Dyspnea in Palliative Care

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					Dyspnea in Palliative Care

        Kittiphon Nagaviroj, MD
     Department of Family Medicine
         Ramathibodi Hospital
 Objectives:
• To increase the participants awareness of the prevalence
  of this devastating symptom.
• To review the common causes of dyspnea in the palliative
  care population.
• To summarize available etiologic and management for
  dyspnea.
          What is “Dyspnea”?
• Subjective experience of discomfort in breathing
  that consists of qualitatively distinct sensations
  that vary in intensity.
                            American Thoracic Society (1999)



• It arises from interactions among physiological,
  psychological, social and environmental factors
Multidimensional aspects of symptoms in palliative care

                               Mechano-receptors
         Production            Chemo-receptors
                               Respiratory centers

                               Modulators:
                                  -Anxiety-depression
         Perception
                                  -Somatization
                                  -Opioids

                               Intrapsychic
         Expression            Beliefs
                               Cultural



         Assessment + Treatment
                                    Ripamonti et al, JPSM 1997;13:220-232
               How common?
• a Canadian study found that out of 923 cancer
  out-patients, 46% reported breathlessness but
  only 4% had lung cancer and 5.4% had lung
  metastases

• Cancers in which at least 50% of patients reported
  breathlessness included lung, lymphoma, head
  and neck, genito-urinary and breast.
                  Case example
• 49-year-old gentleman was diagnosed with metastatic
  non-small cell cancer of the lung two months ago.

• Hx: Increased shortness of breath over the last few days,
  no cough, no fever, no hemoptysis, mild constant achy
  pain in the middle of the chest (no radiation, no incident
  pain, no neuropathic component)

• He received radiotherapy to right side of his chest as well
  as the mediastinum two weeks ago.

• Previously he was healthy. No underlying diseases.
  20-pack-year smoking Hx. No Hx of EtOH.
               Physical Exam
• Vital signs: T 37 c, P 100/min, RR 30/min, BP
  110/70, Oxygen sat 88% (room air)
• alert and well cooperated, using accessory
  muscles to breath, mild pallor, pitting edema 1+ in
  both lower extremities, no signs of DVT
• CVS: JVP 2 cm above sternal angle, normal heart
  sounds, no murmur audible
• RS: clear, no crackles or wheezing
• Abdomen: Shifting dullness and fluid thrill
  negative, liver and spleen not palpable
How would you assess dyspnea in
        this patient?
             Assessment tools
• Most used in non cancer patients with chronic dyspnea.
• No single tool takes into account all the different
  components of dyspnea.
• Choice of tool according to the purpose of the
  assessment.
• Should not worsen patient’s QOL (burdensome,
  complicated tools).
• VAS and NRS : useful in daily assessment
  and assessment of therapies.
• No correlation between dyspnea and
  objective measurements (PFT, oxygen
  saturation).


• No correlation with respiratory effort (use of
  accessory muscles, respiratory rate, laboured
  breathing)
            Assessment scores
• ESAS: Pain 2/10, Tiredness 7/10, Depressed 6/10,
  Anxiety 6/10, Appetite 5/10, Well-being 7/10, SOB
  9/10

• MMSE 29/30

• PPS 40%
         Psychosocial Hx
• He was a financial consultant before this illness.
• Married, 2 teenage sons ( 16 and 13)
• Very supportive wife and family
• He is having difficult time coping with his
  functional decline.
• He also stated that he doesn’t want to “choke to
  death”.
What are the possible causes
  of the dyspnea in this
          patient?
Conditions Resulting in Dyspnea
  • Dyspnea Caused Directly by Cancer

  • Dyspnea Caused Indirectly by Cancer

  • Dyspnea From Cancer Treatment

  • Dyspnea Unrelated to Cancer
  Dyspnea Caused Directly by Cancer
• Pulmonary parenchymal involvement (primary or
  metastatic)
• Lymphangitic carcinomatosis
• Intrinsic or extrinsic airway obstruction by tumor
• Pleural tumor
• Pleural effusion
• Ascites
• Hepatomegaly
• Phrenic nerve paralysis
Dyspnea Caused Indirectly by Cancer

