Dyspnea in the Cancer Patient 33 rd Annual PSONS Nursing Symposium April 1, 2011

Transcription

1 Dyspnea in the Cancer Patient 33 rd Annual PSONS Nursing Symposium April 1, 2011 Kathy Witmer, MN, ARNP Swedish Cancer Institute Thoracic Surgery - Oncology

2 Dyspnea The word denotes disordered breathing Greek root: dys, abnormal or disordered and pnoia, breath Breathing is normally an unconscious act Dyspnea is an uncomfortable awareness of breathing.

3 Prevalence Dyspnea is more prevalent in lung cancer patients than the cancer population in general % of patients diagnosed with lung cancer (Dudgeon, Kristjansion, Sloan, Lertzman & Clement, 2001; Muers & Round, 1993) % of advanced cancer population at the time of referral to palliative care 18-79% in the same population in the last week of life (Ripamonti & Fusco, 2002)

4 Pathophysiology Complex Feedback Loop Potential Mechanisms commonly divided into 4 major categories involving disturbances of: Chemosensitivity Pulmonary Receptors Respiratory Muscle Receptors Outgoing Respiratory Muscle Commands (Tobin, 1990)

5 Pathophysiology Generally accepted theory is that dyspnea results from a disassociation or a mismatch between incoming afferent information from receptors in the airways, the lungs and the chest wall structures and central respiratory motor activity. This mismatch produces the sensation of respiratory discomfort. (ATS, 1999)

6 Cancer Demographics % of all cancers in patients 55 years or older Many of those patients also have comorbidities that may contribute to the development of dyspnea

7 Clinical Causes of Dyspnea in Cancer Patients Airway Disease endobronchial obstruction due to tumor or foreign body, extrinsic compression Inflammation (ILD) or Infection (bacterial, viral, fungal) Pleural Disease - tumor spread, malignant effusion

8 Clinical Causes of Dyspnea in Cancer Patients Chest Trauma Rib Fractures, Pneumothorax, Bone Mets Pericardial Effusion Restrictive Cardiomyopathy, Tamponade Cancer Spread Lymphangitic, metastasis Anemia

9 Dyspnea Caused by Cancer Treatment Surgery Volume loss, Phrenic Nerve Injury, Chest Wall Resections, VC injury Radiation Pneumonitis or Fibrosis Chemotherapy induced Pulmonary Toxicity, ILD Chemotherapy induced Cardiomyopathy, Pericardial Effusion Pericardial Disease Resulting from Radiation (Dudgeon, Kristjanson, Sloan, Lertzmanm & Clement, 2001).

10 Case Study # 1 26 year old female with history of asthma and recurrent URIs. She recently gave birth to her 1 st child. She had an uneventful pregnancy & delivery but complained of SOB She presented to her OB with complaints of wheezing and dyspnea

11 Case Study # 1 Her exam was positive for low grade fever, expiratory wheezes & decreased breath on the right CXR revealed RML and RLL infiltrates & atelectasis, elevated R hemi-diaphragm,? Widened mediastinum

12 Chest X-ray with RLL Atelectasis

13 Case Study # 1 1. What is your differential diagnosis? 2. What will you do next?

14 Carcinoid Tumor Obstructing the Right Mainstem Bronchus

15 Right Upper Lobe Sleeve Lobectomy

16 Case Study # 2 64 year old male, 47 pack year smoking history, went to his PCP with a persistent dry cough and DOE On exam you note dullness to percussion and decreased breath sounds on the right

17 Case Study # 2 CXR demonstrated an undifferentiated RUL lung mass arising from the right main stem bronchus

18 Case Study # 2 1. What is your differential diagnosis? 2. What will you do next?

19 RUL Tumor invading RMS Bronchus Pleural Effusion Tumor Right Upper Lobe with large right pleural effusion

20 Case Study # 3 40 year old male with testicular cancer undergoing chemotherapy (Bleomycin, Etoposide, Cisplatin) Presents in clinic after 3 rd cycle of chemo with complaints of dyspnea & tachypnea Denies fever, reports occasional dry cough

21 Case Study # 3 1. What is your differential diagnosis? 2. What will you do next?

22 Chest X-ray & CT demonstrating Pulmonary Toxicity after Chemotherapy

23 Case Study # 4 55 year old male, lifetime nonsmoker, with a biopsy proven RLL NSCLC Surgical staging, bronchoscopy & mediastinoscopy were negative. Underwent right thoracotomy and RLL Uneventful post-operative course, discharged POD 4

24 Case Study # 4 He returns to clinic on POD 10 for routine follow-up He complains of progressive DOE and some orthopnea, but otherwise is doing well Post-op CXR stable with volume loss evident on right, platelike atelectasis but no infiltrates and no pneumothorax.

