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Palliative care approaches to symptom management in advanced respiratory disease: anxiety and breathlessness

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Title: Palliative care approaches to symptom management in advanced respiratory disease: anxiety and breathlessness


1
Palliative care approaches to symptom management
in advanced respiratory disease anxiety and
breathlessness
Dr Jonathan Martin Consultant in Palliative
Medicine, St Joseph's Hospice Visiting Fellow,
Harris Manchester College, University of
Oxford 28th June 2013 Thanks to Rebecca
Jennings, St Josephs Hospice Dr Sara Booth,
Cambridge Breathlessness Intervention Service
2
Palliative care needs of COPD patients
  • Heavy burden of symptoms.
  • (Fan 2007, Habraken 2009, Gardiner 2009)
  • Symptoms at least as severe as lung cancer.
  • (Edmonds 2001, Habraken 2009)
  • Impaired quality of life and emotional well being
    compared to lung cancer.
  • (Gore 2000)
  • Information needs also great.
  • (Randall Curtis 2002, 2008)

3
Information needs
  • Qualitative study in 2009
  • Understanding of COPD poor
  • Lack of awareness of progressive nature
  • Lack of awareness that they might die of COPD.
  • Despite this the patients
  • Were concerned that their disease might progress
  • Were frightened that they would die of
    breathlessness or suffocation.
  • None had discussed these fears with any health
    care professional.
  • (Gardiner 2009)

4
Balance of Management Approaches
Non-pharmacological
NonPh
NonPh
NonPh
Non-pharmacological interventions are the most
effective interventions currently available to
palliate breathlessness in the mobile patient
Booth et al 2011
Pharm
Pharm
Pharmacological
Pharm
Dyspnoea at rest
Terminal dyspnoea
Dyspnoea on exercise
Wilcock, 1998
5
Focus of non-pharmacological management in
advanced disease is not on decreasing
breathlessness but helping individuals to feel
more in control of their breathing and be as
independent as possible
6
Anxiety
7
Anxiety and breathlessness are probably linked
8
CBT
Thoughts I might die How will my wife cope?
Feelings Fear/anxiety
Physical Breathless Deconditioned Weight loss
Behaviours Staying in the house Not talking to
wife Not eating well
9
Vicious daisy
I might die
Breathless
How will my wife cope?
Weight loss
Fear / anxiety
Not talking to wife
Not eating well
Staying at home
Breathless
Deconditioned
10
Anxiety (and depression)
  • Non-drug treatments good evidence for effect
  • Pulmonary rehabilitation. (Withers 1999, Paz
    2007, Coventry 2009)
  • Cognitive behavioural therapy (CBT). (Coventry
    2008, Heslop 2009, Kunik 2008, Livermore 2010)
    N.B. No RCT evidence
  • Drug treatments limited contradictory evidence
    in COPD
  • TCAs, SSRIs (Lacasse 2004, Yohannes 2001)

11
Breathlessness
12
Non-pharmacological and Pharmacological
Approaches Breathlessness
Non-pharmacological
Pharmacological
  • Personalised goals
    of care
  • Symptom orientated
  • Multidisciplinary Approach
  • Maximise quality of life for
  • patients and their families
  • Involve patient and family in
  • care planning
  • Maximise physical function
  • and emotional wellbeing
  • Holistic
  • Maximise usual treatments as appropriate eg
    inhalers
  • Manage exacerbations actively as appropriate
  • Consider oxygen for hypoxia
  • Cautious use of opioids and benzodiazepines
  • Education Physiology and Anatomy
  • Positioning
  • Hand Held Fan
  • Breathing Control Techniques
  • Functional Exercise
  • Walking Aid (4 wheel rollator)


Beware the hypercapnic patient
13
Non-pharmacological Management
Intervention Rationale Summary of Evidence
Education simple anatomy and physiology of breathing Empowers patient and carer to understand condition, why they become breathlessness. Reduces fear and promotes self management Insufficient evidence Bausewein 2009
Positioning Forward lean High sitting Increase efficient use of accessory muscles Offload diaphragm Improve ventilation/ perfusion ratio Limited. Recommended in clinical practice but further research needed. Booth et al 2011
Handheld Fan Stimulates nasal receptors altering the signal to brainstem respiratory complex and changing respiratory pattern Abernethey et al 2010 Strong evidence. Crossover RCT 51 patients with chronic breathlessness. Significant decrease in breathlessness measured on VAS when fan directed to cheeks vs leg (p0.003) Galbraith et al 2010
Breathing Control Techniques Promotes efficient breathing pattern, decrease distressing symptoms of hyperventilation Moderate quality evidence to support Bausewein 2009 Cochrane Systematic Review Compounded by variation in definition of techniques Booth et al 2011

