Oliver A. Cerqueira, D.O. - PowerPoint Presentation

Oliver A. Cerqueira, D.O.Assistant Professor of Internal medicineClerkship director, internal medicineOu-tulsa school of community medicine Non-pain Symptomatic Management in Palliative Care

ObjectivesApply generalized principles of symptom management to "real world" clinical scenariosChoose appropriate management for a variety of non-pain symptoms that are addressed by palliative care

Palliative Care

So, what S/Sx are out there to be addressed? Nausea & Vomiting** Dyspnea** Constipation Diarrhea Ascites/Pleural Effusions Bowel Obstruction Fatigue Singultus DepressionLymphedema/EdemaAnuriaInsomniaHot Flashes Anxiety Delirium/Confusion** Secretions Pruritus Fever Cough Anorexia/Cachexia Xerostomia Mucositis/Stomatitis Pressure Ulcers/Wound Care/Wound Odor Bladder Spasms Candidiasis

Generally, what are two ways to manage S/Sx?Non-pharmacologic/MechanicalPharmacologic Routes of Administration PO IV IM Sub-Q Buccal & SL TDPRIntranasal/Inhalation

Principles of Symptom Control Four domains of the human suffering experience: Physical Emotional Social Spiritual

Principles of Symptom ControlDo NOT overlook symptomatic management while focusing on disease-oriented care e.g. Pleuritic CP & PNA When possible, identify the underlying pathophysiology &/or mechanism Symptoms are the patient’s experience of the illness The clinician is obligated to relieve those symptoms Unrelieved suffering is demoralizing & demeaning Suffering patients may lose the will to live, become depressed & withdrawn, & decline more rapidly

Principles of Symptom ControlTreatment considerations:Anticipate predictable complications of disease states e.g. colorectal cancer patients & bowel obstruction; head & neck cancer patients & sudden exsanguination Anticipate associated complications of palliative treatments e.g. opioids & N/V, constipation, sedation, delirium Evaluate for psychosocial difficulties e.g. poor home support & complex treatment regimens; low income & medication affordability Ultimately, patient’s goals of care drive symptomatic management decisions e.g. clarity of mind vs. suffering pain Frequent re-evaluation

Nausea & VomitingOccurs 60-70% of patients with advanced cancerPrevention is key: Regular dosing of antiemetics can often prevent recurrent nausea Associated with autonomic s/sx, including pallor, cold sweats, decreased respiratory rate, & sometimes diarrhea Hypersalivation Cardiac rhythm disturbances may occur Gastric emptying is reduced in the presence of nausea – don’t assume PO medications will work, even if there is no vomiting!

Nausea & Vomiting – 4 Inputs

Nausea & Vomiting

Nausea & Vomiting – Pharmacologic TreatmentV.O.M.I.T. acronym V estibular Cholinergic, Histaminic Scopolamine, Promethazine O bstruction of bowel by constipation ( NOT mechanical obstruction) Cholinergic, histaminic, likely 5HT3 Stimulate myenteric plexus – Senna Dys M otility of the upper gut Cholinergic, histaminic, 5HT3, 5HT4 Metoclopramide I nfection, I nflammation Cholinergic, histaminic, 5HT3, NK1 T oxins stimulating CTZ Dopamine 2, 5HT3 Haloperidol, Odansetron, Prochlorperazine

Nausea & Vomiting – Pharmacologic Treatment

Nausea & Vomiting – Non-pharmacologic Ginger Root5HT3 antagonism in animal models Measures to enhance gastric emptying and decrease gastric distention Liquid diet Frequent small meals Foods low in fats & fiber, high in protein Measures to minimize other noxious or associated stimuli Cool foods Foods with a pleasant appearance & w/o odorsAcupuncture At the P6 or pericardium 6 point Produces vagal modulation & enhances 5HT3RA efficacy Cognitive—Behavioral Therapy Induces muscle relaxation & reverses autonomic arousal that accompanies ALL nausea

Delirium - Definition

Delirium – Subtype ManifestationsThree subtypes based on arousal levels & psychomotor behaviorHyperactive delirium Hallucinations, agitation, delusions, & disorientation Hypoactive delirium Decreased consciousness, somnolence In PC, is more common – up to 80% Mixed-form with alternating features

