Management of Dyspnoea_Dr Yeat Choi Ling
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Transcript of Management of Dyspnoea_Dr Yeat Choi Ling
MANAGEMENT OF
DYSPNOEA – EFFECTIVE
INTERVENTIONS
DR. YEAT CHOI LING
PALLIATIVE MEDICINE PHYSICIAN
HOSPITAL RAJA PERMAISURI BAINUN
IPOH
2nd JUNE 2012
What is Dyspnoea?
A subjective experience of breathing discomfort that vary in intensity, deriving from interaction among multiple physiological, psychological, social, and environmental factors and may induce secondary physiological and behavioural responses.
American Thoracic Society Statement1999
It can cause great distress to the patients, caregivers as well as their physicians.
Patient’s Experience of Dyspnoea
Can be very frightening!
Fear of each breath will be one’s last.
Patients use words such as suffocating, choking or tightness
to describe the sensation.
3 dimensions:
Air hunger – the need to breath while being unable to
increase ventilation
Effort of breathing – physical tiredness associated with
breathing
Chest tightness – the feeling of constriction and inability to
breath in and out WHO Pain & Palliative Care Communications Program 2009
What is Dyspnoea (cont…)
Objective measures e.g. RR, O2 saturation, blood
gasses and lung function test may not correlate
closely with the sensation of dyspnoea.
In the cancer population, dyspnoea occurs more
often in patients with lung cancer but not only
associated with lung cancer:
46% reported breathlessness
4% had lung cancer, 5.4% had lung
metastases Dudgeon DJ 2001
Prevalence of Dyspnoea
General cancer population at diagnosis: 15-55%
Prevalence increases closer to death, up to 70% cancer patient experiencing dyspnoea in the last 6 weeks of life.
Reuben 1986
Incidence of dyspnoea in advanced non-malignant diseases: COPD: 90-95%
Heart disease: 60-88%
AIDS: 11-62%
Renal disease: 11-62%
Anxiety and Dyspnoea
Anxiety may contribute to dyspnoea but may also arise from
dyspnoea. Dudgeon 1998; Driscoll M et al. 1999
Anxiety can aggravate dyspnoea leading to a progressive
spiral of exacerbated breathlessness and greater
psychological distress. WHO Pain & Palliative Care Communications Program 2009
Mdm AZ/51/teacher
Has been diagnosed to have breast cancer with
lung metastases and pleural effusion.
Referred to Palliative Care Team for continuing
management.
Upon review, she was on N/P O2 3L/min, breathless
with RR 40/min. ECOG 4. Lungs: Right pleural
effusion.
Mdm AZ/48/housewife (cont…)
Right pleural tapping was done.
She felt better but still dyspnoeic at rest, worsen with exertion.
Mdm AZ/48/housewife (cont…)
Started on aq. morphine 3mg 4hrly and PRN, with
bisacodyl 2tabs on.
However, noted patient ‘refused’ to take morphine.
“My husband told me not to take morphine…”
“Morphine causes confusion…”
Explanation and reassurance!
Mdm AZ/48/housewife (cont…)
Breathless score reduced from 7/10 to 4-5/10. Not
drowsy or sleepy. No nausea/vomiting. Has hard
stool.
Subsequently, aq. morphine was increased to 5mg
4hrly and PRN. Sy. Lactulose 15ml on was added.
Able to have art therapy session with occupational
therapist. Good appetite!
Mdm AZ/48/housewife (cont…)
A week later later…
c/o severe lethargy with giddiness. Noted pallor.
Transfused 2 pints PC.
Able to sit on chair for ½ hour and spend quality
time with family.
The Principle - Treat The Reversible
Causes
It is important to reverse what is reversible depending on the patient’s physical and psychological condition and personal preferences.
Pre-existing causes
Cause of Dyspnoea Treatment Options
Infection Antibiotics , chest
physiotherapy
Asthma / COAD Bronchodilators,
corticosteroids
Cardiac Failure Diuretics
Radiation induced lung
fibrosis
Corticosteroids
Direct causes from Malignancy
Causes of Dyspnoea Treatment Options
Large airway obstruction RT, brachytherapy, laser
therapy, stent,
corticosteroids
Lung parenchymal damage Opioids, oxygen
Lymphangitis carcinomatosis Corticosteroids, opioids,
oxygen
Pleural Effusion Pleural drainage /
Pleurodesis
Pericardial Effusion Pericardiocentesis
SVC Obstruction Corticosteroids,
radiotherapy, stent
Indirect causes from Malignancy
Causes of dyspnoea Treatment options
Ascites Paracentesis, diuretics
Cachexia and muscle
weakness
Positioning,
physiotherapy
Pulmonary embolism Oxygen, DVT prophylaxis,
anticoagulation
Anemia Blood transfusion
ASSESSMENT
What should be included in the clinical assessment of
dyspnoea?
