Management of Breathlessness. Alison Graham Lead Nurse Integrated Respiratory Service Central & East Cheshire

Transcription

1 Management of Breathlessness Alison Graham Lead Nurse Integrated Respiratory Service Central & East Cheshire

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3 Breathlessness is a complex event linking physical, psychological, emotional and functional factors and it is a multifaceted symptom

4 Breathlessness we suppress- not abolish, and it is a constant reminder of deterioration (Dr G Corcoran 1997)

5 Dyspnoea Definition a subjective sensation of difficulty in breathing, not related to exertion, that compels the individual to increase ventilation or reduce activity (Professor Sam Ahmedzai)

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7 Causes of breathlessness Increased airflow resistance e.g. chronic obstruction or tumour Increased elastic load, reduced lung compliance e.g. ascites Increased drive to breathe e.g. anaemia Reduced respiratory muscle power e.g. neuromuscular disease, weakness or fatigue.

8 Causes of breathlessness Breathlessness can occur as a direct consequence of lung pathology e.g.chronic lung disease, fibrosis, pneumothorax, infection, pulmonary embolism, heart failure, neuromuscular disease. Anxiety can cause and certainly can exacerbate breathlessness

9 Assessment of breathlessness Whether breathlessness occurs intermittently and if so what triggers it e.g. cold air, exertion or adopting certain positions Whether breathlessness is continuous and experienced at rest The meaning and accompanying thoughts and feelings during episodes of breathlessness

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11 Assessment of Breathlessness The extent to which anxiety and depression may be a component of breathlessness The person s general physical state and rate of decline Disabilities/difficulties breathlessness is causing which might be amenable to help Personal goals and thoughts about the future

12 Management of breathlessness Pharmacological strategies Non-pharmacological strategies

13 Non-pharmacological Positioning Breathing exercises Relaxation Use of fan / open window Management of panic attacks

14 Positioning Forward lean sitting or forward lean standing Leaning back with support High sitting in bed High side lying Avoid lying flat

15 Breathing Exercises Posture! Avoid raised shoulders / tight neck muscles Relaxed abdominal / diaphragmatic breathing Slows down respiratory rate Utilises diaphragm rather than accessory muscles Counting techniques

16 Breathing Techniques - Teaching and Practicing Skills -

17 Aims To understand the principles of breathing techniques To understand how breathing techniques can be used with the breathless patient To be able to perform/teach basic breathing control To have knowledge of positions which will assist a breathless patient To practice other basic adjuncts/skills which may help a patient who is breathless

18 Breathing At rest around 2-3% of body s energy resources are used in breathing Heavy exercise is 3-4% Severe lung disorders 33%

19 Poor Breathing Techniques E.g. Apical Breathing Normally used in heavy exercise Accessory muscles can be utilised Fixing of upper limbs Increased respiratory rate Inefficient breathing leads to poor posture, increases work of breathing results in fatigue, leads to increased breathlessness, this leads to anxiety.

20 Breathing Techniques Breathing control Breathing exercises Positioning for relief Rectangular Breathing Counting Visualisation Relaxation

21 Breathing Control Known as Diaphragmatic Breathing / Normal Breathing Normal tidal breathing Most effective way to breathe Uses lower chest Relaxation in chest and shoulders. Check jaw for tension Comfortable, well supported position, use pillows. E.g. sitting, high side lying

22 Breathing Control Inspiration is the active phase Expiration should be relaxed, passive and effortless Do not instruct to take a deep breath in Difficult to master initially Stress to the patient that this isn t always an easy technique and even people without breathing difficulties can find correct abdominal breathing difficult Useful technique when walking up slope or stairs Used to control bouts of coughing The breathing control should be practiced several times a day

23 Positioning for Relief Supporting the shoulders relaxes the upper chest allowing the abdomen and diaphragm to expand Ensure shoulders are relaxed and check for jaw tension Comfortable position with the support of pillows Sitting in a chair/ semi supine in bed/ keep knees bent. Do not slump in bed. High side lying Forward lean sitting Forward lean standing Leaning forwards on a table

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25 Rectangular Breathing Easy technique Easy access to a square/rectangle e.g. a TV, magazine, picture frame Breathe in on the corner and breathe out along the line OR Breathe in along the shorter edge and out along the longer side Smooth process rather than disjointed As breathing becomes under control the speed at which they go round the rectangle will slow down.

