TREATING RESPIRATORY SYMPTOMS IN PEDIATRIC PALLIATIVE CARE: Objectives 10/23/18 FROM DYSPNEA TO NOISY BREATHING

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1 TREATING RESPIRATORY SYMPTOMS IN PEDIATRIC PALLIATIVE CARE: FROM DYSPNEA TO NOISY BREATHING Kris Catrine, MD, FAAP, HMDC October 24, 2018 Objectives Discuss pathophysiology of common respiratory symptoms in PPC Develop a strategy to achieve symptom relief Practice use of opioids as a first-line agent in dyspnea in small groups No disclosures 1

2 ? Step 1: Treat Causes & Factors 1 Step 2: Integrative Therapies 2 1 2

3 Step 3: Pharmacotherapy DYSPNEA Definition Distressing sensation of difficulty breathing Subjective Separate from work of breathing Perceived Need Function DYSPNEA Prevalence Very common in neurologic impairment Occurs in most at end-of-life n Regardless of pulmonary disease Perceived Need Function 3

4 Dyspnea Assessment Self-Report Distress Observational Scale Expressive Signs Restlessness Panicked facial expression Fish breathing Dyspnea Assessment Causes and Contributing factors Anxiety Loneliness Fluid Overload Perceived MalaciaNeed Effusion Parent Distress Anemia Secretions Acidosis Function Dyspnea Treatment: Step 1 Treat Causes & Factors Anxiety Loneliness Malacia Fluid Overload Effusion Anemia Secretions Parent Distress Acidosis Drain CPAP Atropine Volunteers ABX Social Work RBCs Diuretics Albuterol Routine Function 4

5 Dyspnea Treatment: Step 2 Integrative Therapies Anxiety Loneliness Malacia Fluid Overload Effusion Parent Distress Anemia Secretions Acidosis ABX Drain CPAP Atropine Diuretics RBCs Social Work Albuterol Volunteers Routine Function Dyspnea Treatment: Step 2 Integrative Therapies Fan & humidifier Cool temp Positioning Relaxation Distraction Decrease exertion Dyspnea Treatment: Step 3 Pharmacotherapy Anxiety Loneliness Malacia Fluid Overload Effusion Parent Distress Anemia Secretions Acidosis ABX Drain CPAP Atropine Diuretics RBCs Albuterol Social Work Volunteers Routine Function 5

6 Dyspnea Treatment: Step 3 Pharmacotherapy: Oxygen Subjective Hypoxic symptoms Fan effect? Placebo? Past effect? Dyspnea Treatment: Step 3 Pharmacotherapy: Opioids LOWER: Dyspnea perception drive Response to low O2/high CO2 Oxygen consumption Pulm vascular resistance Dose (50% of pain dose) Dyspnea Treatment: Step 3 Pharmacotherapy: Benzodiazepines Second line GABA Anxiety 25-50% of dose Palliative sedation 6

7 Dyspnea Treatment Myths depression Adult RCT studies double effect Opioid Side Effects Prophylactic treatment Rotation Sedation Careful titration Addiction dependence ANDREW 20KG ROUND 1 7

8 Why is Andrew Dyspneic? ACIDOSIS A 1 PT ANXIETY B 2 PTS INFECTION ASPIRATION C 1 PT What Should We Do? ANTIBIOTICS A 1 PT FAN OPIOID B 2 PTS C 2 PT DISTRESSING SECRETIONS Inability to control Neurologically based Worsening with neuro or contributing factor change End of Life Distressing for others Secretions Swallow Cough 8

9 Secretion Assessment Expressed distress Past expression pattern Severity Behavioral observation Frequency Duration Secretion Assessment Causes and Contributing factors Allergies Dying? Medications Autonomic Dysfunction Hydration Volume Secretions Inflammation Swallow Cough Secretion Treatment: Step 1 Treat Causes & Factors Dying? Medications Meds Autonomic Dysfunction Hydration Volume Allergies Hydration Volume Allergies Inflammation Bronchodilator Clonidine Antihistamine Swallow Anti- Inflammatory Cough 9

10 Secretion Treatment: Step 2 Integrative Therapies Dying? Meds Autonomic Dysfunction Hydration Volume Allergies Inflammation Clonidine Bronchodilator Swallow Antihistamine Anti- Inflammatory Cough Gag Secretion Treatment: Step 2 Integrative Therapies Positioning Suction Secretion Mobilization Aromatherapy Salivary gland ligation Secretion Treatment: Step 3 Pharmacologic Therapies Dying? Meds Autonomic Dysfunction Hydration Volume Allergies Inflammation Clonidine Bronchodilator Swallow Anti- Inflammatory Cough 10

