Palliative care workshop for EM residents July 29 2015 Disclosures No disclosures Case CTAS 1 to the resus room mid 70s female in acute respiratory distress Has been placed on O2 by FM by EHS but despite this still only has O2 ID: 229330
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Slide1
Breathlessness in the ED
Palliative care workshop for EM residents
July 29, 2015Slide2
Disclosures
No disclosuresSlide3
Case
“CTAS 1 to the
resus
room”
mid 70s female in acute respiratory distress
Has been placed on O2 by FM by EHS but despite this still only has O2
sats
of 88% and significant WOB
Hx
of severe COPD, on home O2 and max medical therapy. Frequent hospitalizations in past 3 months and steadily declining, now fully bed bound at home due to symptoms
What do you do next?Slide4
What is dyspnea
?Slide5
“I feel like I am suffocating.”
“I am afraid and feel like I am drowning.”
“I have a tightness in the chest”Slide6
Total dyspneaSlide7Slide8Slide9Slide10
Cancer pts: lung, GI (esophagus), Breast, ENT, lung
mets
most common to have symptoms
CHF: 65% will have some
dyspnea
COPD: 90% will have some
dyspnea
IPF
Motor diseases: ALS, MS
Any patient with a life-threatening illnessSlide11
When to think of palliative care?
C
ancer
, especially if metastatic or if lung, esophagus or ENT
cancer
A
dvanced
COPD: on home
02
CHF
with EF <25%
Other
significant co-morbidities
Recurrent
ED visits/admissions for same problem in last 3 months
Poor functional status:
ie
ECOG
3 or
4
Pt
expresses wish for comfort care or DNR
Surprise
question Slide12Slide13
Goals of Care
Concurrently treat the symptom while addressing the underlying cause (if appropriate)
Outcomes are better when a palliative approach is adopted earlier in the disease process
Once those causes are no longer treatable, managing the symptom becomes the main prioritySlide14Slide15
Non-pharmacologic options
fans directed towards face, open windows, cold compresses on face can help
pulmonary rehab
Acupuncture
breathing training (upright forward leaning position, controlled breathing, pursed-lip breathing)
relaxation strategies
walking aidesSlide16Slide17Slide18Slide19Slide20Slide21Slide22
Home O2 criteria
Arterial oxygen saturation (SpO2) less than 88% for 6 min
Ambulatory
Desaturation
to less than 88% for 1 minSlide23
O2 delivery systems
Nasal Prongs (NP) : 1-6
lpm
, 22-40% Fi02
Simple Mask (SM) : 5-12
lpm
, 35-50% FiO2
Non
Rebreather
Mask : 15lpm, 60-90% Fi02
High Flow Face Mask : up to 95 % Fi02
High Flow Nasal Prongs (HFNP) : 100% Fi02 with very high
flowrates
Bi-Level Positive Airway Pressure (
Bipap
) : set Fi02 plus
ventilatory
support ( aka non invasive ventilation )Slide24
High Flow Nasal ProngsSlide25
NIVPPSlide26Slide27Slide28
Situations to consider HFNP/
BiPAP
Time-limited trial
Goal-limited trialSlide29Slide30Slide31Slide32
Back to our case
Patient’s symptom are controlled with HFNP and
opioids
.
Goals of care are discussed with patient and family
Patient is clear that she does not want further life prolonging treatment
Symptoms are managed with
opioids
and
midazolam
Patient passes away 2 days later on the palliative unitSlide33
Summary
Determine patient’s values/goals of care
Investigate and treat underlying cause if appropriate
Oxygen has a role in palliative care, but only use it if it is helping to achieve the patient’s goals
Opioids
are main treatment for refractory
dyspnea
and will not hasten death when used appropriately
Concept of total
dyspnea
– address other factors which may be contributingSlide34