Transcript Slide 1

Palliative Care of
Respiratory
Symptoms
James S. Botts, MD, FACP
Southwest Area Medical Director
VistaCare
Outline of Topics…
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Identification of the Patient with Endstage Pulmonary Disease
Dyspnea
Cough
Pulmonary Infections
Hemoptysis
Pulmonary Hypertension and Cor pulmonale
Primary Pulmonary Hypertension
Pulmonary Fibrosis
Pulmonary Emboli
Stridor
Neuromuscular Disorders & Restrictive Pulmonary Disease
Bronchiectasis and Cystic Fibrosis
α-1 Antitrypsin Deficiency
List of Links
2
Identification of Endstage
Pulmonary Disease
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No single event or parameter signals end stage
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Persistent dyspnea despite optimal medical treatment
Dyspnea impairing efforts to leave home
Increasing number of hospital admissions
Limited improvement after hospitalization
Increasing number of physician visits
Onset of fear, anxiety or panic attacks
Expression of concerns about dying
No reference to oxygen saturation or other parameter of
pulmonary function
It is difficult to accurately identify those with a
prognosis of six months or less
1. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 903
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Identification of Endstage
Pulmonary Disease
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Using CMS LCD pulmonary guidelines
 50%
of patients qualifying for pulmonary disease will
live six months or less (n = 94)*
 Pulse rate > 100 has the best correlation with a
prognosis of six months or less in patients with
endstage pulmonary disease
 65.38% of patients meeting the CMS LCD guidelines
for pulmonary disease with a pulse rate > 100 will live
less than six months (n = 29)*
* Hospice Eligibility Evaluation Database (HEED) ; J.S. Botts
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Palliative Care of
Dyspnea
Main Menu…
Palliative Care of Dyspnea
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Definition of Dyspnea (American Thoracic
Society)
“A subjective experience of breathing
discomfort consisting of qualitatively distinct
sensations that vary in intensity. Physiologic,
psychologic and environmental factors all may
play a role. The severity varies widely among
patients.”(2)
2. American Journal of Respiratory and Critical Care Medicine - Jan 1999
ARS-1
6
Palliative Care of Dyspnea
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Correlation of the complaint with the pathology
of the underlying disease.
 Little correlation in general
 Some correlation of the following:
 “I am drowning.” – Pulmonary edema with CHF
 “I can’t get enough air in.” – Interstitial disease or pulmonary
emboli.(2,3)
 “Tight”, “Constricted” – a sensation used by those with
airways obstruction such as asthma and cystic fibrosis but
not COPD
2. Chest. 2005;127:1877-1878
3. Excerpt: Chest. 2005;127:1877-1878
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Adapted From: Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 898
Motor
Cortex
Peripheral
Chemoreceptors
Sensory
Cortex
Emotions
Personality
Aorta and Carotid Arteries
Dyspnea
Central
Chemoreceptors
Medulla
Sense levels of oxygen,
carbon dioxide and pH
of the blood.
Midbrain
Respiratory
Center
Sense levels of oxygen,
carbon dioxide and pH
of the blood.
Mechanoreceptors
Lungs and Chest Wall
Respiratory
Muscles of
Breathing
Sense stretching of
structures in lungs and
chest wall
Pathophysiology of Dyspnea
9
Palliative Care of Dyspnea
Assessment of Dyspnea
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Five etiologic categories
 Cardiac
 Pulmonary
 Neuromuscular
 Psychiatric
/ Social / Spiritual
 Any combination of the above
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Palliative Care of Dyspnea
Assessment of Dyspnea
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History and Physical Examination
 Frequently
identifies the specific system
responsible for the dyspnea
 Indicated diagnostic testing follows
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Palliative Care of Dyspnea
Assessment of Dyspnea - Testing
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Pulmonary Testing
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ABG
Chest X-ray
Pulmonary Functions
Bronchial Challenge
High resolution CT
Lung scan
PET
Diaphragmatic Fluoroscopy
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Cardiac Testing
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EKG
Echocardiography
Coronary angiography
Myocardial perfusion scan
Other
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Sleep studies
Esophageal pH monitoring
Laryngoscopy
Often hospice and palliative care patients choose not to be tested, placing
more reliance on the history and physical examination.
