The Use of Nebulized Opioids in the Management of Dyspnea: Evidence Synthesis

Margaret M. Joyce

Maryellen McSweeney

Virginia L. Carrieri-Kohlman

Josephine Hawkins

ONF 2004, 31(3), 551-561. DOI: 10.1188/04.ONF.551-561

Purpose/Objectives: To analyze the evidence about the use of nebulized opioids to treat dyspnea using the Priority Symptom Management (PRISM) level-of-evidence framework and to make a practice recommendation.

Data Sources: Computerized database and manual search for articles and abstracts that included experimental trials, chart reviews, and case studies.

Data Synthesis: 20 articles with evaluable evidence were identified. Analysis was complex because of heterogeneous variables and outcome measures. A major limitation is small sample sizes. The majority of PRISM level I and II studies indicated unfavorable evidence.

Conclusions: Scientific data supporting the use of nebulized opioids to treat dyspnea in patients with chronic pulmonary disease, including malignancy, are lacking.

Implications for Nursing: Insufficient data identify a need for further research with random crossover designs involving larger samples that are stratified according to prior opioid use. Consistency of study variables should be emphasized.

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    References

    Ahmedzai, S. (1988). Respiratory distress in the terminally ill patient. Respiratory Disease in Practice, October/November, 20-29.

    American Thoracic Society. (1999). Dyspnea. Mechanisms, assessment, and management: A consensus statement. American Journal of Respiratory and Critical Care Medicine, 159, 321-340.

    Beauford, W., Saylor, T.T., Stansbury, D.W., Avalos, K., & Light, R.W. (1993). Effects of nebulized morphine sulfate on the exercise tolerance of the ventilatory limited COPD patient. Chest, 104, 175-178.

    Belman, M.J., Brooks, L.R., Ross, D.J., & Mosenifar, Z. (1991). Variability of breathlessness measurement in patients with chronic obstructive pulmonary disease. Chest, 99, 566-571.

    Briss, P.A., Zaza, S., Pappaioanou, M., Fielding, J., Wright-De Aguero, L., Truman, B.I., et al. (2000). Developing an evidence-based guide to Community Preventive Services—Methods. The Task Force on Community Preventive Services. American Journal of Preventive Medicine, 18(1 Suppl.), 35-43.

    Carrieri-Kohlman, V., Gormley, J.M., Douglas, M.K., Paul, S.M., & Stulbarg, M.S. (1996). Differentiation between dyspnea and its affective components. Western Journal of Nursing Research, 18, 626-642.

    Chetta, A., Gerra, G., Foresi, A., Zaimovic, A., DelDonno, M., Chittolini, B., et al. (1998). Personality profiles and breathlessness measurement in outpatients with different grading of asthma. American Journal of Respiratory and Critical Care Medicine, 157, 116-122.

    Cioffi, D. (1991). Beyond attentional strategies: A cognitive-perceptual model of somatic interpretation. Psychological Bulletin, 109(1), 25-41.

    Corfield, D.R., Fink, G.R., Ramsay, S.C., Murphy, K., Harty, H.R., Watson, J.D., et al. (1995). Evidence for limbic system activation during CO2 stimulated breathing in man. Journal of Physiology, 488(Pt. 1), 77-84.

    Davis, C.L., Hodder, C., Love, S., Sham, R., Slevin, M., & Wedzicha, J. (1994). Effects of nebulized morphine and morphine 6-glucuronide on exercise endurance in patients with chronic obstructive pulmonary disease [Abstract]. Proceedings of the British Thoracic Society, 49, 393P.

    Davis, C.L., Penn, K., A'Hern, R., Daniels, J., & Slevin, M. (1996). Single-dose randomized, controlled trial of nebulized morphine in patients with cancer-related breathlessness [Abstract]. Palliative Medicine, 10, 64-65.

    Dudley, D.L., Martin, C.J., & Holmes, T.H. (1964). Psychophysiologic studies of pulmonary ventilation. Psychosomatic Medicine, 26, 645-659.

    Farncombe, M., & Chater, S. (1993). Case studies outlining use of nebulized morphine for patients with end-stage chronic lung and cardiac disease. Journal of Pain and Symptom Management, 8, 221-225.

    Farncombe, M., Chater, S., & Gillin, A. (1994). The use of nebulized opioids for breathlessness: A chart review. Palliative Medicine, 8, 306-312.

    Gift, A. (1991). Psychologic and physiologic aspects of acute dyspnea in asthmatics. Nursing Research, 40, 196-199.

    Hadorn, D.C., Baker, D., Hodges, J.S., & Hicks, N. (1996). Rating the quality of evidence for clinical practice guidelines. Journal of Clinical Epidemiology, 49, 749-754.

    Harris-Eze, A.O., Sridhar, R., Clemens, R.E., Zintel, T.A., Gallagher, C.G., & Marciniuk, D.D. (1995). Low-dose nebulized morphine does not improve exercise in interstitial lung disease. American Journal of Respiratory and Critical Care Medicine, 152, 1940-1945.

