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Dyspnea in palliative home care

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Dyspnea in palliative home care Dr. Rojanasak Thongkhamcharoen M.D., RCFPT Overview Review of dyspnea pathophysiology Evidence in dyspnea management Assessment ... – PowerPoint PPT presentation

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Title: Dyspnea in palliative home care


1
Dyspnea in palliative home care
  • Dr. Rojanasak Thongkhamcharoen M.D., RCFPT

2
Overview
  • Review of dyspnea pathophysiology
  • Evidence in dyspnea management
  • Assessment
  • Pharmacologic management
  • Non-pharmacologic management
  • Case ????????

3
??????????????????????? (why framework)
  • WHY? (??????????????)
  • Is it reversible or irreversible?
  • Where is the patient in disease trajectory?
  • Can we do something about this symptom?
  • Adapt from Why framework David Currow, Flinder
    university,2010

4
Lynn J, Adamson DM. White Paper Living Well at
the End of Life. RAND Health, 2003 1-19
5
Symptom management by Buddhist principle
  • ????? ??? ?????-???????????????? ???????????????
    (suffering)
  • ?????? ??? ????????????????????
  • ????? ??? ???????????? (goal of care)
  • ???? ??? ?????????????

6
  • The gold standard for diagnosis of dyspnoea is
    the patients self-report.
  • Thomas JR, von Gunten CF. Clinical management in
    dyspnea. The Lancet 2002,april3 223-228

7
Dyspnea
  • Definition a subjective experience of breathing
    discomfort that consists of qualitatively
    distinct sensations that vary in intensity
  • The experience derives from interactions among
    multiple physiological, social, and environmental
    factors, and may induce secondary physiological
    and behavioral responses
  • ATS ad hoc Committee,1999.

8
Dyspnea
  • cancer 10-70
  • AIDS 11-62
  • Heart disease 60-88
  • COPD 90-95
  • Renal disease 11-62

Solano JP, Gomes B, Higginson IJ. A Comparison of
Symptom Prevalence In Far Advanced Cancer, AIDS,
Heart Disease,Chronic Obstructive Pulmonary
Disease And Renal Disease. JPSM 200631(1) 58-69
9
????????????????????????????????????????????
????? ?? (??????) ?? (??????) ?? (??????) ?? (??????) ?? (??????)
????? 2550 2551 2552 2553 2554 (2 ???????)
pain 60.7 38.6 32.7 49.2 30 ???
dyspnea 39.3 15.8 20 58.5 21 ???
fatigue 46.4 8.8 12.7 63 28 ???
10
readmission
???????????? ??. Frequency Percent
dyspnea 42 33
pain 38 30
confusion 7 5.5
fatigue 14 11
bleeding 13 10.2
infection 7 5.5
other cause 6 4.8
Total 127 100
11
Intubation ??????????????????????
???????????????? ?? ?? ?? ??
???????????????? 2550 ???(??????) 2551 ???(??????) 2552 ???(??????) 2553 ???(??????)
?????????????????? 6(10) 4(7) 5(9) 3(4)
???????????????? 34(61) 35(61) 28(50) 32(49)
12
Ripamonti C, Bruera E. Dyspnea Pathophysiology
and assessment. JPSM199713(4)220-232
13
3 possible mechanisms
  • increase afferent input from chemoreceptors and
    mechanoreceptors from upper airway, chest wall,
    and lung
  • increase sense of respiratory effort
  • afferent mismatch

Oxford textbook of palliative med,4th 2010 Booth
S and Dudgoen D. Dyspnoea in advanced disease a
guide to clinical management Oxford university
press, New York,2006
14
Management of dyspnea
  • Management of dyspnea in cancer patients involves
    the following stepwise approach
  • assessment of dyspnea
  • management of specific dyspnea syndrome
  • non-pharmacologic management
  • oxygen
  • pharmacologic treatment
  • other potential drugs
  • palliative sedation

