Vol. 48 No. 5 November 2014
Letters
palliative care unit. He also had chronic rhinitis and mild impaired consciousness caused by Parkinsonian syndrome; his performance status was 4. One day, he complained of dyspnea and uncomfortable respiration without respiratory failure. Initially, there were no identifiable causes of dyspnea on clinical examination. We then examined the nasal cavity and detected an enormous volume of dried nasal mucus bilaterally in the nasal cavity (Fig. 1). After removing the dried nasal mucus with tweezers, the dyspnea immediately disappeared. The same symptom was reported again two weeks later, and the same treatment proved effective. We periodically examined the nasal cavity and applied moisturizing cream to the region.1 Once this protocol was enacted, the dried nasal mucus no longer accumulated.
Case 2 A 70-year-old man with a three-month history of hepatocellular carcinoma and mild impaired consciousness from hepatic encephalopathy was admitted to the palliative care unit. His performance status was 4. He previously lost swallowing function and, therefore, was fed using a nasogastric tube. One day, he complained of dyspnea and uncomfortable respiration without respiratory failure. On clinical examination, a large amount of dried nasal mucus was detected bilaterally in the nasal cavity. The nasal mucus was removed in a manner similar to that used for Case 1, and his respiratory symptoms were similarly relieved.
Comment Dried nasal mucus comprises a desiccated piece of nasal mucus and dust from the air. Relatively large accumulations of dried nasal mucus cause discomfort and respiratory symptoms; however, most patients can eject the debris on their own. Therefore, dried nasal
Fig. 1. Enormous volume of dried nasal mucus bilateral in nasal cavity.
e5
mucus does not typically grow to an extremely large size. Patients with advanced cancer often have impaired consciousness and cannot eject dried nasal mucus themselves; thus, the debris can grow to enormous size. Large pieces of dried nasal mucus obstruct the nasal cavity, resulting in dyspnea. In these cases, the patient compensates by breathing through the mouth; this ensures that oxygen saturation does not decrease. If we can assess the cause of dyspnea appropriately, then treatment is simple and easy and does not require medication or oxygen supplementation. In our experience, patients at a high risk of recurrence of dried nasal mucus obstructions may be any patient with an impaired consciousness, low performance status, nasal tumor, nasal catheter or oxygen cannula, and chronic rhinitis.2 Although observation of the nasal cavity is sometimes forgotten and easily overlooked, examination is an important component in relieving dyspnea in patients with advanced cancer. Keisuke Kaneishi, PhD, MD Palliative Care Unit JCHO Tokyo Shinjuku Medical Center Tokyo, Japan E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.08.005
References 1. Bj€ ork-Eriksson T, Gunnarsson M, Holmstr€ om M, Nordqvist A, Petruson B. Fewer problems with dry nasal mucous membranes following local use of sesame oil. Rhinology 2000;38:200e203. 2. Das SK. Etiological evaluation of foreign bodies in the ear and nose. J Laryngol Otol 1984;98:989e991.
Re: Recommendations for Bowel Obstruction With Peritoneal Carcinomatosis by Laval et al. To the Editor: Laval et al. are to be commended for their comprehensive review article on management of malignant bowel obstruction (MBO) in patients with peritoneal carcinomatosis.1 They address an issue, however, which I would like to comment on from a palliative care perspective. Current evidence does not support their statement that ‘‘rehydration is needed for virtually every patient.’’ An earlier observational study on patients with MBO reported intravenous volume depletion with signs of fluid retention, regardless of artificial hydration (AH) administration.2 According to a large survey conducted by the same group, health
e6
Letters
care professionals witnessed volume-dependent adverse effects of AH on patients with terminal cancer.3 The lack of benefit of AH on dry mouth and thirst in MBO, a correlation of large AH volumes with an increase of bowel secretions, but also possible preventive effects of AH on metabolic symptoms, have to be considered.4 Moreover, focusing on the last week of life in cancer patients, a systematic review found conflicting evidence of AH effects: Although some studies reported improved nausea and dehydration symptoms, others found increases of ascitic fluid and gastrointestinal secretions.5 Finally, a recent randomized placebo-controlled trial was not able to demonstrate any benefit of AH in terms of symptom control, quality of life, and survival.6 Being aware that these studies include conditions other than MBO, most of the observed patients share common features, such as dehydration, edema, abdominal symptoms, low serum albumin levels, and a very poor prognosis. Thus, an individual risk-adapted approach that carefully balances harms and benefits of AH seems more appropriate than a global recommendation in favor of this intervention. Johannes B€ ukki, MD Institute of Nursing Science and Practice Paracelsus Medical University Salzburg, Austria HospiceCare DaSein Munich, Germany E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.07.006
References 1. Laval G, Marcelin-Benazech B, Guirimand F, et al. Recommendations for bowel obstruction with peritoneal carcinomatosis. J Pain Symptom Manage 2014;48:75e91. 2. Morita T, Tei Y, Inoue S, Suga A, Chihara S. Fluid status of terminally ill cancer patients with intestinal obstruction: an exploratory observational study. Support Care Cancer 2002;10:474e479. 3. Morita T, Shima Y, Miyashita M, Kimura R, Adachi I, Japan Palliative Oncology Study Group. Physician- and nurse-reported effects of intravenous hydration therapy on symptoms of terminally ill patients with cancer. J Palliat Med 2004;7:683e693. 4. Ripamonti CI, Easson AM, Gerdes H. Management of malignant bowel obstruction. Eur J Cancer 2008;44: 1105e1115. 5. Raijmakers NJ, van Zuylen L, Costantini M, et al. Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol 2011;22:1478e1486. 6. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol 2013;31: 111e118.