11 Secretion Treatment: Step 3 Pharmacotherapy: Anti-cholinergics Atropine drops Glycopyrrolate Botox Saline nebs Mucolytics ROUND 2 JANE 5KG 11

12 Why is Jane Struggling with Secretions? HYDRATION VOLUME A 2 PTS INFLAMMATION B 1 PT INFECTION ASPIRATION C 1 PT What Should We Do? ANTI INFLAMMATORY A 1 PT SUCTION B 1 PT ANTI CHOLINERGIC C 2 PT What Should We Do If Jane s Breathing Were Agonal? STOP HYDRATION A 3 PTS EDUCATE FAMILY C 3 PTS POSITION B 3 PT 12

13 QUESTIONS COUGH Reflex of vagal and glossopharyngeal nerves Mechanical triggers Secretions Chemical triggers Inflammation Irritants Cough Assessment Observe effectiveness May be silent Triggers by history Position Timing Associated factors Level of distress Wet vs dry 13

14 Cough Assessment Causes and Contributing factors Aspiration Medications Infection Reflux Irritants Cough Treatment: Step 1 Treat Causes & Factors Bronchodilators Aspiration Meds Infection Reflux Irritants Antacid JT Nissen Antibiotics Cough Treatment: Step 2 Integrative Therapies Aspiration Bronchodilators Meds Reflux Irritants Antacid Infection JT Nissen Antibiotics 14

15 Cough Treatment: Step 2 Integrative Therapies Chest physiotherapy Positioning Humidifier Cough Treatement: Step 3 Pharmacologic Therapies Aspiration Bronchodilators Meds Reflux Irritants Antacid Infection JT Nissen Antibiotics Cough Treatment: Step 3 Pharmacotherapy: Nebulized saline Bronchodilators Opioids Dextromethorphan 15

16 References: 1. Chan KS, Sham MMK, Tse DMW, Thorsen AB. Palliative Medicine in malignant respiratory disease. In: Doyle D, Hanks G, Cherny N, Calman K, eds. Oxford Textbook of Palliative Medicine. 3rd ed. New York, NY: Oxford University Press; 2003: McGrath PJ, Pianosi PT, Unruh AM, Buckley CP. Dalhousie dyspnea scales: construct and content validity of pictorial scales for measuring dyspnea. BMC Pediatrics. 2005;5: Campbell ML, Templin T, Walch J. A Distress Observation Scale for patients unable to self-report dyspnea. J of Palliat. Medicine. 2010;13(3): Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database System Review. 2008;16(2):CD Friedrichsdorf SJ, Collins JJ. Managing Non-Pain Symptoms in Pediatric Palliative Care. Medical Principles and Practice. 2007;16(1): 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 of Symptom Manage. 2010;39: Currow DC, Agar M, Smith J, Abernethy AP. Does palliative home oxygen improve dyspnoea? A consecutive cohort study. Palliative Medicine. 2009;23(4): Abernethy AP, McDonald CF, Frith PA, Clark K, Herndon JE, 2nd, Marcello J, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnea: a double-blind, randomized controlled trial. Lancet. 2010;376(9743): Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Systems Review. 2008;16(2):CD Clemens KE, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care in Cancer. 2009;17(4): References: 11Clemens KE, Quednau I, Klaschik E. Is there a higher risk of respiratory depression in opioid-naive palliative care patients during symptomatic therapy of dyspnea with strong opioids? J of Palliat. Medicine. 2008;11(2): Mazzocato C, Buclin T, Rapin CH. The effects of morphine on dyspnea and ventilatory function in elderly patients with advanced cancer: a randomized double-blind controlled trial. Ann Oncology. 1999;10(12): Bruera E, Currow T. Strategies for the palliation of dyspnea in cancer. HIV/AIDS Cancer Pain Release. 2009;22(1&2): Qaseem, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Internal Medicine. 2005;148(2): Kvale PA, Selecky PA, Prakash UB. Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition). Chest. 2007;132(3 Suppl):368S-403S. 16 Rapoport A. Sublingual atropine drops for the treatment of pediatric sialorrhea. J of Pain Symptom Manag. 2010;40(5): Wee B and Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008;(1):CD Definition of Cough. MedTerms online medical dictionary A-Z List. Accessed April 16, Ahmedzai, SH. Cough in cancer patients. Pulmonary Pharmacology Therapeutics. 2004;17(6): Friedrichsdorf SJ, Wolfe J, Remke S, Hauser J, Foster L, Emanuel L (eds). The Education in Palliative and Endof-Life Care for Pediatrics Curriculum. EPEC-Pediatrics