25 Case Study # 4 Denies fever, chills or sputum production. Post-op pain 2/10, only using Tylenol prn. On exam, AFVSS, Sats 92% at rest on RA

26 Case Study # 4 1. What is your differential diagnosis? 2. What will you do next?

27 Chest X-ray & CTA in patient with a PE

28 Case Study # 5 62 year old female with previously treated breast cancer was doing well until recently She presents with complaints of insomnia, increased anxiety, a dry cough and shortness of breath On exam she is afebrile with normal BP, HR 120, mild JVD

29 Case Study # 5 1. What is your differential diagnosis? 2. What will you do next?

30 CXR, Echo, CT and EKG demonstrate Cardiac Tamponade

31 Case Study # 6 72 year old male with prostate cancer presents with complaints of exertional fatigue, headache, irritability and dyspnea. On exam, he is AFVSS, Sats 90% on RA A&O, NAD at rest

32 Case Study # 6 1. What is your differential diagnosis? 2. What will you do next?

33 Anemia Presentations

34 Assessment of Dyspnea in Cancer Patients 1. Airway central airway obstruction? external compression? 2. Parenchymal Disease infection? inflammation? interstitial process? 3. Pleural Involvement malignant effusion? hemothorax? pneumothorax?

35 Assessment of Dyspnea in Cancer Patients 4. Diaphragm and Vocal Chord Function impaired due to surgery? tumor spread? 5. Cardiac pericardial effusion?, tamponade? 6. Vascular PE?, SVC syndrome?

36 Assessment of Dyspnea 7. Anemia acute or chronic? chemotherapy? 8. Other causes maybe related to comorbidities?

37 Airway Infection or Inflammation? Vascular? Cardiac? Pleural Process? Diaphragm? Anemia? Other Causes?

38 Assessment of Dyspnea History & Physical Heart, lung or neuromuscular abnormalities? Cancer type & treatment history? Tachypnea? Tachycardia? Desaturation? At rest? With ambulation? Pursed Lip Breathing? Using Accessory muscles? Decreased breath sounds? Pallor? Cyanosis? Decreased activity tolerance? Mental status changes?

39 Assessment of Dyspnea Diagnostic Testing CXR infiltrate? pleural effusion? CT Chest tumor progression? metastasis? PFTs restrictive versus obstructive disease? EKG & Echocardiogram, VQ scan, CTA Assess respiratory drive & diaphragmatic function Exercise Testing

40 ATS Approach to the Treatment of Dyspnea Treatment of dyspnea is rooted in the discussions of the mechanisms underlying shortness of breath Treatments are categorized and related to pathophysiologic mechanism versus the underlying disease Therapeutic interventions relieve dyspnea by addressing different mechanisms

41 ATS Approach to the Treatment of Dyspnea Pathophysiologic Mechanism Reduce Ventilatory Demand Reduce Metabolic Load Therapeutic Intervention Exercise Training Supplemental Oxygen Decrease Central Drive Supplemental Oxygen Pharmacy Opiates Anxiolytics Inhalers Fans Pursed-Lip Breathing

42 ATS Approach to the Treatment of Dyspnea Pathophysiologic Mechanism Reduce Ventilatory Impedance Reduce lung hyperinflation Reduce Resistive Load Improve Respiratory Muscle Function Therapeutic Interventions Surgical Volume reduction CPAP Pharmacy (Inhalers) Nutrition Inspiratory Muscle Training Positioning Minimize use of steroids

43 ATS Approach to the Treatment of Dyspnea Pathophysiologic Mechanism Alter Central Perception Therapeutic Interventions Education Congitive-behavioral counseling Distraction Meditation Relaxation Desensitization Pharmacologic Therapy Opiates Anxiolytics

44 Treatment of Dyspnea in the Cancer Patient Treat the cause (cancer therapy) Supplemental Oxygen Medications: Steroids, Bronchodilators, Antibiotics, Opioids, Anxiolytics Blood Transfusions or Epoetin Alpha Drain Effusions / Treat pneumothorax Assess exercise tolerance and plan activities Assess Anxiety & Teach Coping Strategies (Houlihan, Inzeo, Joyce, & Tyson, 2004)

45 Treatment of Dyspnea in the Cancer Patient Dyspnea is a complex symptom! Subjective Multiple Causes Variability in: Intensity Time of Day Activity Emotional Response

46 Goals for Treatment of Dyspnea in Cancer Patients Promote Patient Comfort Increase Exercise Tolerance Promote Physical and Social Well Being (Carrieri & Johnson-Bjerklie, 1986) Modest alterations in physiologic and psychological variables, as a result of a particular treatment, can produce a clinically meaningful reduction in symptoms. (ATS, 1999)

47 Treatment of Dyspnea in the Cancer Patient Effectively managing dyspnea in any patient is a clinical challenge and often requires a combined approach of various interventions. Please consider Quality of Life in your cancer patients with dyspnea as you make your treatment decisions.

48 Thank you for your attention! Questions?