DYSPNEA: A Multidisciplinary Palliative Approach S H A L I N I N A Y A R , M . D . , F R C P C I N T E R N A L M E D I C I N E

R E S P I R A T O R Y M E D I C I N E P A L L I A T I V E C A R E S P E C I A L I S T

C L I N I C A L A S S O C I A T E P R O F E S S O R

D E P A R T M E N T O F M E D I C I N E U N I V E R S I T Y O F B R I T I S H C O L U M B I A

Disclosure

● No disclosures

● No potential conflict of interest anticipated

Objectives

● Overview of Dyspnea

● Discuss a case

● Review management strategies○ Pharmacologic

○ Non-pharmacologic

● End-of-Life considerations

● Summary

● Discussion/questions

The American Thoracic Society defines breathlessness as:

“a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioural responses” (ATS 1999, update 2011).

Dyspnea is a common and often debilitating symptom that affects up to 50% of patients admitted to acute, tertiary care hospitals and a quarter of patients seeking care in ambulatory settings.

Control of respiration.

Rao A , and Gray D Postgrad Med J 2005;81:99-102

Copyright © The Fellowship of Postgraduate Medicine. All rights reserved.

Dyspnea is Multifactorial

www.painconsortium.nih.gov

Qualities of Dyspnea

● Effort – multiple etiologies

● Tightness-bronchoconstriction

● Air Hunger- Increased ventilatory demand

● The qualities are not limited to above and rarely happen in isolation!

● It is a sensation

Case - Mr. F

● 65 y.o. male

● CC: Pain L chest wall, severe dyspnea, decreased fxn over 2 months (now in wheelchair)

● PmHx:○ COPD – FEV1 1.23 L (36%)

○ Recurrent hospitalizations, pseudomonas colonization

○ L pneumonectomy for NSCLC

○ Remote PE/DVT L

○ CAD – CABG x 3 2002, STEMI 2009

○ HTN/Dyslipidemia

○ Duodenal ulcer

Case - Continued

● Medications:

○ Azithromycin 250 mg daily (COPD)○ Prednisone 50 mg (on taper)○ Theophylline 600 mg daily○ Advair 250 mcg 2 inh BID○ Tiotropium inh daily○ Bisoprolol 2.5 mg○ Simvastatin 40 mg○ Ramipril 2.5 mg○ Nortriptyline 50 mg qhs○ Clopidogrel 75 mg ○ Vit D/CaCO3○ Pantoprazole 40 mg○ Gabapentin 900 mg tid○ Oxycontin 80 mg tid, 20-30 mg PRN ○ Lasix 40 mg daily

● Social: Lives with wife, no other supports, ongoing smoking, pays for O2 privately, difficult finances

Assessment

● History○ Broad – pattern, triggers, exposures, infections, associated symptoms,

OPQRST○ Dyspnea can be measured

What measurement scale?What is most reliable?

● Physical Exam○ Dyspnea may not correlate with P/E or O2 sats!○ Intensity of dyspnea can be reflected in accessory muscle use

● Etiologies ○ Acute vs. Chronic○ Divide differential by pathophysiology

Assessment of dyspnea

● O: onset: when; identify triggers● P: place(s); on exertion or at rest● Q: quality; what does it feel like● R: relief; exacerbating or relieving

factors● S: severity; 0-10, or verbal scale,

faces etc.● T: timing; when started, daily

pattern● U: understanding shortness of

breath and its impact● V: values; patient’s wishes and goals

Reproduced from Elizabeth Beddard-Huber

Case - Continued

● History:

○ Dyspnea -Limiting factor

MRC Dyspnea scale 5

No IADLs

Worse in early am and exertion

Insidiously progressive

No infectious/sputum/cough

○ Pain -Old pain from chemotherapy – peripheral neuropathy

Worsening chest wall pain – OPQRST, not acute

F/U BCCA in 3 mos re: RLL abnormality on CT

Case - Continued

● Exam:

○ Cushingoid appearance

○ On O2 2L/min

○ No dyspneic during conversation

○ Quiet breath sounds R

○ Pain along L incision site – not reproducible

○ Reduced sensation toes – ankle bilaterally

○ No edema

Questions a nurse may ask…

● How do you manage your breathing?

● What works?

● What has not worked?

● Have you noted a change in your activity level?

