Transcript Dyspnoea - Southern Health NHS Foundation Trust

Dr Steve Plenderleith
Consultant in Palliative Medicine
Dyspnoea (Breathlessness)
&
Fear
Session Objectives
To move our focus from “diagnosis” onto
the causes and symptom of SOB.
 From “treatment” to thinking about how to
manage the symptom.
 To increase your ability to help the patient
to understand their breathlessness.
 To spend a couple of minutes considering
Death Rattle.

Dyspnoea
>1% of the population at any time.
> 50% of EoL patients
Find princess alice 100% circle slide
The Problem
Experienced in;
94% of chronic lung disease
83% of heart failure patients
70% of cancer patients in the last 6 weeks of life
Palliative Care
Main symptom in 21% of homecare patients in
last week of life
Post-it Mayhem
60 seconds
The condition causing the most SOB on
your caseload.
1
Best treatments for SOB.
2
Physiology
Nasal breathing 10 000litres per day
Diaphragm main inspiratory muscle
Expiration passive – normally!
Midbrain Respiratory Centre > phrenic and
IC nerves
Neurogenic factors – conscious, limb receptors
(proprioception?), pulmonary receptors (stretch &
irritation), J receptors (congestion)
Chemical factors
Strongest pCO2 – detected in resp. centre; lost in COPD
pO2 below 8kPa – N 11-13; carotid & aortic bodies
H+ rise in respiratory acidosis > incr. ventilation
Physiology
Airway Tone
autonomic control via cholinergic vagal efferents
Circadian rhythm 04:00hrs bronchioles tight
Incr. Tone – cigarettes, dust, post infection,
NSAID’s
Decr. Tone – beta agonists
WHY AM I FEELING
BREATHLESS
What is causing SOB ??
What is causing SOB ??
What is causing SOB ??
Causes
Musculoskeletal
Airway
Obstruction
Lung
Decreased Volume
Increased Lung stiffness
Decreased Alveolar gas exchange
Increased Demand
Tumour
anaemia
Dyspnoea - MEANING
Intensity less important than how unpleasant
Likert scale
Unpleasantness may depend upon
meaning.
The Admiral Graf Spee
Social aspect
How many die a social death long before they
physically die.
Being close to someone SOB is distressing.
Dyspnoea
“Breathlessness, is as bad as the person experiencing it says it is”
Fear of Suffocation
“I really should
have shaved
this morning”,
thought Mable
Normal
1 Lung
1 dodgy lung
Management - MEDICAL
Treat reversible causes
Pleural Effusion
Diaphragmatic Hernia !
Mesothelioma
Invasive Tumour
Sarcoid Masses
Management - MEDICAL

Treat reversible causes
 Pleural
effusion
 LRTI
 Infection
 Bronchospasm
 Cardiac
Failure
 Anaemia
 Obstruction – stent
 SVCO
 etc
So is oxygen the answer?
If O2 saturation is low.
BTS/NICE O2 guidance !!!!

Currow et al. Does palliative home O2
improve dyspnoea?
 Large
5862 patient cohort study, 92% cancer.
 Baseline, 1 & 2 weeks O2 therapy.
 No significant difference in dyspnoea overall
or for any subgroup analysis.
Management - MEDICAL

Treat reversible causes
 etc

O2 ? – only if low, pO2 <92% or <88%

Risk of patient being a CO2 retainer
Over 65, smoker or ex, Hx. of bronchitis, obese.
 Max saturation 92% and monitor
 Chronis et al. AM Thor Soc 2007. Those not on long
term O2. COPD Saturation improved. Cancer NAD. No
clinical benefit proven for either

AND O2 is seen to help
– ?? fan effect
Management - Drug Treatment
Nebulisers – Beta agonist or ipratroprium
Opioids – long acting or patient controlled?
Mahler et al.Eur Resp J 2009 naloxone Vs saline
Abernethy et al. BMJ 2003 MST. NNT 1.5
Benzodiazepines
Lorazepam – very patient controllable SL
Diazepam – back ground anxiety control
Midazolam – Syringe driver or SL
No evidence
Anti-depressants / Diuretics / Analgesics
Nebulised - Saline
Our Aim
Fear of
Breathlessness
Post-it Mayhem 2
List at least 5 non medicine FINGS you can use
to HELP breathlessness
The Panic Hand
Controlled
breathing
(long
breath out)
Fan or air
(via window)
O2 if OK
Splint
chest
(sit up)
Cool
Room
Cool
Drink
Cool
flannel
Nebuliser
or
volumatic
Oramorph
& / or
lorazepam
Visualisation
Phone a
friend
999
Management - ANXIETY
Reassurance / Explain
Perception of breathlessness
Patients don’t suffocate / choke – MND, All
Non drug treatment
Fans
Cold water
Physiotherapy – panic hand, chest breathing,
rehabilitation
Visualisation
New Stuff – horizon scanning
Limbic system – emotion, long term memory –
appears more active (functional MRI) in patients
with dyspnoea associated affective distress. More
scared??
Nebulised fentanyl being lipophilic is rapidly
absorbed leading to Rx serum levels after 5
minutes
Inhaled Fentanyl Citrate Improves Exercise Endurance During HighIntensity Constant Work Rate Cycle Exercise in Chronic Obstructive
Pulmonary Disease. Jensen D et al. J Pain &Sympt Mx 43, 4, 2012,
706–719. BUT doesn’t decrease perception of dyspnoea.
NIV may have a role in hypercapnoeic COPD
Requires a very clear contract of goals of care in
palliative patients.
New Stuff – horizon scanning
Prednisolone 1mg/kg/day (max 60mg) may improve
diuresis in CHF.
Glucocorticoid effect BAD
Mineralocorticoid effect GOOD
So far nothing convincingly works for
dyspnoea in Interstitial Lung Disease.
Constant 19% –both 20% –breakthrough 61%
dyspnoea. 68% <5/day. 88% <10minutes.
Drug
Therapy
Reduce
Oxygen
Use
Alter
Exercise
Perception
Nibble Away
Any Questions
Rattle
“The noisy secretions in a patient close to death”
51-92%
Type 1 – salivary secretions – poor swallow
Type 2 – Bronchial secretions – poor cough
Pulmonary Oedema
Infection – treat or not!
Noisy tachypnoea
Rattle - Aims
Stop that damn noise
Patient Suffering
Education
It’s a sign
Rattle - treatment
Glycopyrronium
Minimal CVS, ocular or CNS effects
200microg stat
600 - 2400mg syringe driver or higher / 24hrs
Less effective at clearing established secretions - anec.
Cheap
Hyoscine Hydrobromide
Crosses blood brain barrier
Sedation or aggitation
400 microg stat
1200 – 2400 microg syringe driver / 24hrs
Best for clearing established secretions – anec.
Expensive
Hyoscine butylbromide
Rattle - treatment
30 – 120mg syringe driver / 24hrs
No sedation
Large volume needed in CSCI
Short acting so less use PRN
Cheap as chips
Oral secretions
Scopoderm patch
Anti-cholinergic
Atropine 1% eye drops
Botox the salivary glands
Suction – for oro-pharyngeal secretions only
Diuretics?
Session Objectives
To move our focus from “diagnosis” onto
the causes and symptom of SOB.
 From “treatment” to thinking about how to
manage the symptom.
 To increase your ability to help the patient
to understand their breathlessness.
 To spend a couple of minutes considering
Death Rattle.
