Pulmonary Disease. A Systematic Review. Ann Am Thorac Soc 2015; 12: 1079-1092
    CrossrefPubMedGoogle Scholar
  • 38 Ekström M, Bornefalk-Hermansson A, Abernethy A. et al. Low-dose opioids should be considered for symptom relief also in advanced chronic obstructive pulmonary disease (COPD). Evid Based Med 2015; 20: 39
    CrossrefPubMedGoogle Scholar
  • 39 Ekström MP, Abernethy AP, Currow DC. The management of chronic breathlessness in patients with advanced and terminal illness. BMJ 2015; 349: g7617
    CrossrefPubMedGoogle Scholar
  • 40 Maddocks M, Lovell N, Booth S. et al. Palliative care and management of troublesome symptoms for people with chronic obstructive pulmonary disease. Lancet 2017; 390: 988-1002
    CrossrefPubMedGoogle Scholar
  • 41 Migliore A. Management of Dyspnea Guidelines for Practice for Adults with Chronic Obstructive Pulmonary Disease. Occup Ther Heal Care 2009; 18: 1-20
    Google Scholar
  • 42 Barnes H, McDonald J, Smallwood N. et al. Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness. Cochrane Database Syst Rev 2016; (03) CD011008
    PubMedGoogle Scholar
  • 43 Mahler DA. Opioids for refractory dyspnea. Expert Rev Resp Med 2014; 7: 123-135
    CrossrefPubMedGoogle Scholar
  • 44 Johnson MJ, Hui D, Currow DC. Opioids, Exertion, and Dyspnea. Am J Hospice Palliat Medicine 2016; 33: 194-200
    CrossrefPubMedGoogle Scholar
  • 45 Abdallah SJ, Wilkinson-Maitland C, Saad N. et al. Effect of morphine on breathlessness and exercise endurance in advanced COPD: a randomised crossover trial. Eur Respir J 2017; 50: 1701235
    CrossrefPubMedGoogle Scholar
  • 46 Ben-Aharon I, Gafter-Gvili A, Leibovici L. et al. Interventions for alleviating cancer-related dyspnea: A systematic review and meta-analysis. Acta Oncol 2012; 51: 996-1008
    CrossrefPubMedGoogle Scholar
  • 47 Currow DC, McDonald C, Oaten S. et al. Once-Daily Opioids for Chronic Dyspnea: A Dose Increment and Pharmacovigilance Study. J Pain Symptom Manag 2011; 42: 388-399
    CrossrefPubMedGoogle Scholar
  • 48 Johnson MJ, Bland MJ, Oxberry SG. et al. Opioids for chronic refractory breathlessness: patient predictors of beneficial response. Eur Respir J 2013; 42: 758-766
    CrossrefPubMedGoogle Scholar
  • 49 Zebraski SE, Kochenash SM, Raffa RB. Lung opioid receptors: Pharmacology and possible target for nebulized morphine in dyspnea. Life Sci 2000; 66: 2221-2231
    CrossrefPubMedGoogle Scholar
  • 50 Clemens K, Klaschik E. Effect of hydromorphone on ventilation in palliative care patients with dyspnea. Support Care Cancer 2008; 16: 93-99
    CrossrefPubMedGoogle Scholar
  • 51 Rice KL, Kronenberg RS, Hedemark LL. et al. Effects of chronic administration of codeine and promethazine on breathlessness and exercise tolerance in patients with chronic airflow obstruction. Brit J Dis Chest 1987; 81: 287-292
    CrossrefPubMedGoogle Scholar
  • 52 Johnson M, Woodcock A, Geddes D. Dihydrocodeine for breathlessness in “pink puffers”. Br Med J Clin Res Ed 1983; 286: 675-677
    CrossrefPubMedGoogle Scholar
  • 53 Woodcock AA, Gross ER, Gellert A. et al. Effects of Dihydrocodeine, Alcohol, and Caffeine on Breathlessness and Exercise Tolerance in Patients with Chronic Obstructive Lung Disease and Normal Blood Gases. N Engl J Med 1981; 305: 1611-1616
    CrossrefPubMedGoogle Scholar
