Fans and RectanglesDR TRACY SMITH AND MS MARY ROBERTS

WESTMEAD HOSPITAL

Pathophysiology of breathlessness

Booth et al, 2014

Air hunger/unsatisfied inspiration

Occurs with increased respiratory drive

Occurs when demand exceeds capacity

Right anterior insular cortex lights up when air hunger is induced in healthy subjects

Parshall et al. AJRCCM 2011

TightnessCommonly experienced during bronchoconstriction

Mechanical ventilation relieves effort ◦ But not tightness

Bronchodilators relieve tightness faster than effort

Blocking pulmonary afferents can diminish tightness

Parshall et al. AJRCCM 2011

Work/effortPhysiology is less well understood than tightness

◦ Involves respiratory motor area

◦Respiratory muscle afferents

Occurs in exercise

◦Not unpleasant until capacity reached

◦Discomfort occurs earlier in cardiopulmonary disease

In respiratory muscle weakness, the perception of respiratory effort is magnified

Parshall et al. AJRCCM 2011

Assessment of breathlessnessSeverity

Unpleasantness

Descriptions – tightness; work/effort; air hunger

Functional impact/ quality of life

Affective distress associated with breathlessness

◦ Association with past episodes

◦ Beliefs about breathlessness

◦ Prediction about possible consequences of what is perceived

Need to also assess associated symptoms e.g. cough, anxiety, painParshall et al. AJRCCM 2011

Measurement toolsBorg scales

Visual analog scales

Numerical rating scales

Multi-item scales eg CRQ, MDP, Dysp 12

Ratings of disability or activity limitation, e.g. MRC scale

Acknowledge breathlessnessPatients need to hear that you ‘get it’

Is their breathlessness proportional to pathophysiology?

◦ If no, what are you missing?

◦Cardiac co-morbidity

◦Musculoskeletal co-morbidity

◦Deconditioning

◦Psychological co-morbidity

◦Medication adherence

◦What do they mean by breathlessness?

Principles of breathlessness management

Initiate & optimise opioid

therapy

Initiate & optimise non-phamacologic therapiesPulmonary rehab, energy conservation, hand held fan,

breathing techniques & positioning

Initiate & optimise disease specific therapiesSABA, SAMA, LABA, LAMA

Magnitude of breathlessness

Regular follow up and reassessmentEnd of life care

Exclude contributing factors

Modified from Marciniuk et al, Canadian Respiratory Journal, 2011

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Non-Pharmacological ManagementM S M A R Y R O B E R T S

M A R Y . R O B E R T S @ H E A L T H . N S W . G O V . A U

R E S P I R A T O R Y C L I N I C A L N U R S E C O N S U L T A N T

W E S T M E A D H O S P I T A L

Non-pharmacological Mx of breathlessness2 Cochrane reviews ◦Rueda et al, 2011- Lung /thoracic ca◦Bausewein et al, 2008 - COPD, IPF, lung ca, CCF, MND

5 systematic reviews◦Kamal et al, 2012 - COPD◦Booth et al, 2011 - Malignant & non malignant diseases

◦ Thomas et al, 2011 - Advanced ca◦ Simon & Bausewein, 2009 - COPD◦ Zhao & Yates, 2008 - Lung ca

Non Pharmacological strategies

FansPulmonary

rehab

Breathing retraining

Relaxation

Medication technique

Energy conservation

Walking framesNutritional

supplementation

Inefficient breathingIncreased work ofbreathing

Thoughts about dyingMisconceptionsAttention to the sensationMemories, past experiences

Increased respiratory rateUse of accessory musclesDynamic hyperinflation Anxiety, distress

Feelings of panic

De-conditioning of limbs,chest wall and accessory muscles

Reduced activityTendency to self-isolateMore help from others

Breathing Thinking

Causes of breathlessness multifaceted

Treatment needs to be multifaceted

Booth et al, 2014

Functioning

Breathing

Check medication adherence -BreathingEven the nicest patients don’t always do what they are advised!!

Sometimes they don’t know what they don’t know!

Breathing techniques & positioning –BreathingLean forward position (over railing, walking stick, table)

Pulse lipped breathing

Paced breathing

Recovery breathing

Breathing techniques & positioningReported in all reviews to be of benefit however difficult to rate evidence due to differing definitions of techniques◦ Breathing control ◦ Promotes efficient breathing pattern deters hyperventilation (BTS/ACPRC, 2009)

◦ Pursed lip breathing ◦ Creates PEEP to maintain patency of unstable airways (BTS/ACPRC, 2009)

◦ Recovery breathing◦ Focuses on ‘breathing out’ to deter dynamic hyperinflation (Booth et al, 2011)

◦ Paced breathing (blow as you go)◦ Helps maintain control of breathing and deter dynamic hyperinflation (BTS/ACPRC, 2009)

◦ Lean forward position◦ Enhances respiratory muscle function by loading the diaphragm

Breathing around the rectangleLong slow breath out

Long slow breath out

Sh

ort b

rea

th in

Sh

ort

bre

ath

in

Hand Held Fan - BreathingCool air blowing across the face and nasal mucosa reduces the sensation of breathlessness

◦ Stimulation of 2nd and 3rd branches of trigeminal nerve

◦ Simple

◦Portable

◦Cheap

◦Gives the patients a sense of control

◦Gives carer something to do

Hand held fan - Evidence3 studies involving 116 participants (Schwartzstein et al, 1987; Simon et al, 1991; Galbraith et al, 2010)

More recently, a secondary study was carried out reviewing qualitative data from 3 RCTs, 133 patients, Luckett et al, 2017)

Emerging evidence

Thinking

Dispel myths - Thinking

Breathlessness

is dangerous

I need to

STOP doing

everything

If only I

had

oxygen….