 •   Cachexia
 •   Electrolyte abnormalities
 •   Anemia
 •   Pneumonia
 •   Pulmonary aspiration
 •   Pulmonary emboli
 •   Neurologic paraneoplastic syndromes
 Dyspnea From Cancer Treatment
• Surgery
• Radiation pneumonitis or fibrosis
• Chemotherapy-induced pulmonary toxicity
 (Bleomycin, Methotrexate, Mtomycin, Busulfan)

• Chemotherapy-induced cardiomyopathy
 (Doxorubicin, Daunorubicin, Mitoxantrone)

• Radiation-induced pericardial disease
Dyspnea Unrelated to Cancer
•   Chronic obstructive pulmonary disease
•   Asthma
•   Congestive heart failure
•   Interstitial lung disease
•   Pneumothorax
•   Anxiety
•   Chest wall deformity
•   Obesity
•   Neuromuscular disorders
•   Pulmonary vascular disease
Pre-existing diseases:
• Usually forgotten as contributors to the
  development of dyspnea.
• Treatment not always present/ maximized.
• Many irreversible but yet treatable.
• COPD a contributor in 50% of the lung and head
  and neck cancer population.
• Therefore……Treat those contributing
  causes!!!
What types of investigations will you
             do next?
       Lab & Investigation
• EKG: Normal
• CBC : Hb 85, WBC 7.6 (N 5.5, L 2.2), Plt 350
• Chemistry: Urea 4, Creatinine 44, Na 140, K
  3.5, Cl 117, CO2 19, Albumin 30, Calcium 2.2
  Lymphangitis carcinomatosis
• Usually asymmetric and occasionally unilateral

• Chest radiographic manifestations
  – Interlobular septal thickening
  – reticular opacities
  – Nodules
  – Pleural effusion
  – Lymphadenopathy
What is your diagnosis?
          Radiation Pneumonitis
• Develop in as many as 5-15% of patients with thoracic
  irradiation

• Acute radiation pneumonitis occurs within 1-6 months
  following treatment

• Symptoms can include low-grade fever, cough, and
  fullness in the chest

• The radiographic hallmark of radiation pneumonitis is a
  diffuse infiltrate corresponding to a previous radiation
  treatment field
What is your plan of management for
         this patient? Why?
          Management
• Treat underlying causes of dyspnea –
  including co-morbid conditions!!!

• Pharmacologic treatment

• Non-pharmacologic treatment
             Disease-specific treatments
Diseases/Conditions            Treatments
• Central airway obstruction   • Endoscopic interventions;
                                  debulking and stent placement,
                                  palliative radiation

• Pleural effusion             • Thoracentesis, Indwelling
                                 pleural catheter, Pleurodesis
                                 after lung re-expansion

• Pneumonia                    • Appropriate antibiotic, relief of
                                 CAO if present

• Lymphangitis                 • Chemotherapy + Steroid
  carcinomatosis
              Disease-specific treatments
Diseases/Conditions         Treatments
• Pulmonary embolism        • Anticoagulation; if not
                               anticoagulation candidate, IVCF


• Pulmonary edema           • Diuresis


• Drug toxicity             • Stop presumed offending drug,
                              steroids if significant respiratory
                              compromise

• Pericardial effusion      • Pericardiocentesis
      Cancer-directed treatment
• Both chemoRx and RT can reduce dyspnoea but
  the response rates are variable and often less
  than those for palliating cough and haemoptysis
Pharmacologic treatments
                   Opioids
• Mainstay of the treatment of dyspnea since the
  late nineteenth century
• a Cochrane systematic review have shown the
  benefit of opioids in managing the
  breathlessness of cancer, COPD and heart failure
• Relieve the sensation of breathlessness
• Reduce pain which may be contributing to the
  restriction of chest wall or diaphragmatic
  movements
                               Opioids
• If patient is opioid naïve, can start opioids PRN or
  ATC at same doses used for pain management.
• Class benefit, no evidence that any opioid is
  superior for dyspnea management.
• Titrate slowly!!!.
• If already on opioids for pain increase regular opioid
  by 25-50% of the 4 hourly dose.
  (Allard et al, JPSM1999;17:256-265)