1. A comprehensive history
The onset, exacerbating and relieving factors
2. Assess the intensity of dyspnoea with a scale
To establish a baseline measurement
A simple categorically (mild-moderate-severe) or numerically (0-10) scale can be used.
3. Assess concomitant physical and psychological symptoms
To evaluate its impact on quality of life
4. Physical examination
To look for possible causes such as a pleural effusion or an arrhythmia
Useful Tests
Investigations should be carefully selected to guide
specific treatment.
The burden/benefit of the intervention for the
patient needs to be evaluated.
1st line investigations include Hb, O2 saturation by
oximetry and CXR.
Oximetry is non-invasive, enables us to
differentiate whether the patient is hypoxemic or
not.
It is often not possible to reverse all causes of dyspnoea in
patients with advanced cancer.
At this point, dyspnoea is refractory and the primary goal
should be symptom palliation to decrease the sensation of
dyspnoea.
SYMPTOMATIC MANAGEMENT
Clinical Symptomatic Management
Effective management requires both pharmacological and non-
pharmacological approaches.
Pharmacological intervention
Opioids
Benzodiazepines
Inhaled drugs
Oxygen
Non-pharmacological interventions
Positioning
The fan
Breathing techniques
Anxiety-reduction training
Pulmonary rehabilitation
Non-invasive ventilation
PHARMACOLOGICAL
MANAGEMENT
Opioids
There is significant positive effect of opioids (oral and parenteral routes) on the sensation of breathlessness (P = 0.0008).
Jennings et al 2002
No evidence of respiratory depression (measured by
RR, O2 saturation or levels of CO2) when morphine
is carefully titrated for dyspnoea.
No excess mortality demonstrated with the use of
opioids in any studies. Sara Booth 2008
Opioids (cont…)
For opioid naïve patients, a starting dose of mist. morphine 2.5-5 mg is a reasonable choice. E.g. mist. morphine 2.5mg 4hrly
mist. morphine 2.5mg PRN for breakthrough dyspnoea
It is reasonable to increase the dose of regular morphine, orally or subcutaneously, by 25–50% to control dyspnoea.
It is important to monitor the side effects of drowsiness and RR during opioid titration.
Kin-Sang Chan et al 2004
Benzodiazepines (bzd)
Bzd enhance the action of the neurotransmitter GABA (Gamma Amino Butyric Acid) and reduce anxiety.
No evidence that bzd modify the sensation of dyspnoea as there is with opioids, but they are widely used, often empirically for anxiety.
Bzd may improve mood in patients with dyspnoea and help to lessen the intensity of the sensation.
Benzodiazepines (cont…)
Doses for oral bzd: Po diazepam 2 mg -5 mg on
Sl/po lorazepam 0.5 - 1 mg prn
Midazolam at low doses in addition to morphine may be used at the end of life (EoL): sc 5–10 mg in 24 h with 2.5–5.0 mg PRN.
Sara Booth et al 2008
Side effects bzd including delirium, falls and severe sedation.
Haloperidol may be used when patient fear is prominent at the EoL.
Nebulised Drugs
Saline May be helpful for breathlessness or to aid expectoration
Limited evidence but minimal risk
Bronchodilaotrs Consider a trial of bronchodilators e.g. nebulised salbutamol 2.5mg tds
Frusemide May relieve dyspnoea in cancer patients.
Opioids No benefit so not for routine use
The Myth of Palliative Oxygen
Currently, no evidence shows palliative O2 relieves the sensation of dyspnoea in cancer patients unless they have hypoxemia (O2 Sat <90%), although the use of O2 remains a common practice.
Cochrane review showed no overall improvement of breathlessness in cancer patients when O2 breathing was compared to air breathing.
Cranston JM et al 2008
A small meta-analysis showed O2 did not provide symptomatic benefit for mildly- or non-hypoxemic patients with cancer.
Uronis HE et al 2008
The Myth of Palliative Oxygen (cont…)
Adverse effect of O2 therapy:
Worsens dry mouth and nostril,
with a risk of nosebleeds from
the nasal cannula
Reinforces sick role
Barrier to close contact
Costly
Hinders mobility due to rapid
dependence
The need to rely on a machine
Therefore, it should not be a knee
jerk reaction to start it.
The Role Of Corticosteroids
Corticosteroids work by decreasing inflammation in the
respiratory tract.