I’m going

to stop

breathing

I’m never

going to

catch my

breath

I’m going

to have a

heart

attack

I’m going

to die

Psychological interventions -ThinkingRelaxation

◦ Progressive muscle relaxation and guided imagery

◦ 4 studies involving 238 participants

Counseling and support

◦ Nurse clinics and home visits

◦ 6 studies involving 1127 participants

Psychotherapy

◦ Emerging evidence that Cognitive Behavioural Therapy and Mindfulness may have a role in the management of breathlessness (often included in multimodality interventions)

◦ RCT at Westmead Hospital

Functioning

Physical activity - FunctioningSitting is the new smoking!

Promote physical activity◦ Give a pedometer◦ Give simple hints on increasing step counts

Pulmonary rehabilitation

Suggest walking aids◦ 4 wheeled walkers◦ Walking stick◦ Shopping trolley◦ Bunnings trolley

Exercise & physical activity - FunctioningExercise, physical activity and pulmonary rehabilitation (Cochrane review - McCarthy, 2015)

◦ Improves the efficiency of muscle function

◦ Stops / reverses deconditioning

◦ Desensitises the patient to breathlessness

◦ 65 RCTs involving 3822 participants

◦ Strong evidence (essential component of COPD management)

Energy conservation◦ Maintains independence, encourages pacing however lack of robust

evidence

◦ Most studies focusing on the use of walking aids decreasing work of breathing (Criafulli et al, 2007; Gupta et al, 2006; Probst et al, 2004)

◦ 7 studies involving 202 participants

◦ Strong evidence

Plan for breathlessnessWhen breathless,

remember the 3 Ps

Pause(stop what you are doing)

Position(get into a position that relieves your breathlessness, lean

forward, drop your shoulders)

Purse lips(smell the roses, flicker the candle)

And use your fan!Booth et al, 2014

Plan for breathlessness

The 3 FsI have had this feeling before – I know it

will go away soon!

1. I am going to lean forward

2. I am going to use my fan (and Ventolin)

3. I am going to focus on gently breathing

out

Booth et al, 2014

Pharmacological ManagementDR TRACY SMITH, STAFF SPECIALIST

RESPIRATORY AND SLEEP MEDICINE

WESTMEAD HOSPITAL

Off-label prescribingNone of the following drugs have breathlessness as an approved indication anywhere in the world

Efforts currently to change this for opioids ONLY

Opioids for dyspnoeaExtensive evidence base

No evidence of clinically significant worsening in respiratory failure with opioids

Morphine >> other opioids

Usual effective dose 10-30mg morphine/ day(Currow2011 JPSM)

Watch for constipation and other side effects

Most effective for dyspnoea at rest

Systemic opioids for dyspnoeaRecent systematic review in COPD (Ekstrom 2015 AJRCCM)

◦ 8 studies of oral opioids; 118 participants. Longest trial 6 weeks.

◦ No serious adverse events

◦ Reduced breathlessness

Recent systematic review in adv. cancer (Vargas-Bermúdez, 2015 J Pain PC pharm)

◦ No serious adverse events episodes of respiratory failure (or worsening of blood gas parameters)

◦ 14 trials (different routes and opioids)

◦ Improved dyspnoea

Benzodiazepines for dyspnoeaConflicted evidence base

Variety of agents tried

Cochrane review (2000 and 2016)

◦ Ineffective

◦High rate of side effects

Despite this, I know they are commonly prescribed

Please don’t!

Other strategies

Nebulised furosemide1,2,3

Nebulised opioids1,4

Antidepressants 5

1. Boyden J Aerosol med 2014; 2. Vahedi 2013 Respiratory Care (AECOPD) 3. Jensen D

2008 Thorax 4. Ekstrom AJRCCM 2015; 5. Marciniuk Can Resp J 2011

Oxygen for dyspnoea?

Forest plot summarising randomised trials of the symptomatic effect

of oxygen on breathlessness in people with COPD who do not

qualify for long-term oxygen therapy; all trials.

Hope E Uronis et al. Thorax 2015;70:492-494Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.

Two large studies completed

after this review found oxygen

did not reduce breathlessness

A few words about other things…

Symptoms in “advanced” COPD

Janssen, 2008 Pall Med 22;8

Other symptoms

Pain

Anxiety/ Depression

Cachexia

Mouth

Will I

choke to

death?

Is the Dr

holding

out on

me?

Am I

dying?

What will

death be

like?

How long

have I

got?

Who’ll look

after the dog/

cat/ wife/ vege

patch/

Kingswood?

Shall we dance?

Patients wait for us to raise advance care planning

We may wait for patients to raise advance care planning

Putting it all together – Part 1Acknowledge the symptom!

Include the carer

Treat reversible factors/ Identify co-morbidities

Complete an accurate assessment◦ Physical

◦ Emotional

◦ Social and Spiritual aspects

◦ What has / hasn’t worked in the past

Putting it all together – Part 2

Multicomponent non-pharm treatment first◦ Fans

◦ Rectangles

◦ Purse lip breathing

◦ Pulmonary Rehab

◦ Exploit your multidisciplinary team (nurses, physio, OT)

Opioids are good!

Beware the benzos!