    Jankelson, D., Hosseini, K., Mather, L.E., Seale, J.P., & Young, I.H. (1997). Lack of effect of high doses of inhaled morphine on exercise endurance in chronic obstructive pulmonary disease. European Respiratory Journal, 10, 2270-2274.

    Janson-Bjerklie, S., Ferketich, S., Benner, P., & Becker, G. (1992). Clinical markers of asthma severity and risk: Importance of subjective as well as objective factors. Heart and Lung, 21, 265-272.

    Jennings, A.L., Davies, A.N., Higgins, J.P., Gibbs, J.S., & Broadley, K.E. (2002). A systematic review of the use of opioids in the management of dyspnoea. Thorax, 57, 939-944.

    Kwiatkowski, M., Carrieri-Kohlman, V., Janson, S., & Stulbarg, M.S. (1995, March). Patients with chronic obstructive pulmonary disease (COPD) increase coping strategies for dyspnea after an exercise program. Paper presented at International Conference on Pulmonary Rehabilitation and Home Ventilation, Denver, CO.

    Lang, E., & Jedeikin, R. (1998). Acute respiratory depression as a complication of nebulised morphine. Canadian Journal of Anaesthesia, 45(1), 60-62.

    Leung, R., Hill, P., & Burdon, J. (1996). Effect of inhaled morphine on the development of breathlessness during exercise in patients with chronic lung disease. Thorax, 51, 596-600.

    Masood, A.R., Reed, J.W., & Thomas, S.H. (1995). Lack of effect of inhaled morphine on exercise-induced breathlessness in chronic obstructive pulmonary disease. Thorax, 50, 629-634.

    Masood, A.R., Subhan, M.F., Reed, J.W., & Thomas, H.L. (1995). Effects of nebulized morphine on ventilation and breathlessness during exercise in healthy man. Clinical Science, 88, 447-452.

    Noseda, A., Carpiaux, J.P., Markstein, C., Meyvaert, A., & de Maertelaer, V. (1997). Disabling dyspoena in patients with advanced disease: Lack of effect of nebulized morphine. European Respiratory Journal, 10, 1079-1083.

    Oncology Nursing Society. (n.d.). Evidence-based practice process model: Critique. Retrieved December 29, 2002, from http://onsopcontent.ons.org/toolkits/ebp/process_model/critique/critique.htm

    Peterson, G.M., Young, R.S., Dunne, P.F., Galloway, J.G., & Parks, T.E. (1996). Pilot study of nebulized morphine for dyspoena in palliative care patients. Australian Journal of Hospital Pharmacy, 26, 545-547.

    Quelch, P.C., Faulkner, D.E., & Yun, J.W. (1997). Nebulized opioids in the treatment of dyspnea. Journal of Palliative Care, 13(3), 48-52.

    Ripamonti, C., & Fusco, F. (2002). Respiratory problems in advanced cancer. Supportive Care in Cancer, 10, 204-216.

    Ropka, M.E., & Spencer-Cisek, P. (2001). PRISM: Priority symptom management project, phase I: Assessment. Oncology Nursing Forum, 28, 1585-1594.

    Smith, E.L., Hann, D.M., Ahles, T.L., Furstenberg, C.T., Mitchell, T.A., Meyer, L., et al. (2001). Dyspnea, anxiety, body consciousness, and quality of life in patients with lung cancer. Journal of Pain and Symptom Management, 21, 323-329.

    Stetler, C.B., Morsi, D., Rucki, S., Broughton, S., Corrigan, B., Fitzgerald, J., et al. (1998). Utilization-focused integrative review in a nursing service. Applied Nursing Research, 11, 195-206.

    Tanaka, K., Shima, Y., Kakinuma, R., Kubota, K., Ohe, Y., Hojo, F., et al. (1999). Effect of nebulized morphine in cancer patients with dyspnea: A pilot study. Japanese Journal of Clinical Oncology, 29, 600-603.

    Tooms, A., McKenzie, A., & Grey, H. (1993). Nebulised morphine. Lancet, 342, 1123-1124.

    Wilson, R.C., & Jones, P.W. (1991). Differentiation between the intensity of breathlessness and the distress it evokes in normal subjects during exercise. Clinical Science, 80(1), 65-70.

    Wilson, R.C., Oldfield, W.L., & Jones, P.W. (1993). Effect of residence at altitude on the perception of breathlessness on return to sea level in normal subjects. Clinical Science, 84(2), 159-167.

    Young, I.H., Daviskas, E., & Keena, V.A. (1989). Effect of low-dose nebulized morphine on exercise endurance in patients with chronic lung disease. Thorax, 44, 387-390.

    Zeppetella, G. (1997). Nebulized morphine in the palliation of dyspnoea. Palliative Medicine, 11, 267-275.