04 19 05 by U115Ts


									Controlling COPD Symptoms
     at the End of Life

    Helen M. Sorenson MA RRT FAARC
Death rate per 100,000 from COPD

  CDC MMWR Chronic Obstructive Pulmonary Disease Surveillance
  Report, 1971 – 2000; August 2, 2002.
 A long course of chronic disease
  characterized by exacerbations and
  remissions, but a clear or steady decline

 When the patient gets to “last days”,
  careful attention to symptom control can
  prevent, minimize or eliminate distress –
  thus improve quality of life till time of death
        Emerging Profile of Dying COPD
           Patient ( Within a Year)
•   Best FEV1 < 30% of predicted
•   Declining performance in ADL
•   Uninterrupted walk distance < a few steps
•   1 urgent hospitalization in past year
•   Left-heart and/or other comorbid diseases
•   Older age
•   Depression
•   Unmarried
Hansen-Flaschen J. COPD: The Last Year of Life. Respiratory Care, 2004; 49(1): 90-98.
       Signs of Impending Death
            (hours to days)

Hypersomnolence      Urine production
Disorientation      Cool extremities
Irregular breathing Altered vital signs
Mottled skin        Hypothermia
Retained secretions  Interest in food
  in upper airway       and/or water
             Symptom Assessment
   Subjective nature ( self-reported)
   Clinician accuracy poor
   Symptom measurement must be considered
   Symptom measurement instruments
        MSAS – Memorial Symptom Assessment
        RSC – Rotterdam Symptom Checklist
        VAS – Visual Analog Scale (0 / 10)
        Dyspnea Assessment (Ventilator check)
Barriers to Symptom Assessment

Advanced disease accompanied by
fatigue, depression, delirium
        Difficult in patients with more than
         one symptom
        Caregivers not willing to share
        Disease itself not open to
            Severity of COPD symptoms
      3 days prior to death, per family members

Lynn J,Teno, JM et al. Perceptions by family members of the dying experience
of older and seriously ill patients. Ann of Intern Med 1997;126(2): 97-106.
Common Distressing COPD symptoms

      Management of symptoms

General principles of palliation
Determine and treat underlying cause
Relieve symptoms without adding any
 new problems
Consider if treatment is worthwhile - for
 the patient and/or family
Discuss all reasonable treatment options
     Causes of Dyspnea (COPD)
 Airway obstruction or restriction,
  hypoxemia, reduced respiratory muscle
  force (deconditioning)
 Cardiovascular – CHF, cor pulmonale
 Anxiety/fear
 Anemia
 Fluid overload
        Control of Dyspnea

 Pharmacotherapy
  Bronchodilators (COPD)
  Diuretics (CHF)
  Opioids – oral is preferred route
  Oxygen –as needed and/or
   tolerated but not monitored
            Control of Dyspnea

 Benzodiazepines - anxiolytic

 Phenothiazine (Thorazine) – antipsychotic
  which may be used for severe agitation

 Corticosteroids – anti-inflammatory side
  effects not an issue at this point
     Nebulized Opioids (Anecdotal)

Direct action of OPM on lung afferent nerves
 OPM may diminish response to hypoxia and
  hypercapnia at chemoreceptor level
 May alter perception of breathlessness
 May exert peripheral effect on opioid receptor in
 [Nebulized morphine may cause histamine-mediated
  bronchospasm during 1st nebulization]
            Control of Dyspnea

 Non-Pharmacological
   Elevate head of bed 30 (whatever works)
   Pursed-lip breathing
   Calming presence
   Relaxation therapy
   Massage therapy
   Fans ( cool air)
            COPDers and Fans
In end-stage COPD, primary ventilatory muscle
  10% efficient, secondary muscle 3% efficient.
Increased WOB, increased energy expenditure,
  increased body temp, do fans provide relief ?