26 Counting This technique can be variable in effectiveness secondary to the speed of counting If able, breathe in through your nose and out through your mouth As you breathe in count 1, 2 and then breathe out 3,4,5,6 Breath out should be twice as long as the breath in Assists in focussing the patients mind on something other than the struggle for breath

27 Other techniques/adjuncts Use of fans Blowing on a feather slowly Blowing bubbles Blow football (straws and ping pong balls) Paper bags Licking lips

28 Relaxation Deep breathing Calm environment Music Relaxation tapes Visualisation

29 Provide pulmonary rehabilitation Make available to all appropriate people, including those recently hospitalised for an acute exacerbation Tailor multi-component, multidisciplinary interventions to individual patient s needs Pulmonary rehabilitation An individually tailored multidisciplinary programme of care to optimise patients physical and social performance and autonomy Hold at times that suit patients, and in buildings with good access Offer to all patients who consider themselves functionally disabled by COPD [new 2010]

30 Effects of Pulmonary Rehabilitation Increased exercise capacity Reduction in hospitalisation Increase knowledge/ self management Decreased anxiety & depression Improved quality of life Enhanced ability to carry out ADL s Desensitisation to dyspnoea

31 Energy Conservation

32 Prioritisation Identify 3 daily activities you do each day Self maintenance (personal care) Productivity (Work/ Occupation/ domestic role Leisure (Hobbies/ interests)

33 Advantages of Prioritisation Gives patient some sense of control by focusing on what is important to them Avoids engagement in pointless activity Enables the patient to consider delegation Minimises loss- encourages pleasurable activities

34 Pacing Consider the rate (speed) at which an activity is achieved- education! What is the patients starting point? Setting goals- (small achievable chunks of the things that matter to the patient)

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36 Stop smoking Encouraging patients with COPD to stop smoking is one of the most important components of their management All COPD patients still smoking, regardless of age, should be encouraged to stop, and offered help to do so, at every opportunity Record a smoking history, including pack years smoked Offer nicotine replacement therapy, varenicline or bupropion (unless contraindicated) combined with a support programme to optimise quit rates [ [

37 Nutrition and COPD/malnutrition 1. Decreased intake Illness Difficulty breathing Anxiety / Stress Food taste changes Fatigue Coughing 2. Increased requirements Increased effort to breathe To fight infection

38 Consequences of Malnutrition Loss of muscle mass Decreased muscle strength/respiratory muscles Impaired heart and lung function Increased vulnerability to infections Decreased recovery from infections Depression & Anxiety Poor self image

39 Diet Diet is very important as patients with advanced COPD are often underweight or even cachexic. Low BMI is suggestive of poor prognosis and increasing their BMI with treatment will improve their prognosis.

40 Advice Eat little and often 3 small meals and 3 snacks if underweight. Avoid gas forming foods e.g. beans, cabbage, fizzy drinks. Reduce dairy produce if prone to producing large amounts of sputum (NB. Calcium). Include oily fish twice a week as omega 3 fish oils protect lungs due to antioxidants. Maintain adequate fluid intake to keep lung secretions thin. Sit at a table to eat. Use oxygen via nasal cannula if needed whilst eating. Avoid lying down 2 hours after eating.

41 Consequences of Obesity Decreased mobility Increased respiratory demands Depression Self-Image Increased risk of Diabetes Mellitus Increased risk of heart disease

42 Sexual Relationships Some help ideas to think about when discussing these areas: Some medications can decrease sex drive or sexual function, e.g. Beta-blockers. Nasal cannula may be needed rather than using a mask, if oxygen is required, it may also be worth suggesting pausing and taking deep breaths from the diaphragm rather than stopping altogether. You may suggest to use short acting bronchodilator before. Changes in sex life are normal part of aging. Positions may be an important factor in ensuring sex is enjoyable, try to use positions that use less energy.

43 Management of Panic Attacks Identify fear Stop thought / internal dialogue Positioning Reassurance Massage Visualisation Involve family

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45 Anxiety

46 What is anxiety? Anxiety is an extremely unpleasant feeling making someone feel frightened, uneasy, unhappy and even desperate. It can affect anyone, male or female, of any age and social background The symptoms of anxiety can affect the whole body, thoughts and emotions.

47 Symptoms of anxiety Breathing difficulty Bowel problems Muscle aches Pounding heart Lump in throat Feeling faint/dizzy headache Tiredness Dry mouth Sweating shakiness

48 Emotional Manifestations Crying Panic Irritability Lack of concentration Negative feelings Fear Loss of confidence

49 Ways To Help Problem solving techniques Relaxation skills Positive thinking Positive action-thought stopping Goal setting Anxiolytics Complimentary Therapies

50 Pharmacological Oxygen Therapy Benzodiazipines Opioids

51 Oxygen Therapy Is the patient hypoxic? Avoid overuse if not Short burst Longer periods Nasal cannulae Less drying to nasal oral mucosa

52 Benzodiazipines Help to reduce fear / anxiety Promote feeling of calm Oral diazepam 2mg tds, Titrate against effect Sublingual lorazepam 0.5mg tds

53 Opioids Respiratory sedatives Only for use in end -stage disease Use to reduce respiratory drive Oral morphine 2.5-5mg, 4 hourly Monitor patient

54 Thank you for Listening