Vol. 48 No. 5 November 2014
Pain Assessment Using the Critical-Care Pain Observation Tool: Comment on Li et al. To the Editor: The recent report on pain assessment using the Critical-Care Pain Observation Tool (CPOT) is very interesting.1 Li et al. concluded that ‘‘The CPOT has good psychometric properties and can be used as a reliable and valid instrument for pain assessment.’’1 In fact, there are some concerns regarding the use of the CPOT. First, the tool still has limitations in some situations. Gelinas and Johnston2 noted that the tool should be further assessed in ‘‘critically ill populations (e.g., head injury).’’ Second, Gelinas et al.3 also found that the tool ‘‘did not allow an effective communication’’ among critical care team members. Finally, it also was reported that the CPOT assessment has a poor relationship to patient self-report.4 Viroj Wiwanitkit, MD Wiwanitkit House Bangkok, Thailand E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.05.020
References 1. Li Q, Wan X, Gu C, et al. Pain assessment using the Critical-Care Pain Observation Tool in Chinese critically ill ventilated adults. J Pain Symptom Manage 2014;48: 975e982. 2. G elinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain 2007;23:497e505. 3. G elinas C, Ross M, Boitor M, et al. Nurses’ evaluations of the CPOT use at 12-month post-implementation in the intensive care unit. Nurs Crit Care 2014 May 9. [Epub ahead of print]. 4. Keane KM. Validity and reliability of the Critical-Care Pain Observation Tool: a replication study. Pain Manag Nurs 2013;14:e216ee225.
Author’s Reply To the Editor: We read with great interest the correspondence from Dr. Wiwanitkit about our recent report in the Journal of Pain and Symptom Management.1 In our report, we concluded that ‘‘The CPOT [Critical-Care Pain Observation Tool] has good psychometric
Letters
palliative care unit. He also had chronic rhinitis and mild impaired consciousness caused by Parkinsonian syndrome; his performance status was 4. One day, he complained of dyspnea and uncomfortable respiration without respiratory failure. Initially, there were no identifiable causes of dyspnea on clinical examination. We then examined the nasal cavity and detected an enormous volume of dried nasal mucus bilaterally in the nasal cavity (Fig. 1). After removing the dried nasal mucus with tweezers, the dyspnea immediately disappeared. The same symptom was reported again two weeks later, and the same treatment proved effective. We periodically examined the nasal cavity and applied moisturizing cream to the region.1 Once this protocol was enacted, the dried nasal mucus no longer accumulated.
Case 2 A 70-year-old man with a three-month history of hepatocellular carcinoma and mild impaired consciousness from hepatic encephalopathy was admitted to the palliative care unit. His performance status was 4. He previously lost swallowing function and, therefore, was fed using a nasogastric tube. One day, he complained of dyspnea and uncomfortable respiration without respiratory failure. On clinical examination, a large amount of dried nasal mucus was detected bilaterally in the nasal cavity. The nasal mucus was removed in a manner similar to that used for Case 1, and his respiratory symptoms were similarly relieved.
Comment Dried nasal mucus comprises a desiccated piece of nasal mucus and dust from the air. Relatively large accumulations of dried nasal mucus cause discomfort and respiratory symptoms; however, most patients can eject the debris on their own. Therefore, dried nasal
Fig. 1. Enormous volume of dried nasal mucus bilateral in nasal cavity.
e5
mucus does not typically grow to an extremely large size. Patients with advanced cancer often have impaired consciousness and cannot eject dried nasal mucus themselves; thus, the debris can grow to enormous size. Large pieces of dried nasal mucus obstruct the nasal cavity, resulting in dyspnea. In these cases, the patient compensates by breathing through the mouth; this ensures that oxygen saturation does not decrease. If we can assess the cause of dyspnea appropriately, then treatment is simple and easy and does not require medication or oxygen supplementation. In our experience, patients at a high risk of recurrence of dried nasal mucus obstructions may be any patient with an impaired consciousness, low performance status, nasal tumor, nasal catheter or oxygen cannula, and chronic rhinitis.2 Although observation of the nasal cavity is sometimes forgotten and easily overlooked, examination is an important component in relieving dyspnea in patients with advanced cancer. Keisuke Kaneishi, PhD, MD Palliative Care Unit JCHO Tokyo Shinjuku Medical Center Tokyo, Japan E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.08.005
References 1. Bj€ ork-Eriksson T, Gunnarsson M, Holmstr€ om M, Nordqvist A, Petruson B. Fewer problems with dry nasal mucous membranes following local use of sesame oil. Rhinology 2000;38:200e203. 2. Das SK. Etiological evaluation of foreign bodies in the ear and nose. J Laryngol Otol 1984;98:989e991.
