Palliative Care: Shortness of Breath and Secretions - PowerPoint Presentation

Slide1

Palliative Care:Shortness of Breath and Secretions

Hong-

Phuc

Tran, M.D.Slide2

Learning Objectives

Understand

pathophysiology

of dyspnea

Learn how to evaluate dyspnea

Understand reversible causes / potential contributors of shortness of breath

Manage shortness of breath in terminally ill patientsSlide3

Introduction

Shortness of breath is common in terminally ill patients

“Death rattle” (noisy breathing) occurs in 23-92% of dying patients

Patients lose ability to clear secretions as

mentation

worsens

Appropriate management of excessive secretions is important in providing palliationSlide4

Pathophysiology of Dyspnea

Multifactorial

Increased work of breathing

Chemical effects

Medullary

chemoreceptors

sense

hypercapnea

Carotid and aortic body

chemoreceptors

sense hypoxemia

Neuromechanical

association

Mismatch between what brain desires for respiration and sensory feedback brain receivesSlide5

Evaluation of Dyspnea

Patient’s self-report is most reliable measure

Can have dyspnea with normal O2 saturation

Physical exam findings

Accessory muscle use

Tachypnea

Rhonchi, crackles, decreased breath sounds, stridor

Cyanosis (central or peripheral)Slide6

Examples of Some Reversible Causes / Potential Contributors of Shortness of Breath

Bronchospasm

Pleural effusion

Anemia

Airway obstructionSlide7

Management of Shortness of Breath (1)

First, treat underlying, reversible causes (if any)Slide8

Examples of Management of Some Reversible Causes/Potential Contributors of Shortness of Breath

Bronchospasm

Albuterol

,

ipratropium

, steroids

Pleural effusion

Thoracentesis

,

pleurodesis

, diuretics, catheter drainage

Anemia

Transfusion

Airway obstruction

Steroids, Clean out

tracheostomy

tube (if present)Slide9

Management of Shortness of Breath (2)

After treating reversible causes (if any), then treat symptomatically

Pharmacologic

Opioids

Benzodiazepines

Anticholinergics

Non-pharmacologicSlide10

Opioids (1)

Most effective for alleviating dyspnea

Exact mechanism unclear but thought to alter perception of dyspnea

Common Routes: oral,

parenteral

Unlikely to hasten death or cause addiction if adhere to dosing guidelinesSlide11

Opioids (2)

Opioid naïve patients

Start with Morphine 10 -15mg

po

q1hr

prn

or morphine 5mg SC q 30min

prn

Titrate to patient’s relief using standard opioid dosing guidelines

Opioid non-naïve patients

Increase opioid dose by 25%

Titrate to patient’s relief using standard opioid dosing guidelines

Once chronic dyspnea controlled, provide extended release formulation and short acting formulation

Short acting formulation: 10% of total dose of same opioid in 24 hr period, offered at q1hr

prnSlide12

Benzodiazepines (1)

Can relieve dyspnea associated with anxiety

Potential side effects, especially in elderly patients

Increased risk of confusion, falls

Can use conjunction with opioids without causing respiratory depression when dosing guidelines followedSlide13

Benzodiazepines (2)

Common routes: oral, sublingual, subcutaneous

Example of dosing for dyspnea

Lorazepam 0.5 mg

po

/ SL q 1 hr

prn

, titrate to patient’s relief

Once total dose in 24 hr period determined, then can give 1/3 of total dose q8hrs Slide14

Anticholinergics (1)

Dries excessive secretions

Effective for patients with weak cough reflex

Examples: Atropine,

Hyoscyamine

(

Levsin

), Scopolamine,

Glycopyrrolate

(

Robinul

)

Atropine,

hyosyamine

, scopolamine are equally effective in treatment of death rattle

Effectiveness of medications better at lower initial rattle intensity Slide15

Anticholinergics (2)

Atropine 1%

ophthalmic

drops

1-2 drops SL every 1 hr

prn

Scopolamine

1-3

transdermal

patches q72hrs

0.1-0.4 mg SC / IV q4hrs

10­80mcg/hr by continuous IV or SC infusion

Hyoscyamine

0.125 mg PO / SL q8hrs

prn

Glycopyrrolate

0.4-1.0 mg daily by SC infusion

0.2 mg SC / IV q4-6hrs PRN Slide16

Non-pharmacologic Interventions

Educate patients, families/caregivers

Repositioning

Turning patient on side, Elevate head of bed

Suctioning

Gentle, anterior (not deep) suctioning

Increase airflow

Fans, open windows, oxygen nasal

cannula

Stimulates V2 branch of trigeminal nerve, which has central inhibitory effect on dyspnea

Reduce room temperature without making patient too cold

Behavioral techniques

Relaxation, DistractionSlide17

References & Suggested Readings

EPEC (Education for Physicians on End-of-Life Care) :

http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/module-3

Mercandante

S,

Villari

P,

Ferrera

P. Refractory death rattle: deep aspiration facilitates the effects of

antisecretory

agents. J Pain Symptom Manage. 2011 Mar;41(3):637-9.

Pantilat

SZ and Isaac M. End-of-life care for the hospitalized patient. Med

Clin

North Am. 2008; 92(2): 349-70.

Quaseem

A et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Jan 15;148(2):141-6.

Shinjo

T, Okada M. Atropine 

eyedrops

for death rattle in a terminal cancer patient. J

Palliat

Med. 2013 Feb;16(2):212-3.

Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database

Syst

Rev. 2008 Jan 23;(1):CD005177

Wildiers

H et al. Atropine,

hyoscine

butylbromide

, or scopolamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manage. 2009 Jul;38(1):124-33