A preliminary investigation of the hand-held fan and the Calming Hand for the management of chronic refractory breathlessness in patients with advanced malignant and non-malignant diseases

Background Chronic breathlessness is a devastating symptom of advanced cardio-respiratory diseases, with extensive consequences for patients and their family carers. Despite optimal management of the underlying disease, problems may persist. Non-pharmacological interventions such as the hand-held fan and the Calming Hand may offer benefits, however there is little supportive evidence.Aim To gain preliminary data about the effectiveness of the hand-held fan and the Calming Hand for the management of exertion-induced breathlessness in people with chronic breathlessness.Methods Mixed method study with integrated findings; Systematic literature review and meta-analyses of airflow; feasibility 2x2 factorial, randomised controlled trial of the handheld fan and/or Calming Hand for the relief of exertion-induced acute-on-chronic breathlessness. Qualitative interviews of patients and carers.Findings Review findings indicate that airflow delivered from the hand-held fan at rest provides discernible breathlessness relief. The “2x2 factorial, pragmatic phase II trial of the Calming Hand and hand-held fan was feasible in terms of recruitment, data completion and trial acceptability. These preliminary results supported use of the fan for exertion-induced breathlessness including for time and rate of recovery after exertion-induced breathlessness. Qualitative data indicated that faster recovery improved patient self-efficacy and confidence. Patients identified the fan as a helpful “medical” device that played a useful role as part of a complex intervention for breathlessness. Conversely, there was little indication from quantitative or qualitative data to signal worthwhile benefit from the Calming Hand. The best candidate primary outcome measure was judged to be recovery rate or recovery time from exertion-induced breathlessness.Conclusion A future definitive trial is feasible to assess the benefits of the hand-held fan with exertion induced breathlessness. Breathlessness recovery rate and the recovery time are novel outcomes that may potentially reflect important patient improvements with exercise. The hand-held fan represents a tool that helps to promote patient self-mastery of breathlessness. These data do not support the use of the Calming Hand

HIDDen: Hospice Inpatient Deep vein thrombosis Detection prospective longitudinal observational study to explore the prevalence, symptom burden and natural history of venous thromboembolism in people with advanced cancer

BACKGROUND: The prevalence of deep venous thrombosis in patients with advanced cancer is unconfirmed and it is unknown whether current international thromboprophylaxis guidance is applicable to this population. We aimed to determine prevalence and predictors of femoral deep vein thrombosis in patients admitted to specialist palliative care units (SPCUs). METHODS: We did this prospective longitudinal observational study in five SPCUs in England, Wales, and Northern Ireland (four hospices and one palliative care unit). Consecutive adults with cancer underwent bilateral femoral vein ultrasonography on admission and weekly until death or discharge for a maximum of 3 weeks. Data were collected on performance status, attributable symptoms, and variables known to be associated with venous thromboembolism. Patients with a short estimated prognosis (<5 days) were ineligible. The primary endpoint of the study was the prevalence of femoral deep vein thrombosis within 48 h of SPCU admission, analysed by intention to treat. This study is registered with the ISRCTN registry, number ISRCTN97567719. FINDINGS: Between June 20, 2016, and Oct 16, 2017, 343 participants were enrolled (mean age 68·2 years [SD 12·8; range 25-102]; 179 [52%] male; mean Australian-modified Karnofsky performance status 49 [SD 16·6; range 20-90]). Of 273 patients with evaluable scans, 92 (34%, 95% CI 28-40) had femoral deep vein thrombosis. Four participants with a scan showing no deep vein thrombosis on admission developed a deep vein thrombosis on repeat scanning over 21 days. Previous venous thromboembolism (p=0·014), being bedbound in the past 12 weeks for any reason (p=0·003), and lower limb oedema (p=0·009) independently predicted deep vein thrombosis. Serum albumin concentration (p=0·43), thromboprophylaxis (p=0·17), and survival (p=0·45) were unrelated to deep vein thrombosis. INTERPRETATION: About a third of patients with advanced cancer admitted to SPCUs had a femoral deep vein thrombosis. Deep vein thrombosis was not associated with thromboprophylaxis, survival, or symptoms other than leg oedema. These findings are consistent with venous thromboembolism being a manifestation of advanced disease rather than a cause of premature death. Thromboprophylaxis for SPCU inpatients with poor performance status seems to be of little benefit. FUNDING: National Institute for Health Research (Research for Patient Benefit programme)