MANAGEMENT OF DYSPNOEA EFFECTIVE INTERVENTIONS

DR. YEAT CHOI LING PALLIATIVE MEDICINE PHYSICIAN HOSPITAL RAJA PERMAISURI BAINUN IPOH 2nd JUNE 2012

What is Dyspnoea?

A subjective experience of breathing discomfort that vary in intensity, deriving from interaction among multiple physiological, psychological, social, and environmental factors and may induce secondary physiological and behavioural responses.
American Thoracic Society Statement1999

It can cause great distress to the patients, caregivers as well as their physicians.

Patients Experience of Dyspnoea

Can be very frightening! Fear of each breath will be ones last. Patients use words such as suffocating, choking or tightness to describe the sensation. 3 dimensions:
Air hunger the need to breath while being unable to increase ventilation Effort of breathing physical tiredness associated with breathing Chest tightness the feeling of constriction and inability to breath in and out

WHO Pain & Palliative Care Communications Program 2009

What is Dyspnoea (cont)

Objective measures e.g. RR, O2 saturation, blood gasses and lung function test may not correlate closely with the sensation of dyspnoea. In the cancer population, dyspnoea occurs more often in patients with lung cancer but not only associated with lung cancer: 46% reported breathlessness 4% had lung cancer, 5.4% had lung metastases

Dudgeon DJ 2001

Prevalence of Dyspnoea

General cancer population at diagnosis: 15-55%

Prevalence increases closer to death, up to 70% cancer patient experiencing dyspnoea in the last 6 weeks of life.
Reuben 1986

Incidence of dyspnoea in advanced non-malignant diseases:

COPD: 90-95% Heart disease: 60-88% AIDS: 11-62% Renal disease: 11-62%

Anxiety and Dyspnoea

Anxiety may contribute to dyspnoea but may also arise from dyspnoea.
Dudgeon 1998; Driscoll M et al. 1999

Anxiety can aggravate dyspnoea leading to a progressive spiral of exacerbated breathlessness and greater psychological distress.
WHO Pain & Palliative Care Communications Program 2009

Mdm AZ/51/teacher
Has been diagnosed to have breast cancer with lung metastases and pleural effusion. Referred to Palliative Care Team for continuing management. Upon review, she was on N/P O2 3L/min, breathless with RR 40/min. ECOG 4. Lungs: Right pleural effusion.

Mdm AZ/48/housewife (cont)

Right

pleural tapping was done. She felt better but still dyspnoeic at rest, worsen with exertion.

Mdm AZ/48/housewife (cont)

Started on aq. morphine 3mg 4hrly and PRN, with bisacodyl 2tabs on. However, noted patient refused to take morphine. My husband told me not to take morphine Morphine causes confusion Explanation and reassurance!

Mdm AZ/48/housewife (cont)

Breathless score reduced from 7/10 to 4-5/10. Not drowsy or sleepy. No nausea/vomiting. Has hard stool. Subsequently, aq. morphine was increased to 5mg 4hrly and PRN. Sy. Lactulose 15ml on was added. Able to have art therapy session with occupational therapist. Good appetite!

Mdm AZ/48/housewife (cont)

A week later later c/o severe lethargy with giddiness. Noted pallor. Transfused 2 pints PC. Able to sit on chair for hour and spend quality time with family.

The Principle - Treat The Reversible Causes

It is important to reverse what is reversible depending on the patients physical and psychological condition and personal preferences.

Pre-existing causes

Cause of Dyspnoea Infection Asthma / COAD Cardiac Failure Radiation induced lung fibrosis

Treatment Options Antibiotics , chest physiotherapy Bronchodilators, corticosteroids Diuretics Corticosteroids

Direct causes from Malignancy

Causes of Dyspnoea Treatment Options

Large airway obstruction

Lung parenchymal damage

RT, brachytherapy, laser therapy, stent, corticosteroids Opioids, oxygen

Lymphangitis carcinomatosis Corticosteroids, opioids, oxygen Pleural Effusion Pleural drainage / Pleurodesis Pericardial Effusion Pericardiocentesis SVC Obstruction Corticosteroids, radiotherapy, stent

Indirect causes from Malignancy

Causes of dyspnoea Ascites Cachexia and muscle weakness Pulmonary embolism Anemia Treatment options Paracentesis, diuretics Positioning, physiotherapy Oxygen, DVT prophylaxis, anticoagulation Blood transfusion

ASSESSMENT

What should be included in the clinical assessment of dyspnoea?

1.

A comprehensive history

The onset, exacerbating and relieving factors

2.