Delirium - Pathophysiology

Delirium – Risk Factors & Causes

Delirium – Risk Factors & CausesMedications are the most common identifiable causes of delirium in the hospital setting! Anti-cholinergics Sedative-hypnotics Opioids Other common causes: Metabolic derangements Infections CNS pathologyDrug/alcohol withdrawal

Delirium – Risk Factors & Causes

Delirium – Pharmacologic Treatment Benzodiazepines may cause paradoxical worsening of symptoms (possibly by a serotonergic mechanism) & should not be used first line Use lowest doses possible, especially with haloperidol as EPS side effects are dose-dependant! IV haloperidol may cause less EPS than PO When reaching maximum dosages of haloperidol, one option is to add or switch to a more sedative neuroleptic

Delirium – Non-pharmacologic

DyspneaExperienced by up to 70% of terminally ill cancer patients at some point during the course of their diseaseDiminishes functional status, social activities, QOL, & the will to live In one multi-center study from 2000, terminal sedation was prompted by dyspnea 3X more commonly than by pain The typical pattern is one of chronic dyspnea, punctuated by unpredictable, but expected, acute episodes SUBJECTIVE!! e.g. patients may be hypoxic & “look dyspneic ,” but when well-palliated, they report no sense of dyspnea Patient self-report is the only accurate measure of dyspnea

Dyspnea – Multidimensional

Dyspnea – Physiology & Pathophysiology The sensory cortex receives copies of respiratory motor commands arising from the medulla or motor cortex & sensory information from peripheral chemoreceptors & mechanoreceptors Dyspnea occurs if the degree of motor output required is perceived to be unsustainable or disproportionate to the sensory information received

Dyspnea – Generalized Treatment MeasuresAddress the underlying etiology or etiologies, if at all possibleReduce the need for exertion Repositioning, usually to a more upright position Keep the compromised lung down in unilateral pulmonary disease Improve air circulation – open doors & windows, use a fan Avoid strong odors, fumes, & smoke Identify & avoid any triggers that precipitate or worsen dyspnea

Dyspnea – OpioidsFirst-line therapyCan be used alone or aside reversible etiologies Most beneficial for dyspnea at rest Evidence has repeatedly shown that opioids can be safe & effective at controlling dyspnea in several clinical populations, including COPD, CHF, pulmonary fibrosis, & cancer Respiratory depression is uncommon when titration is appropriate & is almost always preceded by drowsiness/sedation Hold Parameters

Dyspnea – OpioidsReversal agents (i.e., naloxone) should only be used in the setting of life-threatening opioid toxicityMost published trials studied morphine, but trials of other opioids such as fentanyl, M6G, & hydromorphone suggest a class effect Most common adverse effects experienced in this population: Constipation, nausea, sedation

Dyspnea – OpioidsMechanisms by Which Opioids May Reduce Dyspnea:Decreased metabolic rate and ventilatory requirements Reduced medullary sensitivity & response to hypercarbia or hypoxia Alteration of neurotransmission within medullary respiratory center Cortical sedation (i.e., suppression of respiratory awareness) Analgesia reduction of pain-induced respiratory drive Vasodilation (i.e., improved cardiac function) Anxiolytic effects

Dyspnea – Opioids Opiate-naïve older age or patients with CKD Consider reducing starting dose by ½ Avoid morphine in renal disease if possible DOE or dyspnea with movement Give 30 minutes prior to activity If on stable IR dosage, consider trial of LA as baseline with IR PRN in between doses

Dyspnea – Other TreatmentBenzodiazepinesAddresses concomitant anxiety No evidence that there is a direct benefit Oxygen Often patients report improved dyspnea, even when not hypoxemic or when they remain hypoxemic ? Placebo effect due to inherent medical symbolism Some studies have demonstrated dampening of dyspnea due to stimulation of the trigeminal nerve, V2 branch Depending on patient preference, generally avoid face masks

Dyspnea – Pursed Lip Breathing

The End!!

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