Download UNDERSTANDING BREATHLESSNESS IN 10 MINUTES

UNDERSTANDING
BREATHLESSNESS IN 10’ish
MINUTES!
Dr David Plume
Macmillan GP Facilitator,
Central Norfolk
Dyspnoea
• Unpleasant
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awareness of difficulty
in breathing
Pathological when
ADLs affected and
associated with
disabling anxiety
Resulting in :
physiological
behavioural
responses
Physiology
Psychology
Dyspnoea
Environmental
Social
Dyspnoea
• Breathlessness experienced by 70% cancer
patients in last few weeks of life
• Severe breathlessness affects 25% cancer
patients in last week of life
Causes of breathlessness-Cancer
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Pleural effusion
Large airway obstruction
Replacement of lung by cancer
Lymphangitis carcinomatosa
Tumour cell microemboli
Pericardial Effusion
Phrenic nerve palsy
SVC obstruction
Massive ascites
Abdominal distension
Cachexia-anorexia syndrome respiratory muscle weakness.
Chest infection
Causes of BreathlessnessTreatment
– Pneumonectomy
– Radiation induced fibrosis
– Chemotherapy induced
• Pneumonitis
• Fibrositis
• Cardiomyopathy
– Progestogens
• Stimulates ventilation
• Increased sensitivity to carbon dioxide.
Causes of Breathlessness- Debility
– Atelectasis
– Anaemia
– PE
– Pneumonia
– Empyema
– Muscle weakness
Causes of BreathlessnessConcurrent
o COPD
o Asthma
o HF
o Acidosis
o Fever
o Pneumothorax
o Panic disorder, anxiety, depression
Reversible causes of
breathlessness!
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Resp. Infection
COPD/Asthma
Hypoxia
Obstructed Bronchus/SVC
Lymphangitis Carcinomatosa
Pleural Effusion
Ascites
Pericardial Effusion
Anaemia
Cardiac Failure
PE
Breathlessness Cycle
Fear of Dying
Lack of
understanding
Anxiety
PANIC
Amplified Panic
Breathlessness
Fear of
impending
death
Independent predictor of
survival
weeks
months
days
Symptomatic drug treatment
Non-drug treatment
Correct the correctable
Breathless on
exertion
Breathless at rest
Terminal
breathlessness
Is this Terminal Breathlessness?
Are there appropriate treatments that could
or should be tried at home?
Does this patient want and need
transfer for investigations and treatment?
Consider transfer to hospital
for investigation & treatment if:
Pre-SOB condition good
Acute onset SOB
Patient receiving ongoing
disease modifying treatment
Manage at home if:
Burden of transfer for investigation
& treatment too great
Consider
Oral antibiotics
Nebulisers
Steroids
Oxygen
Non-Drug Therapies
• Explore perception of patient and carers
• Maximise the feeling of control over the
breathing
• Maximise functional ability
• Reduce feelings of personal and social
isolation.
Patient and Carer Perception
• Meaning to patient and carer
• Explore anxiety esp. fear of sudden death
• Inform that not life threatening
• State what is likely to/not to happen
• Realistic goal setting
• Help patient and carer adjust to loss of
roles/abilities.
Maximize control
• Breathing control advice
– Diaphragmatic breathing
– Pursed lips breathing
• Relaxation techniques
• Plan of action for acute episodes
– Written instructions step by step
– Increased confidence coping
• Electric fan
• Complementary therapies
Maximize function
• Encourage exertion to breathlessness to
improve tolerance/desensitise to
breathlessness
• Evaluation by physios/OT’s/SW to target
support to need.
Reduce feelings of isolation
• Meet others in similar situation
• Day centre
• Respite admissions
Breathlessness Clinic
• Nurse lead
• NNUH-Monday Afternoon
• Lung cancer and mesothelioma
• Referral by GP/SPCN/Palliative Medicine
team/Generalist Consultants
• PBL Day Unit-Wednesday, link with NNUH.
Drug Treatment
Salbutamol
Morphine
Dyspnoea
Benzodiazepines
Oxygen
What do I give?
• Bronchodilators work well in COPD and Asthma even if nil known
sensitivity.
• O2
increases alveolar oxygen tension and decreases the work of breathing
to maintain an arterial tension.
– Usual rules regarding COPD/Hypercapnic Resp. failure apply.
• Opioids
reduce the vent.response to inc. CO2, dec O2 and exercise
hence dec resp effort and breathlessness.
– If morphine naïve-Start with stat dose of Oramorph 2.5-5mg or Diamorphine
2.5-5mg sc and titrate Repeated 4hrly as needed.
– If on morphine already for pain a dose 100% or > of q4h dose may be needed, if
less severe 25% q4h may be given
• Benzodiazipines stat dose of Lorazepam 0.5mg SL, Diazepam 25mg or Midazolam 2.5-5mg sc
Repeated 4hrly as needed
Ongoing treatment
A syringe driver should be commenced if a
2nd stat dose is needed within 24hrs
• Diamorphine 10-20mg CSCI / 24hrs
• Midazolam 5-20mg CSCI / 24hrs
Remember to prescribe stats
Review & adjust dose daily if needed
Terminal Breathlessness
• Great fear of patients and relatives
• Treat appropriately- Opioid and
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sedative/anxiolytic- Diamorphine and
midazolam-PRN and CSCI
If agitation or confusion -haloperidol or Nozinan
Some patients may brighten.
Sedation not the aim but likely due to drugs and
disease.
Respiratory Secretions (death rattle)
• Rattling noise due to secretions in hypopharynx moving
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with breathing
Usually occurs within days-hours of death
Occurs in ~40% cancer patients (highest risk if existing
lung pathology or brain metastases)
• Patient rarely distressed
• Family commonly are distressed
• Treat early
• Position patient semi-prone
• Suction rarely helpful
Respiratory Secretions
• If secretions are present, two options.
• A) Hyoscine Butylbromide (Buscopan)
– Stat-20mg 1hrly
– CSCI-80-120mg/24 hrs
• B) Glycopyrronium
– Stat-0.4mg 4hrly
– CSCI-0.6-1.2mg /24 hrs
Remember Stats at appropriate doses
Review & adjust dose daily