Fans improve dyspnea by stimulating receptors in
 the trigeminal nerve located in the cheek and
 nasopharynx, altering the perception of
 breathlessness (Enck, Johns-Hopkins, 1994)
                Pain control
“Pain is whatever the experiencing person says
  it is, whenever the experiencing person says
  it does” McCaffery & Pasero, 1999

Symptom assessment
  VAS (0/10)
  Sad face/happy face
  Establish level of pain!
               Pain control
Most pain can be alleviated
Dosing of pain medications should be on a
 regular round-the clock basis
Analgesics wear off…delay in administration
         = exacerbation of pain
         = anxiety /fright
         = family dissatisfaction
              Cough control

Cough is a normal protective mechanism
 but can also be induced by;
    Airway disease
    Drug induced (ACE inhibitor)
    Aspiration of saliva
                  Cough control
Establish level of distress (0/10)
Educate family
Warm humidified air
Expectorants and/or mucolytics of little value
Codeine 15-30 mg oral Q4
Morphine 2.5 mg oral Q4
Nebulized lidocaine 2 mls (1%, 2% or 4%) Q6
  (wait 30 minutes post before eating – aspiration risk)
   Death Rattle - Last 24 to 48 hours
 Caused by airflow through retained secretions at
  back of throat
 Patients lethargic, comatose – unaware
 Family members find noise distressing – need to
  be educated
 Oropharyngeal suction may be done, but if it
  causes gagging or coughing, it is not palliative
 Lateral recumbent position with head elevated
  slightly may reduce pooling of secretions
    Death Rattle - Last 24 to 48 hours
Anticholinergic use needs to start early – will not dry up
  secretions already present
Drug                           Starting Dosage
Scopolamine                    0.4-0.6 mg SQ q 2-4 hours, prn
Hyoscyamine                    0.125 – 0.250 mg SL q 4-6 hrs,
Glycopyrrolate                 0.2 mg SL or SQ q 2-4 hrs, prn
Atropine                       2 mg via nebulizer q 2-4 hrs, prn
 Rousseau P. Nonpain Symptom Management in the Dying Patient
 Hospital Physician, February 2002.
• Defined as the profuse production of sputum of
  > 100mL/day
• Has been observed in patients with end-stage
  bronchioalveolar carcinoma
• Has been successfully treated with inhaled
  Indomethacin, probably by causing down
  regulation of cyclo-oxygenase
• 2 RCT (1985,1992) case studies (1999) and In-
  vivo study(1995) all indicate efficacy

< 3 days, 55% unable to eat
Common in dying patients
Check for treatable conditions
  Oral candidiasis, poorly fitting dentures,
  mouth sores, pain, nausea
Family education benefit from force feeding
Any food is acceptable worry about nutritional
Enteral – maybe, TPN not recommended
Starvation/dehydration – analgesic effect
Xerostomia associated with dehydration does
  cause discomfort – good oral care, mouth
  swabs, ice chips recommended
Mental changes can accompany
  terminal stage of illness
Causes: drugs, hypoxia, metabolic
 imbalance, urinary retention, sleep
 deprivation, poor pain control
 Treatment: If cause can be determined
Simple treatment may improve
   Confusion /Depression
Non-specific therapy
Handholding, frequent reminders of place and
Unfinished business
Addressing religious/spiritual needs
    Environment – is going home an option
              Music therapy
         Palliative Respiratory Therapy
Palliative care is comfort care! What will be
 comfortable for your patients?
   Nebulized bronchodilators?
   Oxygen therapy – device and liter flow?
   Continuous pulse oximetry?
   Chest physiotherapy?
   ABGs?
   NT suctioning?
   Patient positioning?
        What do Families Need?

Caring for dying patients necessitates caring
 for their families

 Adequate communication
 Feeling supported
 Giving good care to loved ones
               Palliative Care

 Broadening medical care to integrate
  palliative and life-prolonging interventions
  is a major challenge for health care in our
 Allied Health care professionals should be
  prepared to render comfort care at the
  bedside to our patients
                          Palliative Care
All patients with a terminal condition should be
    Access to palliative care delivered by
     knowledgeable practitioners
    Treatment that looks to quality of life as well
     as quality of care
    Information regarding the close collaboration
     between hospice and palliative care
  Clinical Practice Guidelines for Quality Palliative Care; National Consensus Project.
       Integration of Palliative Care
 Pain, symptom control, psychosocial distress,
  spiritual issues and practical needs are
 Patients receive necessary information in a
  timely and understanding manner
 Care of the patient is truly coordinated among
 Both the patient and the family are prepared for
  the dying process
Palliative Care Means

        To cure, sometimes
        To relieve, often
        To comfort, always

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