● What do you think is causing it?

● What concerns/fears do you have?

● What are your goals and expectations?

Reproduced from Elizabeth Beddard-Huber

Physical Assessment

● Assess rate, depth and pattern of respirations

● Use of accessory muscles

● Lung sounds – presence or absence of wheezes, crackles, rales or absent breath sounds

● Oxygen Saturation

Reproduced from Elizabeth Beddard-Huber

Dyspnea is Multifactorial

www.painconsortium.nih.gov

Etiologies

● Is it ACUTE or CHRONIC?○ If chronic, are features the same as previous?

● Physiologic differential :

● Increased respiratory drive ○ increased afferent input to respiratory centers

○ Ex: ILD, impaired gas exchange, pulmonary vascular disease

● Impaired ventilatory mechanics—○ reduced afferent feedback for a given efferent output (corollary discharge of

motor command)

○ Ex: Airflow obstruction, muscle weakness, obesity, effusion

Etiologies

● Can also use a body system approach:

○ Pulmonary

○ Cardiac

○ NMD

○ MSK

○ Hematologic

○ Other: Mood, type of pain

● Or ‘Cancer’ vs. ‘non-cancer’ approach:

○ Directly related to cancer (tumour effects, SVC, LAN)

○ Indirectly related to cancer (ascites, PE, paraneoplastic)

○ Related to cancer therapy (cardiomyopathy, fibrosis)

○ Unrelated to cancer

VAS studied

MRC studied

Dyspnea – Mr. F

● Differential:

● Acute

● Chronic○ COPD

○ Post Lung Ca effects

...Management strategies? Investigations? Depends on the patient!!

Copd

● Morbidity: ○ Dyspnea,

○ depression (up to 50% in studies)

○ anxiety (similar to dyspnea)

○ pain (chest pain, chronic full body pain)

○ repeat infectious exacerbations, repeat hospitalization

○ multiple co-morbidities

○ smoking status

● Debilitating –unpredictable disease trajectory

● Pulmonary rehab

● Opioids/inhalers/smoking cessation

● The O2 story – LTOT criteria

Challenges In COPD

Increasing symptom

burden at home

Unable to see MD for non-

emergent assessment

AECOPD with admission

D/C home without longer-

term care addressed

NO

CONVERSATION

MD reluctance?....

COPD

Physical Psychosocial

Dyspnea - universal

Pain – 30% - 70%!

Physical frailty and homebound

Anxiety – 30%

Depression – up to 70%

Caregiver burnout

Social isolation

ACP and advanced

symptom management

Case – Mr. F

● No change to CXR since hospitalization

● Bloodwork in normal range

● CT done in-hospital 2 wks prior: no PE

● F/U BCCA scan in a week

● At baseline FEV1

● Qualifies for home O2

● Overall: Insidious, no obvious acute pathology

Treatment Goals

● Dyspnea is best treated by addressing causes○ If possible

● Treat symptoms regardless of cause○ Prevent suffering

● Ease patient’s fears

● Ease family’s fears

● Advance care planning

● Future planning around acute episodes

● Treatment plan is guided by the patient’s goals and stage of illness.

Treating the Underlying Cause

Improvement in Dyspnea

Tumour: XRT, chemo

Airflow obstruction: Steroids/bronchodilators/stents

Pleural procedures

Pulmonary edema: diuretics

Transfusions

Cough: Anti-tussive, include opioids

Lymphangitic CA: steroids, opioids

ILD: disease-modifying tx, opioids, steroids

Pain: interventional/meds

Other cardiac: HR meds, anti-anginals

Secretions: anticholinergics/saline/NAC

Trajectories of decline.

Jaarsma T et al. Eur J Heart Fail 2009;11:433-443

Morbidity and MortalityBode score 1-yr

Mortality

(%)

2-yr

Mortality

(%)

3-yr

Mortality

(%)

0-2 2 6 19

3-4 2 8 32

5-6 2 14 40

7-10 5 31 80

Note: Many studies done looking at other variables: co-morbidities, functional capacity alone, rate of decline in FEV1 (> 40 ml/yr) as well.

-25% die within 1-yr of acute hospitalization- Median survival after ICU visit acutely = 2 yrs, with 50% likelihood of repeat hospitalization in 6 months

Celli BR, Cote CG, Marin JM, Casanova C, et al. The body mass index, airflow obstruction, dyspnea, and exercise capacity index in COPD. NEJM 2004, 350: 1005-1012..