Oxford textbook of palliative med,4th 2010
15
Thomas JR, von Gunten CF. Clinical management in
dyspnea. The Lancet 2002,april3 223-228
16
Del Fabbro et al. Symptom Control in Palliative
CarePart III Dyspnea and Delirium. JOURNAL OF
PALLIATIVE MEDICINE 20069(2) 422-436
17
Dyspnea severity
Farncombe M, Support Care Cancer (1997) 594-99
18
Rating scale
19
????????????
20
?????????????????? morphine ?? 2551-2553
Pain level Pain level Pain level Pain level Pain level ??? (???)
Dyspnea mild moderate severe not assess ??? (???)
7 ??? 4 ??? 16 ??? 25 ??? 14 ??? 66 ???
21
????????? 2553-2554
dyspnea dyspnea MO user MO user Total
dyspnea dyspnea yes no
no symptom 17 10 27
not disturb 24 6 30
disturb 5 9 14
severe all time 16 6 22
Total Total 62 31 93
22
????????????????????????????????????????????????
23
Cachia and Ahmedzai, EJC2008 441116 1123
24
Strong Opioids
  • Oral and subcut. route morphine significantly
    improve dyspnea,
  • Nebulized opioids is not enough evidence,
  • Oral or Parenteral Opioids

Jennings et al. Cochrane Database of Systematic
Reviews , 2001 DiSalvo et al. Putting Evidence
Into Practice Evidence-Based Interventions for
Cancer-Related Dyspnea.Clinical Journal of
Oncology Nursing, 2007 Jennings et al. A
systematic review of the use of opioids in the
management of dyspnoea. Thorax 200257939944
25
Strong Opioids
  • Significant improvement in the intensity of
    dyspnea (P0.003)
  • Decrease RR41.8 to 35.5 (30 min) and to 25.7
    /min (90 /min)
  • No opioid-induced respiratory depression
  • SpO2 ,PCO2 and pH normal
  • using opioids for dyspnea was not associated with
    reduced survival2

1.Clemente et al. J Pain Symptom Manage 2007
33(4) 473- 481 2. Bengoechea et al. JPM 2010
13(9) 1079-1083.
26
Benzodiazepine
  • Inhibit GABA pathway decreased anxiety
  • In panic attack-short acting lorazepam 0.5 mg SL
  • Diazepam is not appropriate long acting, delayed
    onset
  • Subcut. Injections or a continuous sc infusion of
    midazolam are helpful
  • Combine midazolam to morphine improved baseline
    dyspnea control
  • Cochrane review showed not enough evidence for
    benefit for dyspnea_at_

Cachia and Ahmedzai, EJC 2008 441116
1123 Navigante et al. J Pain Symptom Manage
20063138-47. _at_ Simon et al. Cochrane Database
of Systematic Reviews 2010,Issue1.
27
Oxygen
  • Oxygen failed to improve dyspnea in mildly-or
    non-hypoxaemic cancer patients two
    meta-analyses,
  • Double blind, multi-center RCT comparing O2 vs
    room air in non-hypoxic cancer patients showed
    that no additional benefit of O2 comparing to
    room air
  • sensory stimulation rather than correction of
    hypoxaemia

Uronis et al. British Journal of Cancer 200898
294299 Cranston et al. Cochrane Database of
Systematic Reviews 2008,Issue3. Abernethy et
al. Lancet 2010 376 78493 Thomas and
Gunten Lancet Oncol 2002 3 22328
28
Galbraith S, Fagan P, Perkins P, Lynch A, Booth
S. Does the use of a handheld fan improve chronic
dyspnea? A randomized, controlled, crossover
trial. J Pain Symptom Management 2010 39
831-838.
29
Stephenson D and McHugh A. The non-pharmacological
nursing management of dyspnoea in end-stage
respiratory disease and palliative care
populations. Collegian 2004 11(2 ) 37-41
30
evidence
  • Recent RCT 49 patients significant difference in
    the VAS scores between the two treatments, with a
    reduction in breathlessness when the fan was
    directed to the face(P 0.003)
  • High strength of evidence that NMES and CWV,
    moderate strength for the use of walking aids and
    breathing training

