Beruflich Dokumente
Kultur Dokumente
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.
Can be very frightening! Fear of each breath will be ones 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
Dudgeon DJ 2001
Prevalence of Dyspnoea
Prevalence increases closer to death, up to 70% cancer patient experiencing dyspnoea in the last 6 weeks of life.
Reuben 1986
COPD: 90-95% Heart disease: 60-88% AIDS: 11-62% Renal disease: 11-62%
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.
pleural tapping was done. She felt better but still dyspnoeic at rest, worsen with exertion.
It is important to reverse what is reversible depending on the patients physical and psychological condition and personal preferences.
Pre-existing causes
Cause of Dyspnoea Infection Asthma / COAD Cardiac Failure Radiation induced lung fibrosis
Lymphangitis carcinomatosis Corticosteroids, opioids, oxygen Pleural Effusion Pleural drainage / Pleurodesis Pericardial Effusion Pericardiocentesis SVC Obstruction Corticosteroids, radiotherapy, stent
ASSESSMENT
A comprehensive history
2.
To establish a baseline measurement A simple categorically (mild-moderate-severe) or numerically (0-10) scale can be used.
3.
4.
Physical examination
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.
SYMPTOMATIC MANAGEMENT
Effective management requires both pharmacological and nonpharmacological 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 nave 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 2550% 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)
Midazolam at low doses in addition to morphine may be used at the end of life (EoL): sc 510 mg in 24 h with 2.55.0 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
Frusemide
Opioids
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
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
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 control
Activity pacing
Relaxation
Cognitive-behavioural therapy
Psychosocial support
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.
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. Elaine Cachia et al. Breathlessness in cancer patients. European Journal of Cancer 2 0 0 8: 44: 1116 1123. Jennings AL et al. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database of Systematic Reviews 2001, Issue 3. 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. Kin-Sang Chan et al. Oxford Textbook Of Palliative Medicine 4th edition: Palliative medicine in malignant respiratory diseases. Pg 588-618. Cranston JM et al. Oxygen therapy for dyspnoea in adults. Cochrane Database of Systematic Reviews 2008, Issue 3. HE Uronis et al. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and metaanalysis. British Journal of Cancer 2008: 98: 294 299. 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. 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. Strategies for the palliation of dyspnoea in cancer. WHO Pain & Palliative Care Communications Program 2009; Vol. 2; Nos 1-2. Quinten C, Coens C, Mauer M, et al. An examination into quality of life as a prognostic survival indicator. Results of a metaanalysis of over 10,000 patients covering 30 EORTC clinical trials. J Clin Oncol 2008; 26 (15S): 9516. 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. 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. 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. Klemen KE et al. Is there a high risk of respiratory depression in opioid nave palliative care patients during symptomatic therapy of dyspnoeawith strong opioids. J Palliat Med 2008; 11(2);204-216. 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. 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. Mahler DA et al. American College of Chest Physicians Consensus Statement on the Management of Dyspnea in Patients With Advanced Lung or Heart Disease. CHEST 2010; 137( 3 ): 674 691.
2. 3.
4.
5.
6. 7.
8.
9.
10. 11.
12.
13.
14.
15.
16.
17.
18.
THANK YOU