Re: Recommendations for Bowel Obstruction With Peritoneal Carcinomatosis by Laval et al. To the Editor: Laval et al. are to be commended for their comprehensive review article on management of malignant bowel obstruction (MBO) in patients with peritoneal carcinomatosis.1 They address an issue, however, which I would like to comment on from a palliative care perspective. Current evidence does not support their statement that ‘‘rehydration is needed for virtually every patient.’’ An earlier observational study on patients with MBO reported intravenous volume depletion with signs of fluid retention, regardless of artificial hydration (AH) administration.2 According to a large survey conducted by the same group, health
e6
Letters
care professionals witnessed volume-dependent adverse effects of AH on patients with terminal cancer.3 The lack of benefit of AH on dry mouth and thirst in MBO, a correlation of large AH volumes with an increase of bowel secretions, but also possible preventive effects of AH on metabolic symptoms, have to be considered.4 Moreover, focusing on the last week of life in cancer patients, a systematic review found conflicting evidence of AH effects: Although some studies reported improved nausea and dehydration symptoms, others found increases of ascitic fluid and gastrointestinal secretions.5 Finally, a recent randomized placebo-controlled trial was not able to demonstrate any benefit of AH in terms of symptom control, quality of life, and survival.6 Being aware that these studies include conditions other than MBO, most of the observed patients share common features, such as dehydration, edema, abdominal symptoms, low serum albumin levels, and a very poor prognosis. Thus, an individual risk-adapted approach that carefully balances harms and benefits of AH seems more appropriate than a global recommendation in favor of this intervention. Johannes B€ ukki, MD Institute of Nursing Science and Practice Paracelsus Medical University Salzburg, Austria HospiceCare DaSein Munich, Germany E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.07.006
References 1. Laval G, Marcelin-Benazech B, Guirimand F, et al. Recommendations for bowel obstruction with peritoneal carcinomatosis. J Pain Symptom Manage 2014;48:75e91. 2. Morita T, Tei Y, Inoue S, Suga A, Chihara S. Fluid status of terminally ill cancer patients with intestinal obstruction: an exploratory observational study. Support Care Cancer 2002;10:474e479. 3. Morita T, Shima Y, Miyashita M, Kimura R, Adachi I, Japan Palliative Oncology Study Group. Physician- and nurse-reported effects of intravenous hydration therapy on symptoms of terminally ill patients with cancer. J Palliat Med 2004;7:683e693. 4. Ripamonti CI, Easson AM, Gerdes H. Management of malignant bowel obstruction. Eur J Cancer 2008;44: 1105e1115. 5. Raijmakers NJ, van Zuylen L, Costantini M, et al. Artificial nutrition and hydration in the last week of life in cancer patients. A systematic literature review of practices and effects. Ann Oncol 2011;22:1478e1486. 6. Bruera E, Hui D, Dalal S, et al. Parenteral hydration in patients with advanced cancer: a multicenter, double-blind, placebo-controlled randomized trial. J Clin Oncol 2013;31: 111e118.
Vol. 48 No. 5 November 2014
Pain Assessment Using the Critical-Care Pain Observation Tool: Comment on Li et al. To the Editor: The recent report on pain assessment using the Critical-Care Pain Observation Tool (CPOT) is very interesting.1 Li et al. concluded that ‘‘The CPOT has good psychometric properties and can be used as a reliable and valid instrument for pain assessment.’’1 In fact, there are some concerns regarding the use of the CPOT. First, the tool still has limitations in some situations. Gelinas and Johnston2 noted that the tool should be further assessed in ‘‘critically ill populations (e.g., head injury).’’ Second, Gelinas et al.3 also found that the tool ‘‘did not allow an effective communication’’ among critical care team members. Finally, it also was reported that the CPOT assessment has a poor relationship to patient self-report.4 Viroj Wiwanitkit, MD Wiwanitkit House Bangkok, Thailand E-mail: [email protected] http://dx.doi.org/10.1016/j.jpainsymman.2014.05.020
References 1. Li Q, Wan X, Gu C, et al. Pain assessment using the Critical-Care Pain Observation Tool in Chinese critically ill ventilated adults. J Pain Symptom Manage 2014;48: 975e982. 2. G elinas C, Johnston C. Pain assessment in the critically ill ventilated adult: validation of the Critical-Care Pain Observation Tool and physiologic indicators. Clin J Pain 2007;23:497e505. 3. G elinas C, Ross M, Boitor M, et al. Nurses’ evaluations of the CPOT use at 12-month post-implementation in the intensive care unit. Nurs Crit Care 2014 May 9. [Epub ahead of print]. 4. Keane KM. Validity and reliability of the Critical-Care Pain Observation Tool: a replication study. Pain Manag Nurs 2013;14:e216ee225.
Author’s Reply To the Editor: We read with great interest the correspondence from Dr. Wiwanitkit about our recent report in the Journal of Pain and Symptom Management.1 In our report, we concluded that ‘‘The CPOT [Critical-Care Pain Observation Tool] has good psychometric
