Dyspnea: The top things you need to you know! Dr. Megan Sellick & Dr. Lawrence Lee Edmonton Zone Palliative Care Program

Transcription

1 : The top things you need to you know! Dr. Megan Sellick & Dr. Lawrence Lee Edmonton Zone Palliative Care Program

2 Faculty / Presenter Disclosure Faculty: Dr. Lawrence Lee Relationships with commercial interests: Grants/Research Support: none Speakers Bureau/Honoraria: none Consulting Fees: none Other: none

3 Faculty / Presenter Disclosure Faculty: Dr. Megan Sellick Relationships with commercial interests: Grants/Research Support: none Speakers Bureau/Honoraria: none Consulting Fees: none Other: none

4 Disclosure of Commercial Support This program has received financial support from: none This program has received in-kind support from: none

5 Objectives By the end of our time together, you will be able to : Recognize the subjective nature of dyspnea Provide an initial management plan for dyspnea (non-pharmacological and pharmacological) Briefly describe palliative sedation and describe the medication used

6 This man has metastatic lung cancer. Which of the following is the best measure of his dyspnea? A- respiratory rate B- use of accessory breathing muscles C- oxygen requirements D- oxygen saturations E- all of the above F- none of the above (patient s report is best)

7 Definition: feeling like one cannot breathe well enough American Thoracic Society: a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.

8 Overall Management Approach: Screen+Assess Identify Cause(s) Management Underlying Cause Symptoms

9 Screen for it ESAS-R ECG of symptoms (here and now) Patient completes if possible Dyspnea/Shortness of breath is included

10 Assessment: History Duration Onset Pattern Severity: Rest vs Exertion Triggers/Alleviating Factors Physical Examination

11 Identify + Manage Underlying Causes in accordance with Goals of Care* Cause Investigations* Treatments* Pleural Effusion CXR Thoracentesis Pneumonia CXR + Bloodwork Antibiotics Airway Obstruction Lymphangitic Carcinomatosis Imaging +/- Bronchoscopy Imaging: CXR/CT Radiation Stenting/Steroids Steroids Anemia Bloodwork Blood Transfusion COPD CHF ALS Bronchodilators, Steroids Cardiac meds, Lasix BiPAP

12 Symptomatic Management: Non-Pharmacological Fan Position: leaning forward, head up Avoid irritants Avoid exacerbating activities: mobilization, transfers, constipation

13 *Symptomatic Management: Pharmacological Oxygen Opioids Other Therapies

14 Symptomatic Management: Oxygen Useful for patients with hypoxia Use cautiously in patients with severe COPD (ie. CO2 retainers) Role in non-hypoxic patients less clear: some may still benefit Not clear whether it is the oxygen or the airflow that is helpful

15 Symptomatic Management: Oxygen When used for comfort, oxygen should be titrated to: A-Improved Oxygen Saturations (ie. O2>95%) B-Reduce Tachypnea (ie. Decrease respiratory rate) C-Decrease Work of Breathing D-All of the Above E-None of the above (titrate to decrease pt s sensation of dyspnea)

16 Symptomatic Management: Oxygen When using O2 for comfort: No need to start if the patient is not complaining of dyspnea No need to continue measuring oxygen saturations at end of life Increase O2 around periods when patient has more dyspnea (ie. Could increase on exertion)

17 Symptomatic Management: Opioids Which is the following is true regarding the use of opioids for dyspnea: A- They block lung opioid receptors to decrease the sensation of dyspnea B- Opioids diminish the sensation of being short of breath in the brain C- They reduce the respiratory rate and allow the patient to rest D- All of the above E- None of the above

18 Symptomatic Management: Opioids Opioids are safe and effective for dyspnea When you start low and go slow, low risk of respiratory depression Similar to cancer pain, they can be provided ATC + PRN (ie. Morphine 2.5 mg PO q6h + q1h PRN for shortness of breath) Diminish the sensation of dyspnea in the brain Nebulized opioids do not show significant benefit

19 Symptomatic Management: Anxiolytics Anti-psychotics: helpful in managing dyspnea-related anxiety Haldol 1 mg PO/SC q12h-q4h ATC + q1h PRN Olanzapine mg PO/Zydis q12h-q4h ATC + q1h PRN Nozinan mg PO/SC q12h-q4h ATC + q1h PRN

20 Palliative Sedation Process of inducing/maintaining deep and permanent sleep in order to relieve refractory symptoms in palliative pts who are close to death. NOT EUTHANASIA Most common indications: delirium, dyspnea?risk of hastening death No evidence! Midazolam: Benzodiazepine with short t1/2 easily titratable by SC infusion

21 Palliative Sedation: Communicating with Family Discuss proactively Review understanding of illness/prognosis, goals of care Sedation used only if symptoms refractory to all other measures Patient will lose ability to communicate Usually irreversible, with death from underlying illness occurring within days

22 Take Home Messages Dyspnea is what the patient self-reports Screen for dyspnea Determine and treat underlying causes when possible/appropriate Use oxygen if it helps and titrate it to comfort, not oxygen saturations Opioids are safe and effective for symptomatic management of dyspnea Treat the anxiety component of dyspnea if it is present Palliative sedation is available for intractable dyspnea