Dyspnea Management

● Non-pharmacologic strategies:○ Cochrane review 2011

NMES, CWV - good

Walking aides, breathing training -good

Relaxation, fan, psychotherapy, combinations – need further data

Accupuncture – mixed results

○ Interventional procedures where appropriate

○ Ventilation

○ Fresh Air Cool temperature

○ Energy Conservation

○ PositionEase of abdomen/chest movements

○ EnvironmentClaustrophobia, humidification

● In hospital:● PCU nurses

● PCU MD

● Consult clinicians, CNS

● Consult MD

● Ward SW, spiritual care, RT, OT, PT

● Pharmacists

● In the community:● Pulmonary rehab

● RT, OT, PT

● CHN, MD, pharmacist

● Home oxygen provider

● End of Life:● The village

● For the caregivers:● All of the above?

The Team

Dyspnea Management

● Pharmacologic strategies:

○ Compliance and inhaler technique, switch to nebs?

○ Opioids

○ Oxygen vs. Fan

○ Steroids – underlying causes

○ Adjuvant medications:

Anxiolytics

Antidepressants

Neuroleptics (Methotrimeprazine, Chlorpromazine)

Opioids

● Studied extensively○ Individual studies

○ Cochrane review : Opioids for the palliation of breathlessness in terminal disease

Cochrane Database Syst Rev. 2001;(4)

● Oral and parenteral opioids for palliation of end-stage diseases useful in Cochrane review○ 18 RCTs

○ 9 nebulised, 9 oral or parenteral

● Strong evidence for systemic, not for nebulised

Opioids – How they Work

● Multiple proposed mechanisms:

● Lessen effects of arterial carbon dioxide (pCO2) levels and oxygen (pO2) levels on ventilation○ In medullary respiratory center

● Reduction in oxygen consumption at rest and exercise

● Altered central perception of dyspnea

● Preload/vasodilatory effects○ Cardiac patients

● Sedating effects

Opioids

● They are pretty safe○ No evidence to suggest that responsible use causes respiratory

compromise (O2 saturations, gas exchange abnormality)

● Start low and go slow○ Short-acting, to start○ Think of side effects (elderly, frail, organ dysfunction)○ Opioid naive: lowest doses (titrate), PRN vs. Q4h○ On opioids: increase the dose overall vs. Increase PRN

25-50% reasonable and common, may need more

Do not allow suffering.

•Jennings, A-L et al. Thorax. 2002;57(11):939-44Clemens, KE and Klaschik, E. J Pain Symptom Manage 2007;33:473-81Estfan, E et al. Palliat Med. 2007;21(2):81-6

Opioids – Mr. F

● Using oxyNEO 80 mg po tid

● Uses 4-6 BTD per day of 30 mg for pain

● Increased dose to 100 mg po tid.○ BTD 30 mg po q1h PRN

● Instructed to use BTD for incident dyspnea ○ Early am, shower, dressing

● Remarkable QOL improvement○ CHN, home OT, smoking cessation, social work, education for wife re: acute

episodes, community DNR, close follow up

Asks about home O2...thoughts?

Oxygen

Effect of palliative oxygen versus room air in relief of

breathlessness in patients with refractory dyspnoea: a double blind, randomised controlled trial

○ The Lancet - 4 September 2010 ( Vol. 376, Issue 9743, Pages 784-793 ) DOI: 10.1016/S0140-6736(10)61115-4

● Take home: 239 palliative patients in 9 centers randomized to oxygen (2L, >15 h/day) by nasal cannula or room air via nasal cannula. Pt’s were NOT hypoxemic at baseline. Oxygen offered no benefit compared to room air. Other studies looking at fan vs oxygen found equivocal benefits. This is for NON-HYPOXEMIC pts.

● What about our patient?

The Benzo story

● Opioids have been extensively studied – We know they are the first line

● Benzodiazepines have also been studied

● How many of you use benzo’s routinely and WHY?

● Cochrane review of benzo’s for malignant and non-malignant disease states – 2011 edition○ Metastatic cancer, COPD (severe stages), CHF, MND, IPF

The Review – Benzo’s

● Authors’ conclusions:

○ There is no evidence for a beneficial effect of benzodiazepines for the relief of breathlessness in patients with advanced cancer and COPD.

