Palliative Medicine Doctors’ Meeting____________________________H - PDF document

Palliative Medicine Doctors’ Meeting____________________________HKSPM Newsletter 2007 Dec Issue 3 p 16 Case histories contributed by Dr Ng Sheung Ching and Dr Ma Chi Ming The Story of Madam C Madam C, a 72-year old retired farmer, had been suffering from right biliary papillomatosis since 2003 with extended right hepatectomy performed. Extensive liver metastases were noted since 2006 and metastatic adenocarcinoma to left lung was detected in improvement in bronchorrhea but were complicated by nausea with erythromycin and impaired renal function with indomethacin. Continuous subcutaneous infusion of hyoscine hydrobromide up to 1.6 mg per day was given with no improvement in sputum volume but resulted in excessive drowsiness. Continuous subcutaneous infusion of fentanyl and midazolam was needed to control her dyspnea and restlessness. second marriage. She was diagnosed to have polymyositis in 1997 presenting with weakness. Multiple immunosuppressive therapies had been tried including glucocorticoids, azathioprine, cyclophosphamide, cyclosporin, intravenous immunoglobulins, mycophenolate mofetil, and rituximab, but her disease progressed. She had an episode of severe pneumonia requiring intubation and subsequent tracheostomy. She was then transferred to the rehabilitation ward for convalescence. to infrequent visits from her family, and anger and frustration about her physical needs not being promptly addressed by staff. She frequently called for help with dramatic gestures and repeated call bells ringing. The multidisciplinary team attempted to address her multiple needs. The physiotherapist performed vigorous chest physiotherapy and hand function enhancement exercises; the occupational therapist designed a special chair and a foot platform to facilitate her sitting out; the Palliative Medicine Doctors’ Meeting____________________________HKSPM Newsletter 2007 Dec Issue 3 p 18 adenocarcinoma of lung at a dose 300-500 micrograms daily. 16 It is postulated to have an inhibitory action on the secretin receptors in the bronchial tree. The patient we presented above further substantiates its potential role in bronchorrhea. The Management of Sialorrhea Normal adults produce 750 to 1500 ml of saliva per day. Unlike bronchorrhea which is usually the result of excessive secretion, sialorrhea is usually due to oropharyngeal dysphagia and impaired cough effort caused by various neurological diseases, or esophageal dysphagia caused by mechanical obstruction or esophageal dysmotility. Sialorrhea may affect feeding, interfere with speech, lead to social embarrassment, induce sense of suffocation with resultant fear, and increase susceptibility to aspiration pneumonia. The management of excessive oropharyngeal secretions comprises of physical modalities, medications, irradiation to salivary glands and various surgical maneuvers. 17 (Table 1) Surgical techniques are limited by its irreversibility and patients’ fitness for surgery. Anticholinergic drugs and antidepressants are limited by their side effects. Radiation to salivary glands may be complicated by development of head and neck malignancies in the long run. There are case reports of the usefulness of local botulinum toxin injection into salivary glands in patients with head and neck cancer, neurodegenerative disorders, and stroke with no reported side effects. 18, 19 Randomized controlled studies have also proven its efficacy. (Table 2) 20 The clinical aspects of botulinum toxin injection have also been reviewed. 20 It can be injected into parotid glands, submandibular glands, or both. The injections can be guided by anatomical landmarks or ultrasound localization of the salivary glands. Use of ultrasound leads to a higher success rate and fewer side effects, and the dose used can be lower. However, it requires certain expertise. The dosages reported varied from 5-75 U into each parotid gland and 5-30 U into each submandibular gland. Usually one to 1.5 milliliters of drugs is injected into each gland, and the effect is achieved by diffusion. The onset of reduced saliva production can be rapid within 1-2 weeks, and the effect can last from a few weeks to several months. The potential side effects are dry mouth, dysphagia, jaw weakness and jaw dislocation. Caution must be exercised in patients with neuromuscular and muscular disease. Its potential indications in palliative care lie in the management of saliva aspiration and drooling in patients with neurological disorders affecting swallowing, surgery involving upper aerodigestive tract, laryngeal and upper Researcher Mancini 21 2003 Lipp 22 2003 Ondo 23 2004 Jongerius 24 2004 Lagalla 25 2006 Patient group Parkinson’s disease Multiple system atrophy Sialorrhea Parkinson’s disease Cerebral palsy Parkinison’s disease N 20 32 16 45 32 Type of study Double blind placebo controlled Dose finding study Double blind placebo controlled Compared with transdermal scopolamine Double blind placebo controlled Outcome Improvement shown at 1 week and 3 months Effect achieved with 75 U into each parotid gland Improved VAS, drooling score and global score Similar effects; fewer side effects Less frequent drooling; less saliva production & improved family and social functioning Table 2: Randomized studies on the use of botulinum toxin in sialorrhea 20 Physical modalities Medications Radiation Surgery Table 1: Management of excessive oropharyngeal secretions 17 Manual suction Various respiratory physical therapy techniques: Postural drainage / Percussion and vibration / Incentive spirometry / Glossopharyngeal breathing / frog breathing / Active cycle of breathing / Forced expiratory maneuvers / Cough assist Anticholinergic dugs Tricyclic antidepressants Botulinum toxin To salivary glands On salivary glands On neural innervation of saliva production Palliative Medicine Doctors’ Meeting____________________________HKSPM Newsletter 2007 Dec Issue 3 p 19 aerodigestive tract tumors, as well as patients with saliva fistula after parotid gland surgery, laryngectomy or pharyngectomy. Conclusion We have reported the usefulness of subcutaneous octreotide infusion and local botulinum toxin injection into submandibular glands in the management of bronchorrhea and sialorrhea respectively, and in both patients, a better symptom control and better quality of life had been achieved. Though these two medications are expensive, its use in selected cases should be carefully considered. References 1. Shimura S, Sasaki T, Sasaki H et al. Viscoelastic properties of bronchorrhea sputum in bronchial asthmatics. Biorheology 1988;25:173-179. 2. Hidaka N, Nagao K. Bronchioloalveolar carcinoma accompanied by severe bronchorrhea. Chest 1996;110: 281-282. 3. Epaulard O, Moro D, Langin T et al. Bronchorrhea revealing cervix adenocarcinoma metastatic to the lung. Lung Cancer 2001; 31:331-334. 4. Shimura S, Takishima T. Bronchorrhea from diffuse lymphangitic metastasis of colon carcinoma to the lung. Chest 1994;105: 308-310. 5. Lembo T, Donnelly TJ. 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