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
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