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The Palliation of Chronic Obstructive Pulmonary Disease

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Physiotherapy. Psychosocial support. Pulmonary rehab. Non-invasive ventilation. Surgery ... Physiotherapy. Suctioning. Tracheostomy. Aerosolized hypertonic ... – PowerPoint PPT presentation

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Title: The Palliation of Chronic Obstructive Pulmonary Disease


1
The Palliation of Chronic Obstructive Pulmonary
Disease
  • May, 2007

2
  • The essence of a breath is filled with
    physiological, psychological and spiritual signals

3
Case study
  • Mr. J.D. is 87 years old from rural Manitoba
  • Long time smoker smokes 2 packs per day for 60
    years
  • Increasingly dyspneic over last 2 years
  • COPD is suspected by the doctor and the patient
    is informed
  • Pt asks you what is COPD? what do you say?

4
What is Chronic Obstructive Pulmonary Disease
(COPD)?
  • OBSTRUCTION to Airflow
  • Airway collapse
  • Bronchospasm
  • Mucosal inflammation
  • Edema
  • Leads to air-trapping and hyperinflation

5
What is COPD?
  • Chronic Bronchitis
  • Cough productive of sputum for 3 months of 2
    consecutive years
  • Emphysema
  • Destruction of airspaces distal to the terminal
    bronchus

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7
Normal Lung
Emphysema
8
How common is it?
  • Accounts for 18 hospitalizations
  • 4th leading cause of death in Canada
  • Affects 6 of the general population
  • Most common reason for ER visits in U.K.

9
Incidence
  • The incidence is increasing
  • By 2020
  • 3rd leading cause of death
  • 5th leading cause of disability
  • Increased by 53 from 1988-1999 in women and is
    still rising

Sullivan, Chest 2000 Michaud, JAMA 2001 Murray,
Lancet, 1997
10
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12
Case Study
  • Mr. D. is referred to a respirologist in the city
  • He asks his nurse what the visit might be like
    what do you say?

13
Diagnosing COPD
14
Diagnosing COPD
Canadian Thoracic Society Recommendations, 2003
15
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16
Case Study
  • Mr. D. returns from the city with a diagnosis
    COPD (Emphysema)
  • He wants to know what life will be like with COPD
    and how long he has to live
  • What do you think his symptoms will be?
  • What do you think his prognosis is?

17
Symptoms
Elkington, Pall med, 2005
18
Natural History
  • Progressive decline in lung function
  • Terminal Disease
  • Acute exacerbations
  • Entry reentry terminal trajectory

Diagnosis
Death
19
Survival
  • Median survival after hospitalization for acute
    exacerbation?
  • Median survival after ICU admission?
  • Percentage of patients readmitted within 6 months?
  • 2 years
  • 224 days
  • 50
  • (Manino, Chest 2002) (Almagro, Chest 2002)
  • (Conners, Am J Resp Med 1996) (Morray, 1995)

20
Survival
  • In hospital mortality?
  • 1 year mortality?
  • 2 year mortality?
  • 11
  • 43
  • 49

Conners, Am J Resp Med, 1996
21
Factors affecting in hospital death
  • Low pO2
  • High pCO2
  • Cardiac disease
  • Age
  • Oral corticosteroids
  • Overall mortality affected by
  • Low albumin
  • Low BMI
  • FEV1 lt 30

Chua, Chest 2005 Gunen, Eur Resp J,
2005 Groenwagen, Chest 2003
22
Case Study
  • Mr. D. is informed that his prognosis (death and
    disability) depends mostly on .?

23
Smoking Cessation
Booker, Br J Nurs, 2005
24
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25
General Treatment of COPD
  • Inhalers
  • B agonists
  • Anticholinergics
  • steroids
  • Theophylline
  • O2
  • hypoxemic
  • cor pulmonale
  • Polycythemic
  • Education
  • Vaccines
  • Flu
  • Pneumococcus
  • Pulmonary rehab

26
General Pharmacologic Approach
Canadian Thoracic Society Recommendations, 2003
27
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28
Case Study
  • Over the next 2 years, Mr. D. has 8
    hospitalizations for AECOPD/ pneumonia
  • He is put on maximal doses of inhalers
  • He is put on continuous oxygen
  • His mood declines, his anxiety increases
  • He refuses to go to his granddaughters wedding
    because of embarrassment of his illness
  • How does his mental health compare to patients
    with lung cancer?

29
Comparing Lung Cancer COPD
(Gore, Thorax, 2000)
30
Comparing Lung Cancer COPD
(Pall. Med, Edmonds 2001)
31
Comparing Lung Cancer COPD
(Gore, Thorax, 2000)
32
(Gore, Thorax, 2000)
33
Case Study
  • Mr. D. develop shingles which breakout across
    half of his face
  • He describes the pain as someone is taking a
    blow torch to my head
  • His doctor struggles to manage his pain, not
    wanting to put him on opioids
  • Palliative care/Pain service never consulted

34
Case Study
  • Mr. D. dies suddenly in hospital 2 weeks later,
    family surprised but relieved
  • How commonly is prognosis not discussed with COPD
    patients/family?

35
Comparing Lung Cancer COPD
(Pall. Med. Edmunds, 2001)
36
Case Study
  • What is the truth about opioids in COPD?
  • Other than inhalers, what has shown to be
    effective for the palliation of COPD?