Galbraith et al. J Pain Symptom
Manage201039831-838. Bausewein et al. Cochrane
Database of Systematic Reviews 2008 2.
31
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32
Differential diagnosis
  • Pleural effusion
  • COPD with exacerbation
  • Cor pulmonale or HF
  • Pericardial effusion
  • SVC syndrome
  • Etc.

33
Family genogram
70 years old CA lung SVC syndrome
50 years old farmer DM
30 years old farmer Alcohol
C
C
55 years old Working in BKK
5 years old
6 month
34
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35
  • Issue
  • end-stage lung cancer SVC syndrome
  • Medical collusion (Conspiracy of silence)
  • Asset management issue
  • Patient concern about alcohol abuse of younger son

36
intervention
intervention Response Recurrent rate Survival and complication
RT 78 (SCLC) and 63 (NSCLC) , Complete response at 1-3wks (symptom relief in 72 hr ) 17 vs 19 (small cell vs NSCLC) 2 to 9.5 months
chemo 80 of patients with NHL or SCLC 40 -59 of NSCLC Same as RT Same as RT
Venous stent 96 improve facial and extremities edema within 24 hr, 72 hr 13 Median 1-2 mo. 5.8 ( 3-7) infection, pulmonary embolus, stent migration, insertion site hematoma, bleeding, and, very rarely, venous perforation.
Lynn et al. NEJM, 20073561862-9. Oxford
textbook of palliative med , 4th 2010
37
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38
???????????? 2 ?????????? 45 ??
  • NPC s/p radiation 2 ???????? bone metastasis
    ???spinal cord compression
  • ??????????? VAS 8.0, incident pain10
  • Consult ??? ortho ?? MST 30 mg BD ?????? morphine
    syr 8 mg orally x 3 rescue doses
  • Serum creatinine 5.2 mg

39
Problem list
  • Pain due to spinal cord compression and rib
    metastasis
  • Dyspnea from chachexia, Lt. pleural effusion
  • ??????????????
  • Suffering from his past

40
????????????????????
  • Recommended pain management in CKD fentanyl1
    (??? ??? ???????)
  • Methadone 2.5 mg q 8 hr
  • ????? no active metabolite, excrete via GI tract
    80, long acting with 30min onset, good for
    neuropathic pain2
  • ??????? drug interaction, QT prolong in high
    dose, ????????? due to pharmacokinetic,
    respiratory depression2

1. Douglas C et al. Symptom management for the
adult patient dying with Advanced chronic kidney
disease A review of the literature and
development of evidence-based guidelines by a
United Kingdom Expert Consensus Group. Palliative
Medicine 2009 23 103110 2. Leppert W. The role
of methadone in cancer pain treatmenta review.
Int J Clin Pract 2009 63(7)10951109
41
Management
  • ??????????? dose ???? MST 2-0-1 every 12 hr ???
    morphine syr 30 ???? ???? bed bath 30 min
  • ???????? VAS 6.0, VAS incident pain 8.0
  • ????????? VAS 4.0, VAS incident pain 6.0
    ???????????????? ???? ?????????????????????? RR
    14/min
  • Morphine side effect ????? co-morbidity CKD
  • Off ?? 2 ??? ??????????????????????? VAS 6.0,
    VAS incident pain 8.0 ?????????? pressure sore

42
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43
Pollock A, et al. Morphine to Methadone
Conversion An Interpretation of Published Data.
American Journal of Hospice Palliative Medicine
28(2) 135-140
44
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45
Example of non-pharmacologic measures in dyspnea
management
46
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47
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48
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49
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50
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