○ There is a slight but non-significant trend towards a beneficial effect but the overall effect size is small.

○ Benzodiazepines caused more drowsiness as an adverse effect compared to placebo, but less compared to morphine.

○ Consider benzodiazepines as a second or third-line treatment within an individual therapeutic trial

○ Need for well-conducted and adequately powered studies.

The Benzo Story

● What is clear:

● Anxiety exists in our patients

● Anxiety may be present in dyspneic patients○ Especially towards EOL

○ Try other non-pharmacologic methods as well

● The goal is for reduction of anxiety○ Not necessarily to reduce dyspnea overall

○ Not a first line treatment for dyspnea

● If these medications are used, consider:○ Intermittent anxiety with dyspnea (low doses)

○ Need for titration to moderate or high doses

○ Exception: Midazolam added to opioids

Case – Mr. F

● Re-admitted to hospital twice since his visit

● Increasing episodes of acute dyspnea○ Plan in place:

○ Call CHN

○ Use BTD Oxycodone

○ Had Sufentanil 25-50 mcg to use PRN as well

○ Lorazepam 0.5-1 mg q4h PRN for anxiety, if present

● Second admission with clear deterioration

● Somnolent, intermittent dyspnea alleviated with increasing opioids

● Resistant PNA, goal of care comfort

● Admitted to PCU with worsening dyspnea

Case – Mr. F

● Continued with difficult to manage dyspnea ○ COPD, muscular weakness (most pts get low MIP)

● Changed to Hydromorphone (for parenteral route)○ Was on OxyNEO 300 mg/d (450 mg/d OME) – increased 25%○ Put on HM 9-10 mg subcut q4h regular

● Addition of neuroleptic○ Nozinan 5 mg subcut q4h regular

● Breakthrough dyspnea○ Initiated midazolam infusion starting at 0.5-1 mg /hr and titrated to 3 mg/hr

infusion

● Dyspnea improved and passed away 24-h after infusion started

Respiratory Tract Secretions

● Usually within last 1-2 d of life● Distressing symptom for family/friends

● Excessive secretions may be seen in:○ Lung cancer (tumour debris)○ Pneumonia (exudate)○ Hydrated patients (?)○ Prolonged EOL course ○ Pulmonary edema

● Try positioning, mouth care, cessation of IV’s, feeding if appropriate

● Avoid deep suctioning● Anticholinergic medications

Dyspnea - Other

● EOL management may include:○ increased frequency/dose of opioids/route change○ control secretions

Scopolamine 0.3-0.6 q1h PRN subcut or patchGlycopyrrolate (max 1.8 mg/d), less agitationAtropine 0.4-1 mg q4h and PRNExpectorants: nebulized saline or bronchodilators

○ Anxiety: lorazepam subcut, frequency as per pt needs○ Terminal delirium: Methotrimeprazine (Nozinan)○ If resistant dyspnea: infusions of midazolam +/- opioid

● A Multidisciplinary team approach○ For both the patient and his family

Summary

● Assess the patient○ History, investigations○ Severity○ Fears

● Look for a treatable cause

● Palliation of symptoms○ Opioids/adjuvants○ Anxiety?○ Oxygen?○ Non-pharmacologic approach

● Supports ○ Home care○ Pulmonary Rehab (eg. COPD)○ Walking aids (OT)

● Re-assess for increasing treatments over course of the illness○ Need for parenteral drugs○ Need for hospitalization○ Changes in goals of care○ midazolam

Additional Resources

● http://www.health.gov.bc.ca/pharmacare/outgoing/palliative.html -BC palliative benefits

● Paul A. Kvale, Michael Simoff and Udaya B. S. Prakash: http://chestjournal.chestpubs.org/content/123/1_suppl/284S.full.html and http://chestjournal.chestpubs.org/content/123/1_suppl/312S.full.html - Chest Palliative care in Lung cancer

● American Lung Association: http://www.lungusa.org/

● ATS: Palliative care for patients with respiratory illnesses. Am J Respir Crit Care Med Vol 177. pp 912–927, 2008 DOI: 10.1164/rccm.200605-587ST. Internet address: www.atsjournals.org