Download Managementn of RespiratorySymptoms in Cancer Patients

F. Soltaninejad MD
Pulmonologist
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54%-76% of advanced cancer patients experience
dyspnea
more than 65% of lung cancer patients have cough
at the time of diagnosis
35% of cancer patients develop death rattle at the
end of life
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Breathlessness is an uncomfortable sensation or
awareness of breathing.
Subjective – measuring lung function does not
correlate with sensation or severity of
breathlessness
A complex experience of mind and body that is
likely to progress with disease severity
Significant correlation with impaired quality of life
and poor survival. Effects Patients and Carers.
A common complex distressing symptom at the
end of life
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Dyspnea is a frequent symptom in advanced cancer
patients with the highest prevalence in lung cancer
(up to 74%) increasing in the terminal phase (up to
80%) with major impact on the quality of life of the
patient and his or her family.
Dyspnea can be described along three dimensions:
 air hunger—the need to breathe while being
unable to increase ventilation
 effort of breathing—physical tiredness associated
with breathing
 chest tightness—the feeling of constriction and
inability to breathe in and out
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Listen/Observe
What does it mean to the patient / carer?
Onset
Triggers / What eases it?
Levels of significance – during activity, in
different positions, at rest
Pattern of breathing, colour, respiratory rate
Are they anxious?
Oxygen saturations
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History
Physical examinations
Paraclinic assessment: ( complete blood count,
electrolytes, creatinine, oximetry and full blood gas
assessment, electrocardiogram, brain natriuretic
peptide or chest X-ray and computed tomography
scan )
Consider active treatment of:
 Infection
 Pleural effusion
 Pneumothorax
 Pericardial effusion
 Airway obstruction
 Anaemia
 CHF
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Positioning
Airflow - use of fan /window
Relaxation / Distraction/ Reassurance
Energy conservation / Pacing
Controlled Breathing techniques
Loose clothing
Mouth Care
Start with position of ease
Relax shoulders / upper chest
Diaphragmatic ‘tummy’ breathing
Breath out twice as long as breath in
Pursed lips on breathing out if needed
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Encourage activity
Allow time for tasks
Starting and stopping with rest intervals
Inspiration: expiration ratio during activity
Use of aids – stair lift etc
Adapting functional tasks
Oxygen therapy
 Oxygen therapy is recommended in hypoxemic
patients
 Oxygen therapy is suggested not to be used in
nonhypoxemic patients
Noninvasive positive pressure ventilation (NPPV) is
suggested to be used in patients with hypoxemia
and hypercapnea
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High-flow nasal cannula oxygen therapy is
suggested to be used in patients with hypoxemia
that is refractory to standard oxygen therapy
Opioids
Systemic morphine is recommended to be used in
cancer patients with dyspnea
Systemic oxycodone is suggested to be used, as
alternative to morphine
Systemic fentanyl is suggested not to be used
Systemic codeine/dihydrocodeine is suggested to be
used
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Benzodiazepines
Benzodiazepines are suggested not to be used alone
Benzodiazepines are suggested to be used in
combination with opioids
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Corticosteroids
Systemic corticosteroids are suggested not to be
used routinely without consideration of dyspnea
etiology.
Systemic corticosteroids are suggested to be used in
patients with lymphangitis carcinomatosa,
radiation pneumonitis, superior vena cava
syndrome, major airway obstruction.
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Neuroleptics such as phenothiazines and
antidepressants and buspirone are reputed to exert
some antidyspnoeic efficacy as mood-enhancing
medication; nevertheless, this has not yet been
proven.
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Thoracentesis with drainage of pleural effusion is
recommended
Pleurodesis should be performed in cancer patients
with dyspnea caused by malignant pleural effusion,
if patients meet all the following conditions: (1)
repeated thoracentesis is required to relieve
dyspnea, (2) patient’s general condition is tolerable
for pleurodesis, and (3) a monthly prognosis is
expected.
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Morphine/codeine/dihydrocodeine and
dextromethorphan are suggested to be used.
Gabapentin/pregabalin and nebulized lidocaine are
suggested not to be used.
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Dextromethorphan 10-15 mg tds/qds
Codeine 30-60 mg qds
Morphine (oramorph) 5 mg (single dose trial of
oramorph; if effective 5-10 mg slow release
morphine bd)
Diamorphine 5-10 mg CSCI/24 hrs
Methadone linctus Single dose 2 mg (2 mL of 1
mg/mL solution)
Dihydrocodeine 10 mg tds
Hydrocodone 5 mg bd
Prednisolone 30 mg daily for 2 weeks
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Often referred to as ‘death rattle’
Caused when a patient’s coughing and swallowing
reflex is impaired or absent, causing fluids to
collect
Not easily relieved by drug therapy once
established
Treatment should therefore be started at first sign
of rattle
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Re-positioning of the patient by tilting side to side,
or tipping bed ‘head up’ to reduce noise
Management of halitosis with frequent mouth care
Discrete management of oral secretions mouth
care – oral hygiene
Suction not advised, except when secretions are
excessive
Reassurance to family that the noise is due to
secretions, and not causing suffocation, choking or
distress
Reduce oral fluids if at risk of aspiration
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Hyoscine Butylbromide (Buscopan)
60- 240mg/24hr s/driver, prn dose SC 20mg
If not effective, discuss with palliative care team
who may consider
Glycopyronium Bromide (Glycopyrolate)
400-2400mcg/24hr s/driver or prn dose 200mcg
Point: Hyoscine Hydrobromide was historically drug
of choice, but not currently recommended due to
side effects of sedation and confusion