14
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15
Recovery breathing
  • Rescue breathing
  • A three-part behaviour for use in distressing
    dyspnoeic episodes
  • Positioning to allow use of accessory muscles
  • Focus on breathing out
  • Use of a fan
  • Cambridge Breathlessness Intervention
    Service

16
Pharmacological Management
  • Opioids
  • Oxygen
  • Benzodiazepines e.g. lorazepam
  • Antidepressants (direct indirect)
  • Major tranquillizers e.g. levomepromazine
  • Others furosemide, heliox, cannabinoids
  • Booth et al, Expert Review of Respiratory
    Medicine, 2009

17
Opioids
  • Consistent evidence of benefit (Jennings 2002,
    Abernethy 2003, Currow 2011)
  • Safety
  • Entrenched societal and professional
    misconceptions
  • No evidence for respiratory depression from low
    dose oral opioids
  • Some evidence for safety (Clemens 2008, Estfan
    2007, Chan 2004)
  • Some evidence against
  • Benefit may be limited to a few sensitive
    subjects (Pauwels 2001/2005)
  • Longer term adverse effects on endocrine system,
    falls and cognitive function (Freynhagen 2013)
  • Need adequately powered safety studies
  • Particular caution with
  • Type 2 respiratory failure no data specifically
    relating to this group
  • Transdermal fentanyl

18
Opioids in Breathlessness
  • When should they be considered?
  • Use them for breathlessness at rest
  • Use them at the end of life
  • Consider them in anyone with severe SOB
  • Consider in moderate breathlessness after other
    interventions

19
Breathlessness opioid palliation
  • Two approaches
  • Currow and colleagues start on 10mgs modified
    release (Currow et al , 2010)
  • Booth, Rocker and colleagues start on 1mg NR o.d.
    (Rocker et al, 2010)

20
Opioid titration in non-cancer in the community
Week AM PM
1 1mg Oramorph Nil
2 1mg Oramorph 1mg Oramorph
3 2mg Oramorph 1mg Oramorph
4 2mg Oramorph 2mg Oramorph
5 5mg MST Nil
6 5mg MST Up to 1mg Oramorph prn
7 5mg MST Up to 2mg Oramorph prn
8 5mg MST Up to 3mg Oramorph prn
9 5mg MST Up to 4mg Oramorph prn
10 5mg MST Consider 5mg MST
21
Oxygen
  • Individual assessment essential for use for
    dyspnoea
  • Some evidence in non-malignant disease related
    to desaturation on exercise and hypoxia at rest
  • Very little evidence in cancer that better than
    air use according to clinical benefit in an
    individual
  • Use the fan first
  • Booth et al, Respiratory Med, 2004
  • Cranston et al, Cochrane Systematic
    Reviews, 2008

22
Benzodiazepines, buspirone
  • Benzodiazepines
  • Recent Cochrane review. (Simon 2010)
  • Non-significant trend for benefit.
  • Buspirone
  • Anxiolytic and respiratory stimulant with
    theoretical benefits (Smoller 1996)
  • Two RCTs with conflicting results (Singh 1993,
    Argyropoulou 1993)

23
Cochrane review of benzodiazepines/dyspnoea
  • Seven studies RCT/CCT meta-analysis of 6
  • 200 participants with advanced COPD cancer
  • No significant impact positive small trend
  • gtdrowsiness placebo, ltdrowsiness morphine
  • Recommend 3rd/4th line treatment after
    non-pharmacological morphine
  • Simon et al, 2010

24
Summary benzodiazepines
  • Little evidence
  • Rather more for major tranquillisers
  • Preferable to achieve anxiety-reduction by
    non-pharmacological means except at the end of
    life
  • Subcutaneous opioid benzodiazepine in severe
    SOB

25
Could antidepressants work?
  • Possibly by
  • By treating depression
  • By treating anxiety/panic disorder
  • By an effect on serotonin-mediated pathways in
    the brainstem
  • Detecting and treating depression essential
  • Brenes, Psychosom Med, 2003

26
Summary of the evidence
  • Good evidence for
  • Pulmonary rehabilitation
  • Breathing training
  • Walking aids
  • Exercise
  • CBT
  • Fan
  • Opioids
  • Limited evidence for
  • Benzodiazepines
  • Oxygen
  • Antidepressants
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