Assess the intensity of dyspnoea with a scale

To establish a baseline measurement A simple categorically (mild-moderate-severe) or numerically (0-10) scale can be used.

3.

Assess concomitant physical and psychological symptoms

To evaluate its impact on quality of life

4.

Physical examination

To look for possible causes such as a pleural effusion or an arrhythmia

Useful Tests

Investigations should be carefully selected to guide specific treatment. The burden/benefit of the intervention for the patient needs to be evaluated. 1st line investigations include Hb, O2 saturation by oximetry and CXR. Oximetry is non-invasive, enables us to differentiate whether the patient is hypoxemic or not.

SYMPTOMATIC MANAGEMENT

It is often not possible to reverse all causes of dyspnoea in

patients with advanced cancer.

At this point, dyspnoea is refractory and the primary goal should be symptom palliation to decrease the sensation of dyspnoea.

Clinical Symptomatic Management

Effective management requires both pharmacological and nonpharmacological approaches. Pharmacological intervention Opioids Benzodiazepines Inhaled drugs Oxygen Non-pharmacological interventions Positioning The fan Breathing techniques Anxiety-reduction training Pulmonary rehabilitation Non-invasive ventilation

PHARMACOLOGICAL

MANAGEMENT

Opioids

There is significant positive effect of opioids (oral and parenteral routes) on the sensation of breathlessness (P = 0.0008).
Jennings et al 2002

No evidence of respiratory depression (measured by RR, O2 saturation or levels of CO2) when morphine is carefully titrated for dyspnoea. No excess mortality demonstrated with the use of opioids in any studies.
Sara Booth 2008

Opioids (cont)

For opioid nave patients, a starting dose of mist. morphine 2.5-5 mg is a reasonable choice.

E.g. mist. morphine 2.5mg 4hrly mist. morphine 2.5mg PRN for breakthrough dyspnoea

It is reasonable to increase the dose of regular morphine, orally or subcutaneously, by 2550% to control dyspnoea. It is important to monitor the side effects of drowsiness and RR during opioid titration.
Kin-Sang Chan et al 2004

Benzodiazepines (bzd)

Bzd enhance the action of the neurotransmitter GABA (Gamma Amino Butyric Acid) and reduce anxiety. No evidence that bzd modify the sensation of dyspnoea as there is with opioids, but they are widely used, often empirically for anxiety. Bzd may improve mood in patients with dyspnoea and help to lessen the intensity of the sensation.

Benzodiazepines (cont)

Doses for oral bzd:

Po diazepam 2 mg -5 mg on Sl/po lorazepam 0.5 - 1 mg prn

Midazolam at low doses in addition to morphine may be used at the end of life (EoL): sc 510 mg in 24 h with 2.55.0 mg PRN.
Sara Booth et al 2008

Side effects bzd including delirium, falls and severe sedation. Haloperidol may be used when patient fear is prominent at the EoL.

Nebulised Drugs

Saline

May be helpful for breathlessness or to aid expectoration Limited evidence but minimal risk

Bronchodilaotrs

Consider a trial of bronchodilators e.g. nebulised salbutamol 2.5mg tds

May relieve dyspnoea in cancer patients. No benefit so not for routine use

Frusemide

Opioids

The Myth of Palliative Oxygen

Currently, no evidence shows palliative O2 relieves the sensation of dyspnoea in cancer patients unless they have hypoxemia (O2 Sat <90%), although the use of O2 remains a common practice. Cochrane review showed no overall improvement of breathlessness in cancer patients when O2 breathing was compared to air breathing.
Cranston JM et al 2008

A small meta-analysis showed O2 did not provide symptomatic benefit for mildly- or non-hypoxemic patients with cancer.
Uronis HE et al 2008

The Myth of Palliative Oxygen (cont)

Adverse effect of O2 therapy:

Worsens dry mouth and nostril, with a risk of nosebleeds from the nasal cannula Reinforces sick role Barrier to close contact Costly Hinders mobility due to rapid dependence The need to rely on a machine

Therefore, it should not be a knee jerk reaction to start it.

The Role Of Corticosteroids

Corticosteroids work by decreasing inflammation in the respiratory tract. Corticosteroids are useful in:

upper airway obstruction related to the tumor radiation pneumonitis lymphangitis carcinomatosis superior vena cava syndrome

Use cautiously because of side effects when used for long periods e.g. hyperglycaemia, proximal myopathy and psychotropic effects.