Corticosteroids are useful in:
upper airway obstruction related to the tumor
radiation pneumonitis
lymphangitis carcinomatosis
superior vena cava syndrome
Use cautiously because of side effects when used for long
periods e.g. hyperglycaemia, proximal myopathy and
psychotropic effects.
Oncology Interventions Dyspnoea due to lung parenchymal damage from infiltration,
lymphangitis carcinomatosis or recurrent malignant effusion may be treated with palliative chemotherapy.
Particularly useful in chemosensitive tumours such as breast, lung, colon cancers and lymphoma.
Bronchial obstruction causing dyspnoea may also be treated with palliative radiotherapy.
NON-PHARMACOLOGICAL INTERVENTIONS
Best Position
The ones that need the least energy or effort
Being tense in the body and gripping things wastes
energy and O2
The Fan
Facial cooling in the areas supplied by the CN V2 and V3 will reduce the sensation of breathlessness.
It is simple to use, no adverse effects, cheap and small.
There was significant
improvement in
dyspnoea with
handheld fan. Galbraith 2007
Breathing Techniques & Activity Pacing
Breathing control Diaphragmatic and pursed-lip breathing improved dyspnoea in
COPD patients. Hochstetter et al 2005
Activity pacing
Anxiety Reduction Training
Relaxation E. g. progressive muscular relaxation, visualization and guided
imagery.
Cognitive-behavioural therapy Patients with cancer-related dyspnoea often too ill both mentally and
physically to complete cognitive or behavioural programs.
Psychosocial support
Patient and Family Education
The ‘Breathlessness plan’:
1. Listen to patient (and their carers) experience during a dyspnoeic episode, to explain and address their fear.
2. Write a ‘dyspnoea plan’ with them to anticipate the possibility of a respiratory failure crisis.
This approach can have an immediate impact on patient anxiety as patients and carers start to exert some control over a difficult situation.
Booth S et al 2006
Dyspnoea At The Very End of Life…
Constant calming presence (education for carers is important). Just be there!
Increased air movement near face
Nurse patient in appropriate position
Good general care - bowels, mouth, skin, pain etc
Convert or start opioids as infusion
Add midazolam if anxious or panicky; Haloperidol for fear.
May need to increase sedation
Dry secretions if needed
Prescribe crisis drugs
Support to both caregivers and staffs
References 1. Sara Booth et al. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic
review of pharmacological therapy. Nature Clinical Practice Oncology February 2008: vol 5 :no 2.
2. Elaine Cachia et al. Breathlessness in cancer patients. European Journal of Cancer 2 0 0 8: 44: 1116 –1123.
3. Jennings AL et al. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database of Systematic Reviews 2001, Issue 3.
4. Paul N. Lanken et al. An Official American Thoracic Society Clinical Policy Statement: Palliative Care for Patients with Respiratory Diseases and Critical Illnesses. American Journal Of Respiratory And Critical Care Medicine 2008:Vol 177.
5. Kin-Sang Chan et al. Oxford Textbook Of Palliative Medicine 4th edition: Palliative medicine in malignant respiratory diseases. Pg 588-618.
6. Cranston JM et al. Oxygen therapy for dyspnoea in adults. Cochrane Database of Systematic Reviews 2008, Issue 3.
7. HE Uronis et al. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. British Journal of Cancer 2008: 98: 294 – 299.
8. Bausewein C et al. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of Systematic Reviews 2008, Issue 2.
9. Solano JP et al. A Comparison of Symptom Prevalence in Far Advanced Cancer, AIDS, Heart Disease,Chronic Obstructive Pulmonary Disease and Renal Disease. Journal of Pain and Symptom Management January 2006; Vol. 3; No. 1; 58-69.
10. Strategies for the palliation of dyspnoea in cancer. WHO Pain & Palliative Care Communications Program 2009; Vol. 2; Nos 1-2.
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12. Zhao I, Yates P. Non-pharmacological interventions for breathlessness management in patients with lung cancer: a systematic review. Palliat Med 2008; 22(6):693-701.
13. Currow DCet al.. Do terminally ill people who live alone miss out on home oxygen treatment? An hypothesis generating study. J Palliat Med 2008; 11(7): 1015-1022.
14. Currow DC, Agar M, Smith J, Abernethy AP. Does palliative home oxygen improve dyspnea? A consecutive cohort study. Palliat Med 2009; 23(4): 309-316.
15. Klemen KE et al. Is there a high risk of respiratory depression in opioid naïve palliative care patients during symptomatic therapy of dyspnoeawith strong opioids. J Palliat Med 2008; 11(2);204-216.
16. Abernethy AP et al. Randomized, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnea. BMJ 2003; 327(7414):523-528.
17. Clemens KE, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer 2009; 17(4): 367-377.
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