37
Palliation of Dyspnea
  • Toll of Dyspnea
  • Physical
  • Fatigue, loss of concentration, loss of appetite,
    loss of memory, sweating, constipation, nausea,
    insomnia, difficulty weight bearing
  • Emotional
  • Anxiety, nervousness, fear, panic, depression
  • Social
  • Barrier to all activities

38
Mechanisms of dyspnea
  • 1) Increase afferent input from chemoreceptors
    and lung receptors
  • (pH, PO2, PCO2, stretch/irritant and J receptors)
  • 2) Increase sense of respiratory effort
  • Ratio of the pressure generated by respiratory
    muscles to the maximum pressure-generating
    capacity of the muscles
  • 3)afferent mismatch
  • Not enough displacement of muscle fibers per
    tidal volume (length-tension inappropriateness)

39
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42
Treatment of Dyspnea
  • Non pharmacologic
  • Vaccines
  • Moving Air
  • Nutrition
  • Physiotherapy
  • Psychosocial support
  • Pulmonary rehab
  • Non-invasive ventilation
  • Surgery
  • Pharmacologic
  • Oxygen
  • Opioids?
  • Benzodiazipines?
  • Antidepressants
  • Mucolytics

43
Booker, Br J Nurs, 2005
44
Palliation of Dyspnea in COPDOpioids
  • Opioids in COPD Controversial!
  • Improvement in dyspnea and sleep over placebo
    with SR Morphine (Abernethy, BMJ 2003)
  • 2 systematic reviews 18 double-blind,
    randomized, controlled trials, showed significant
    relief of dyspnea with oral or parenteral opioids
    (Tomas, Curr Opin Pulm Med, 2004)
  • No significant effect of nebulized opioids.
    (Tomas, Curr Opin Pulm Med, 2004)

45
Palliation of Dyspnea in COPDOpioids
BUT..
(Global Strategy for the Diagnosis, Management
and Prevention of COPD - GOLD recommendations
Am J Resp Crit Care Med, 2001)
46
Palliation of Dyspnea in COPDBenzodiazipines
  • Benzodiazipines
  • NO literature on benzos in COPD
  • Midazolam 5.0 mg improves dyspnea above the
    improvement seen from morphine alone in dyspneic
    terminally ill cancer patients (Navigante, J Pain
    and Symp Management, 2006)

47
Palliation of Dyspnea in COPDOxygen
(Expert Working Group of the scientific committee
of palliative medicine, 2004)
48
Palliation of Dyspnea in COPD
  • Oxygen
  • Current recommendation is that it should be used
    with
  • Hypoxemia (improves survival)
  • Cor pulmonale
  • Polycythemia
  • During and after ambulation if symptomatic
  • ? At rest

49
Palliation of Dyspnea in COPD
  • Take home message
  • Continue previously prescribed inhalers
  • Can use opioids in palliation depending on
    patients goals of care
  • Try benzos if dyspnea refractory depending on
    goals of care
  • Oxygen during ambulation
  • Can try oxygen at rest

50
Management of Cough
  • Protussive therapy
  • Hydration
  • Physiotherapy
  • Suctioning
  • Tracheostomy
  • Aerosolized hypertonic saline
  • N-acetylcysteine
  • B-agonists
  • Guafenisen
  • Antitussive therapy
  • Dextromethorphan
  • Hydrocodone/codeine?
  • Po and aerosolized local anaesthetics
  • Theophylline
  • B- agonists
  • Anticholinergics

51
Case Study
  • Why do you think palliative care was never
    consulted for Mr. D.?

52
Patient Barriers to Palliative Care
  • Would rather concentrate on staying alive
  • Not sure which doctor will take care of me
  • I dont know what kind of care I want
  • I dont like to talk about getting very sick
  • My ideas about care change at different times
  • Doctors look down on me because of smoking
  • I am not ready to talk about it
  • My doctor doesnt want to talk about it

(Chest, 2005)
53
Physician Barriers to Palliative Care
  • Too little time in our appointments
  • Dont want to take away hope
  • Patient is not ready to talk about it
  • Patient has not been very sick yet
  • Patient doesnt know what kind of care they want
  • Patient ideas about care change over time
  • My role as a doctor is to make pt feel better

(Chest, 2005)
54

Murray, Prim Care Resp J, 2006
55
Palliative Care Discussion Starters
  • If things got worse, where would you like to be
    cared for?
  • Whats the most important issue in your life
    right now?
  • What helps you keep going?
  • What is your greatest problem?
  • You seem cheerful at present, but do you ever
    feel down?

(Murray, Prim Care Resp J, 2006)
56
Palliative Care Symptom Management - Dyspnea
  • Very personal experience for the patient
  • Heavy, gasping, hunger, effort
  • Shortness of breath, hard to move air, not
    getting enough air, somebody taking the breath
    away, choking, panting, suffocation

57
Non-Malignant End stage Respiratory Disease
  • COPD
  • Pulmonary Fibrosis
  • Cystic Fibrosis/Bronchiectasis
  • Pneumoconiosis
  • TB
  • Sarcoidosis
  • Circulatory Disease
  • Neuromuscular/ Chest Wall Disease

58
Prognostic Factors
  • Cystic Fibrosis
  • Worse prognosis if
  • Intubated
  • Large annual decrease in FEV1(Texeraeu 2006)
  • FEV1 gt 30 predicted
  • Colonization with Burkholderia
  • Worse hypoxemia and hypercapnia
  • Poor nutritional status
  • 1 yr survival 52 for patients in the ICU
  • (Ellaffi 2005)

59
Cystic Fibrosis
  • Lung Transplant Survival

(Quatrucci 2005)
60
Summary
  • Palliative treatment of respiratory symptoms the
    same regardless of type of pulmonary illness
  • Nonmalignant pulmonary diseases can be very
    symptomatic
  • Little evidence to support palliative management
  • Many barriers to palliative care in nonmalignant
    disease
  • Prognostication for nonmalignant diseases is
    difficult
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