Oncology Interventions

Dyspnoea due to lung parenchymal damage from infiltration, lymphangitis carcinomatosis or recurrent malignant effusion may be treated with palliative chemotherapy. Particularly useful in chemosensitive tumours such as breast, lung, colon cancers and lymphoma. Bronchial obstruction causing dyspnoea may also be treated with palliative radiotherapy.

NON-PHARMACOLOGICAL INTERVENTIONS

Best Position
The ones that need the least energy or effort Being tense in the body and gripping things wastes energy and O2

The Fan
Facial cooling in the areas supplied by the CN V2 and V3 will reduce the sensation of breathlessness. It is simple to use, no adverse effects, cheap and small. There was significant improvement in dyspnoea with handheld fan.

Galbraith 2007

Breathing Techniques & Activity Pacing

Breathing control

Diaphragmatic and pursed-lip breathing improved dyspnoea in COPD patients.

Hochstetter et al 2005

Activity pacing

Anxiety Reduction Training

Relaxation

E. g. progressive muscular relaxation, visualization and guided imagery.

Patients with cancer-related dyspnoea often too ill both mentally and physically to complete cognitive or behavioural programs.

Cognitive-behavioural therapy

Psychosocial support

Patient and Family Education

The Breathlessness plan: 1. Listen to patient (and their carers) experience during a dyspnoeic episode, to explain and address their fear. 2. Write a dyspnoea plan with them to anticipate the possibility of a respiratory failure crisis. This approach can have an immediate impact on patient anxiety as patients and carers start to exert some control over a difficult situation.

Dyspnoea At The Very End of Life

Constant calming presence (education for carers is important). Just be there! Increased air movement near face Nurse patient in appropriate position Good general care - bowels, mouth, skin, pain etc Convert or start opioids as infusion Add midazolam if anxious or panicky; Haloperidol for fear. May need to increase sedation Dry secretions if needed Prescribe crisis drugs Support to both caregivers and staffs

References
1.

Sara Booth et al. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy. Nature Clinical Practice Oncology February 2008: vol 5 :no 2. Elaine Cachia et al. Breathlessness in cancer patients. European Journal of Cancer 2 0 0 8: 44: 1116 1123. Jennings AL et al. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database of Systematic Reviews 2001, Issue 3. Paul N. Lanken et al. An Official American Thoracic Society Clinical Policy Statement: Palliative Care for Patients with Respiratory Diseases and Critical Illnesses. American Journal Of Respiratory And Critical Care Medicine 2008:Vol 177. Kin-Sang Chan et al. Oxford Textbook Of Palliative Medicine 4th edition: Palliative medicine in malignant respiratory diseases. Pg 588-618. Cranston JM et al. Oxygen therapy for dyspnoea in adults. Cochrane Database of Systematic Reviews 2008, Issue 3. HE Uronis et al. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: a systematic review and metaanalysis. British Journal of Cancer 2008: 98: 294 299. Bausewein C et al. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of Systematic Reviews 2008, Issue 2. Solano JP et al. A Comparison of Symptom Prevalence in Far Advanced Cancer, AIDS, Heart Disease,Chronic Obstructive Pulmonary Disease and Renal Disease. Journal of Pain and Symptom Management January 2006; Vol. 3; No. 1; 58-69. Strategies for the palliation of dyspnoea in cancer. WHO Pain & Palliative Care Communications Program 2009; Vol. 2; Nos 1-2. Quinten C, Coens C, Mauer M, et al. An examination into quality of life as a prognostic survival indicator. Results of a metaanalysis of over 10,000 patients covering 30 EORTC clinical trials. J Clin Oncol 2008; 26 (15S): 9516. Zhao I, Yates P. Non-pharmacological interventions for breathlessness management in patients with lung cancer: a systematic review. Palliat Med 2008; 22(6):693-701. Currow DCet al.. Do terminally ill people who live alone miss out on home oxygen treatment? An hypothesis generating study. J Palliat Med 2008; 11(7): 1015-1022. Currow DC, Agar M, Smith J, Abernethy AP. Does palliative home oxygen improve dyspnea? A consecutive cohort study. Palliat Med 2009; 23(4): 309-316. Klemen KE et al. Is there a high risk of respiratory depression in opioid nave palliative care patients during symptomatic therapy of dyspnoeawith strong opioids. J Palliat Med 2008; 11(2);204-216. Abernethy AP et al. Randomized, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnea. BMJ 2003; 327(7414):523-528. Clemens KE, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer 2009; 17(4): 367-377. Mahler DA et al. American College of Chest Physicians Consensus Statement on the Management of Dyspnea in Patients With Advanced Lung or Heart Disease. CHEST 2010; 137( 3 ): 674 691.

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THANK YOU