Post on 23-Dec-2015
{
Management of Advanced Breathlessness
Dr Phil Wilkins, Norfolk and Norwich University Hospital and Priscilla Bacon Lodge, Norwich
Definitions of breathlessness and when it occurs
How to manage the symptom How to implement this
Overview
Breathlessness
Unpleasant awareness of difficulty breathing
“Inability to get enough air” “Smothering feeling” The only reliable measure is patient self-
report RR, pO2 + blood gases do not correlate
with the feeling of breathlessness
Breathlessness
COPD Interstitial Lung Disease Cancer (Primary and Secondary) Left Heart Failure (Anaemia, Muscular disorders,
Bronchiectasis, etc)
Conditions Causing End-stage Breathlessness
Conscious vs Unconscious Useful Concepts
Functions of breathing What the patient thinks What it is actually for
What happens when it goes wrong How should we manage it?
Breathing Regulation
Breathing Control
medullary central pattern
generator : brain stem
respiratory muscles
ventilation
Mechanical receptors: parenchyma,airwaysintercostal muscles + diaphragm
Chemoreceptors in aortic,carotid bodies + medulla
↑CO2 ↓O2
higher centres
Management
Optimise the treatment for the underlying disease first!
Important!
Influenced by: Mental state Posture Exercise Environmental temperature + humidity
High breathlessness score = low QOL score
Affects all aspects of ADL : physical, psychological and social
Cancer - affects 15% at diagnosis : 65% at some time during illness
Breathlessness
In malignant disease breathlessness is usually due to distortion and stimulation of mechanical receptors.
Blood gases are often normal
Fatigue, muscle weakness, phrenic nerve palsy and restrictive chest wall tumours can exacerbate breathlessness
Breathlessness
Drugs
ventilatory response to hypercapnia, hypoxia + exercise
Activation µ and opioid receptors tidal volume + respiratory rate
Breathing more efficient: improves exercise tolerance Reduces sensation of breathlessness Cortical sedative / anxiolytic Suppress cough reflex centre in brain stem
Opiates
Morphine does not cause CO 2 retention if used appropriately
Morphine breathlessness by about 20% Generally more beneficial in patients who
are breathless at rest
In opioid naïve patients: start with 2.5mg oramorph prn + titrate
In patients on morphine for pain increase dose by 30%
Morphine for Breathlessness
Anxiolytic + Respiratory sedative Use formulations with relatively longer half
life to avoid pronounced peaks & troughs which may lead to rebound anxiety Diazepam 2-5mg nocte Midazolam 2.5mg SC stat+ 5-10mg / 24 hrs
CSCI Clonazepam 0.25-2mg PO 12hrly
Panic attacks Lorazepam 0.5-1mg SL prn
* SSRI* Neuroleptic
Benzodiazepines
Non-pharmacological, non-interventional control of dyspnoea
Reassurance Breathing control Activity pacing Relaxation techniques Complementary therapies Psychological support
RCT 119 significant improvement at 8 weeks in dyspnoea score, ECOG status, emotional status
General Considerations
Posture Breathing techniques Anxiety Relaxation Pacing
Hand Held Fans
Shallow rapid breathing is ineffective and causes panic
Encourage slow, regular, deep breathing
Diaphragmatic breathing: consciously expand abdominal wall during inspiratory diaphragm descent
Pursed lip breathing :nasal inspiration + exhale though pursed lips
Breathing Retraining
Panic Attacks
Lack of understanding + fear
Increased respiratory rate
Increased anxiety Dyspnoea PANIC
Oxygen
Oxygen
No evidence of help if not hypoxic Can be prescribed for ‘palliative care’
Optimise the management of the underlying condition
Consider lifestyle / behavioural changes Breathlessness clinics for non-drug
management Drugs to modify the sensation
Opiates Benzodiazepines
(Oxygen)
Summary