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Friday, March 13, 2015

Hospice and Palliative Med Journal Club: Oxygen, BiPap and persistent dyspnea

by Dr. Katherine Sleeman

On Tuesday 17th March from 3-4pm UK time (9-10am Central Standard Time) we will be holding the monthly Twitter Journal Club for hospice and palliative medicine: #hpmjc. The aim of the journal club is to provide an informal multidisciplinary forum for discussion of research findings, and we hope you will join us.

You can find some more information about the #hpmjc journal club here.

The paper for discussion this month is ‘High-flow oxygen and bilevel positive airway pressure for persistent dyspnea in patients with advanced cancer: a phase II randomized trial’. The paper was published in October 2013 in The Journal of Pain and Symptom Management, and is open access .

Lead author of the paper, Dr David Hui (@DrDavidHui) will lead this month’s journal club, and will be available to answer your questions on his study. Dr Hui is an assistant professor at the Department of Palliative Care & Rehabilitation Medicine and the Department of General Oncology, The University of Texas MD Anderson Cancer Center. His research interests include symptom management clinical trials, research methodology, prognostication, and integration of supportive/palliative care into oncology.


Breathlessness is one of the most distressing symptoms in cancer patients. Many patients continue to experience refractory breathlessness despite treatment with opioids, steroids and low flow supplemental oxygen. Novel strategies are needed to address this symptom.

This paper reports a randomised crossover trial of high flow oxygen and non-invasive ventilation. High flow oxygen is a novel gas delivery device that can deliver up to 40 L/min of humidified oxygen via nasal cannula. Bilevel positive airway pressure (BiPAP) provides not only oxygenation but also ventilation and thus respiratory muscle support.

What did the study find?

Among the 30 patients randomized, 13 completed 2 hours of HFO and 10 patients completed 2 hours of BiPAP. The total completion rate was 77%. In a before and after comparison, patients reported improvement in their breathlessness with high flow oxygen (mean change in numeric rating scale 1.9; P=0.02; mean change in modified Borg scale 2.1, P=0.007) and with BiPAP (mean change in numeric rating scale 3.2; P=0.004; mean change in modified Borg scale 1.5, P=0.13). Some physiologic parameters improved. No significant adverse effects were observed.

Questions for discussion:

• Do you have experience using high flow oxygen?
• What do you think about the study findings?
• What are the mechanisms in terms of how high flow oxygen and BiPAP relieve breathlessness?
• Is it ethical to provide non-invasive ventilation in the palliative care setting?
• What are some advantages and disadvantages of crossover designs?
• What are the implications of this research for your practice?

We look forward to discussing this on 17th March, and hope that you can join us. Just follow @hpmjc and use #hpmjc

Archive of past #hpmjc can be found here.

Katherine Sleeman is a clinician and academic in palliative medicine, Cicely Saunders Institute, King’s College London.

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