  Respiratory depression from opioids: depends
  on the rate of change of the dose, previous
  opioid exposure and route of administration
                     Nebulized opioids
• Although there are opioid receptors in the airways,
  systematic review has found no benefit of nebulised
  opioids for this symptom.
  A systematic review of the use of opioids in the management of dyspnoea. Thorax
  2002;57:939–44.
           Nebulized furosemide
• The inhalation of furosemide has been shown in
  several small, single-dose studies to result in
  bronchodilatation and reduction of breathlessness

• Effective dose is from 20-40 mg

• Mechanism of action  stimulation of lung airways
  stretch receptors and parencyhmal j-receptors,
  which modulates afferent signalling to the brain.


• Need further large RCT!!!
 Psychotropic drugs:
• Midazolam plus morphine was found to be
  more effective than Morphine or Midazolam
  alone in one trial. Navigante et al, JPSM 2006;31(1):38-47.
• Neuroleptics more widely studied than
  benzodiazepines.
• Chlorpromazine was found to be effective for
  relief of dyspnea in advanced cancer patients in
  an open-labeled trial. McIver et al, JPSM 1994;9:341-5.
  Corticosteroids:
• Effective to treat bronchospasm in asthma.
• Useful in respondent COPD patients and in acute
  exacerbations of COPD.
• Used in cancer patients with SVCS, Radiotherapy-
  induced fibrosis, lymphangitic carcinomatosis,
  airway obstruction.
• Empiric, no RCT in cancer patients.
• Best agent and appropriate dose not identified yet.
Bronchodilators:

• Indicated in cancer patients with evidence of air
  flow obstruction.
• Beta-2 agonists produce less bronchodilation in
  COPD as compared to asthma.
• Combination of a Beta-2 agonist and an
  anticholinergic agent commonly used.
• ATC and PRN dosing.
Anticholinergic drugs:
• To reduce the incidence of respiratory
  secretions and the so-called “death rattle”.
• Two agents available:
  -Glycopyrrolate 0.3 mg sc ATC and PRN (does
  not cross blood-brain barrier).
  -Scopolamine 0.4 mg sc ATC and PRN (does
  cross blood-brain barrier).
• Scopolamine slightly more effective according
  to one trial.
Non-pharmacologic
  Interventions
                Oxygen therapy
• Patients who have significant (<90%) de-saturation at rest
  or on exertion should be offered a trial of oxygen

• Little evidence for giving supplementary oxygen unless
  the patient desaturates to below 90%, or is very anaemic

• Be careful in COPD  risk of hypercapnic respiratory
  failure

• Best delivered by nasal cannulae, unless high flow rates
  are required
Other interventions:

     • Breathing through pursed lips.
     • Repositioning.
     • Breathing retraining.
     • Open window.
     • Fan aimed at the face.
Complementary therapies:
Modalities supported by RCT:
• Relaxation techniques.
• Counseling.
• Teaching of coping strategies.
• Acupuncture.
• Acupressure.
         Palliative sedation
• Last resort!!!.
• Provides relief for patient, families and staff.
• Exhaust treatment options first.
• Agent selection varies according to centers.
• Midazolam subcutaneous continuous infusion
  used by Edmonton Palliative Care Program.
• Drug association may be necessary in some
  cases.
• Dyspnea is frequently seen in our population.
• Is a “Multidimensional symptom”.
• Poor correlation between severity and
  objective measurements.
• Although subjective, can be measured with
  validated tools.
• Treat pre-existing conditions that may
  contribute to the development of dyspnea
• Interventional procedures or aggressive
  treatments may be indicated.

• Opioids are SAFE and are the mainstay
  of the symptomatic treatment of dyspnea.
• RCT support the use of Alternative/
  Complementary therapies.
• When dyspnea becomes refractory, Palliative
  Sedation is an appropriate option.

				
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posted:12/4/2011
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