AIDS- Ethics and the Intensive Care Unit

Palliative Care Education Palliative Management of Dyspnea in HIV/AIDS Learning objectives Describe the primary causes of dyspnea at the end of life Explain the process of evaluating a patient’s dyspnea Give examples of treatments for dyspnea and their risks and benefits Consider the causes, evaluation and treatment of dyspnea in patients with HIV/AIDS Understand management of dyspnea during the last hours of life Consider a case 42-year-old HIV positive man Presents with progressive dypnea over 6 months PMH otherwise unremarkable –Physical exam normal –Cutaneous Kaposi’s Sarcoma –CXR shows… Outline Causes of severe dyspnea in palliative care Causes of dyspnea in HIV/AIDS patients Treatment options for dyspnea Dyspnea in the last hours of life Causes of dyspnea Many pulmonary and non-pulmonary diseases can cause dyspnea: –Pulmonary: COPD, asthma, pneumonia, PE, lung cancer, lymphoma, pneumothorax, pleural effusion –Non-Pulmonary: Heart failure, anemia, acidosis First step to managing dyspnea is to diagnose and treat underlying cause Some causes of dyspnea in HIV/AIDS Opportunistic Infections: PCP, Fungal, TB, Viral Pulmonary Kaposi’s Sarcoma Lymphoma HIV-Related Myopathy Initial evaluation for dyspnea History, physical examination Chest x-ray Laboratory tests: CBC, chemistries, arterial blood gas Spirometry Approach to managing dyspnea Identify the cause Treat what is treatable Manage with supportive measures What kind of life-support do patients receive? 80 70 60 COPD (n=115) Lung Cancer (n=116) Percent 50 40 30 20 10 0 Mech Vent Tube feed CPR p<0.05 all comparisons Claessens, J Am Geratr Soc, 2000 What kind of life-support do patients want? 100 80 COPD Lung Cancer Percent 60 40 20 0 Prefer Comfort Prefer DNR No Mech Vent Claessens, J Am Geratr Soc, 2000 p>0.05 all comparisons Treatment of dyspnea Oxygen Opioids Benxodiazepines Anti-depressants Non-pharmacologic measures Oxygen Many HIV+ patients with dyspnea do not have low O2 saturations However, O2 therapy may relieve symptoms of dyspnea Pro: Symptom relief, ease of use Con: Uncomfortable, burdensome, expensive Oxygen Indication for oxygen therapy: –PaO2 < 55 mmHgPaO2 55-59 + a) p pulmonale, –b) clinical right heart failure, OR c) hct > 55% –SaO2 < 89% –SaO2 89% plus a, b, or c above –Treatment of dyspnea in hospice care Opioids Primary pharmacologic therapy for dyspnea Important central effects of analgesia and euphoria that palliate dyspnea Choice of administration route (Patch, PO, parenteral) Intermittent vs. continuous dosing Pro: May be efficacious in improving breathlessness Con: Sedating, may cause respiratory depression, constipation Trials of oral opiates for dyspnea in severe COPD Author- Year Woodcock ’81 improved Johnson ’83 Light ’89 improved Rice ’87 Eiser ’91 Poole ’98 change Drug Duration dh-codeine 1 dose dh-codeine 1 wk morphine 1 dose codeine diamorph. MS-SR 1 mo 2 wk Dyspnea improved 6 wk no change no change no Manning, Resp Care, 2000; 45:1342 Other agents with little or no effect on dyspnea Nebulized opiates: –1 positive, 4 negative controlled trials Benzodiazepines: –1 positive, 3 negative controlled trials Buspirone: –1 positive trial, very small effect Phenothiazines: –1 positive, small effect; 1 negative trial Depression and anxiety in severe COPD and stage III/IV lung cancer 12 Hospital Anxiety & Depression Scale COPD Lung Cancer 10 8 6 4 2 0 Depression Anxiety p<0.01 all comparisons Gore, Thorax, 2000 Benzodiazepines Use may alleviate associated fear and anxiety Start at low dose and titrate to dyspnea reduction Once effective dose determined, schedule administration Q4-6H Variety of dosing routes available Treating depression in COPD 12-week randomized controlled trial Two groups: –Nortriptyline vs placebo N=36 –Major depression (n=33) –Residual depression (n=3) Mean duration depression 39 months Borson, Psychosomatics 1992 Nortriptyline improves mood 30 25 Hamilton-D 20 15 10 5 0 NT Entry 12 weeks NT vs Placebo p=0.01 Placebo Nortriptyline (NT) improves anxiety and somatic symptoms 60 50 40 PRAS Differential NT treatment effects: All p < 0.05 NT Entry NT 12 Weeks Placebo Entry Placebo 12 Weeks 30 20 10 0 ANXIETY PHYSICAL SX BREATHING SX Nonpharmacologic interventions Minimize anxiety-producing factors in the environment Address concerns of family members and caregivers as well as the patient Relaxation techniques Fan/cool air Schwartzstein RM, et al (1987) Am Rev Respir Dis 136:58 -61 Dyspnea in the last hours of life Same treatment modalites: oxygen, opioids, and benzodiazepines Titrate opioid dose to patient’s respiratory signs Consider anticholinergic agent for management of secretions Re-consider case 42-year-old man with HIV presents with progressive dypnea over 6 months PMH otherwise unremarkable –Physical exam normal –CXR consistent with KS Summary Dyspnea is common and disabling Identify cause of dyspnea and treat underlying cause when possible Trial of symptomatic treatments –Oxygen, opiates Recognize and treat anxiety and depression Spend time communicating with patients and family Contributors The primary author of this module is Elizabeth Knauft, MD, MS, University of Washington Department of Pulmonary and Critical Care Medicine Anthony Back, MD J. Randall Curtis, MD, MPH Frances Petracca, PhD Liz Stevens, MSW Director Co-Director Evaluator Project Manager Visit our Website at uwpallcare.org Copyright 2003, Center for Palliative Care Education, University of Washington This project is funded by the Health Resources and Services Administration (HRSA) and the Robert Wood Johnson Foundation (RWJF).