  • 54 Pinna M, Bruera E, Moralo M. et al. A Randomized Crossover Clinical Trial to Evaluate the Efficacy of Oral Transmucosal Fentanyl Citrate in the Treatment of Dyspnea on Exertion in Patients With Advanced Cancer. Am J Hospice Palliat Medicine 2015; 32: 298-304
    CrossrefPubMedGoogle Scholar
  • 55 Hui D, Xu A, Frisbee-Hume S. et al. Effects of Prophylactic Subcutaneous Fentanyl on Exercise-Induced Breakthrough Dyspnea in Cancer Patients: A Preliminary Double-Blind, Randomized, Controlled Trial. J Pain Symptom Manag 2014; 47: 209-217
    CrossrefPubMedGoogle Scholar
  • 56 Hui D, Kilgore K, Frisbee-Hume S. et al. Effect of Prophylactic Fentanyl Buccal Tablet on Episodic Exertional Dyspnea: A Pilot Double-Blind Randomized Controlled Trial. J Pain Symptom Manag 2017; 54: 798-805
    CrossrefPubMedGoogle Scholar
  • 57 Benitez-Rosario M, Rosa-Gonzalez I, Gonzalez-Devila E. et al. Fentanyl treatment for end-of-life dyspnoea relief in advanced cancer patients. Support Care Cancer 2019; 27: 157-164
    CrossrefPubMedGoogle Scholar
  • 58 Marsaa K, Gundestrup S, Jensen JU. et al. Danish respiratory society position paper: palliative care in patients with chronic progressive non-malignant lung diseases. Eur Clin Respir J 2018; 5: 1530029
    CrossrefPubMedGoogle Scholar
  • 59 Hadjiphilippou S, Odogwu SE, Dand P. Doctorsʼ attitudes towards prescribing opioids for refractory dyspnoea: a single-centred study. BMJ Support Palliat Care 2014; 4: 190-192
    CrossrefPubMedGoogle Scholar
  • 60 Young J, Donahue M, Farquhar M. et al. Using opioids to treat dyspnea in advanced COPD: attitudes and experiences of family physicians and respiratory therapists. Can Fam Physician 2012; 58: e401-e407
    PubMedGoogle Scholar
  • 61 Smallwood N, Le B, Currow D. et al. Managing breathlessness with morphine. Intern Med J 2015; 45: 898-904
    CrossrefPubMedGoogle Scholar
  • 62 Booth S, Moosavi SH, Higginson IJ. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy. Nat Clin Pract Oncol 2008; 5: 90-100
    CrossrefPubMedGoogle Scholar
  • 63 Hallenbeck J. Pathophysiologies of Dyspnea Explained: Why Might Opioids Relieve Dyspnea and Not Hasten Death?. J Palliat Med 2012; 15: 848-853
    CrossrefPubMedGoogle Scholar
  • 64 Verberkt CA, van den Everdingen M, Schols J. et al. Respiratory adverse effects of opioids for breathlessness: a systematic review and meta-analysis. Eur Respir J 2017; 50: 1701153
    CrossrefPubMedGoogle Scholar
  • 65 Jennings A, Davies A, Higgins J. et al. A systematic review of the use of opioids in the management of dyspnoea. Thorax 2002; 57
    Google Scholar
  • 66 Ekstrom M, Bornefalk-Hermansson A, Abernethy A. et al. Safety of benzodiazepines and opioids in very severe respiratory disease: national prospective study. BMJ 2014; 348: g445
    CrossrefPubMedGoogle Scholar
  • 67 Bausewein C, Simon ST. Shortness of Breath and Cough in Patients in Palliative Care. Dtsch Arztebl Int 2013; 110: 563-571 quiz 572
    PubMedGoogle Scholar
  • 68 Aulbert E, Nauck F, Radbruch L. Lehrbuch der Palliativmedizin. Stuttgart: Schattauer; 2012
    Google Scholar
  • 69 Rote Liste. Im Internet: http://www.rote-liste.de
  • 70 Rocker G, Young J, Donahue M. et al. Perspectives of patients, family caregivers and physicians about the use of opioids for refractory dyspnea in advanced chronic obstructive pulmonary disease. CMAJ 2012; 184: E497-E504
    CrossrefPubMedGoogle Scholar
  • 71 Borg G. Psychophysical bases of perceived exertion. Medicine Sci Sports Exerc 1982; 14: 377
    CrossrefGoogle Scholar