12
Palliative Care of Dyspnea
Assessment of Dyspnea
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Reporting Intensity of Dyspnea
 Verbal
numerical scales (0-10)
 VAS (Visual Analog Scale)
 Modified Borg Dyspnea Scale
Link to Modified Borg Dyspnea Scale
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Palliative Care of Dyspnea
Assessment of Dyspnea
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Common Physiological Measurements of
Respiratory Disease
 Spirometry
 FEV1 is a POOR predictor of dyspnea and improvements in
dyspnea after bronchodilators do not match improvements of
FEV1(4,5)
 Oxygen saturation – with its limitations(6)
 NOT a good predictor of the subjective feeling of dyspnea
4. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 899
5. Lareau, S.C. et al. (1999).Dyspnea in patients with chronic obstructive pulmonary disease: does
dyspnea worsen longitudinally in the presence of declining lung function? Heart & Lung 28 65-73
6. eMedicine - Pulmonary Function Testing : Article by Raed A Dweik, MD, FACP, FCCP, FRCPC
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Palliative Care of Dyspnea
Treatment – Non-Pharmacologic
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Influenza and pneumonia vaccines
Cold facial stimulation (i.e. fan)(6)
Nutrition(7)
 Weight
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gain for malnourished COPD (“pink puffer”)
Weight reduction is accompanied by respiratory muscle
weakness. Non-fluid weight gain will help correct this
Weight gain is difficult to achieve – poor response to
nutritional supplements
 Weight
loss for hypercapnic COPD (“blue bloater”)
6. Am Rev Respir Dis. 1987 Jul;136(1):58-61
7. Am Rev Respir Dis. 1990 Aug;142(2):283-8.
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Palliative Care of Dyspnea
Treatment – Non-Pharmacologic
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Controlled cough
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Forced expiration – incentive spirometry
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Deep breath followed by coughing
For clearing secretions
Good for prevention and treatment of atelectasis
Follow with controlled cough to clear secretions
Emotional, spiritual and social counselling
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These issues are important just as they are in the control of pain
Addressing these factors may improve the sensation of dyspnea
8. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 904
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Palliative Care of Dyspnea
Treatment – Non-Pharmacologic
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Exercise(8)
 Exercise
is the best way to strengthen the respiratory
muscles
 Methods
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Walking; stair climbing;
Upper extremity and shoulder girdle strengthening
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These are accessory muscles of breathing
Pulmonary rehabilitation
Inspiratory resistance breathing
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No better than general reconditioning exercise alone in COPD
patients
8. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 904
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Palliative Care of Dyspnea
Treatment – Non-Pharmacologic
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Controlled Breathing(8)
 Purse
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Improves alveolar ventilation and gas exchange
 Slow
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lipped breathing
expiration
Useful in overcoming associated panic attacks
 Bending
forward position
Improves diaphragmatic function through
increasing intraabdominal pressure
 Helps relieve dyspnea
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8. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 904
19
Palliative Care of Dyspnea
Treatment – Non-Pharmacologic
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BiPAP (Bilevel Positive Airways Pressure)
 Reduces
time in ICU
 Reduces need for intubation
 Reduces mortality in COPD exacerbations
 Improves quality of life in ALS patients (64)
 Value of BiPAP in a skilled care setting to
“rest” the respiratory muscles is uncertain
8. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 904
64. Neurology. 2003 Jul 22;61(2):171-7
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Palliative Care of Dyspnea
Treatment – Non-Pharmacologic
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Summary…
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Immediate treatment
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Cold facial stimulation with a fan
Controlled cough
Forced expiration
Pursed lip breathing
Slow expiration
Bend forward posture
Non-immediate treatment
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Vaccinations – influenza & pneumococcal
Nutritional assessment and treatment
Addressing emotional, social and spiritual issues
Exercise – walking; stair climbing; shoulder girdle strengthening
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Palliative Care of Dyspnea
Treatment – Pharmacologic
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Bronchodilators
Antiinflammatories
Oxygen
Anxiolytics
ARS-2
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Mucolytics
Antidepressants
Antibiotics
22
Palliative Care of Dyspnea
Treatment – Pharmacologic - Bronchodilators
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β2 agonists – in COPD
 Do
not necessarily improve FEV1 or FVC
 Do improve dyspnea
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Anticholinergics
 Improve
FEV1
 Reduce dyspnea
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Phosphodiesterase Inhibitors
 Theophylline
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Leukotriene Antagonists
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Bronchodilators
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β2 agonists
 In
stable COPD
Short acting levalbuterol (Xopenex®) – In stable
COPD patients, no advantage over racemic
mixture (albuterol) in prn doses(9)
 Long acting β2 agonists salmeterol (Serevent®),
formoterol (Foradil®), arformoterol (Brovana®)

9. Chest. 2003 Sep;124(3):844-9
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Bronchodilators
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Anticholinergics
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Short acting –
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Ipratropium (Atrovent®)
Long acting
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Tiotropium (Spiriva®)
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Tiotropium (Spiriva®) alone is more effective than long acting β2
agonists alone in COPD patients (10)
Tiotropium (Spiriva®) added to a regimen of a long acting β2 agonist
and a corticosteroid significantly improved dyspnea, FEV1 and FVC in
COPD patients(11)
Comparing tiotropium alone to fluticasone/salmeterol/tiotropium
therapy showed no difference in rates of COPD exacerbation but the
combination therapy did improve lung function, quality of life, and
hospitalization rates in patients with moderate to severe COPD.(11a)
10. Thorax. 2003 May;58(5):399-404
11. Respirology. 2006 Sep;11(5):598-602
11a. Annals of Internal Medicine. 2007 April 17; 146( 8):545-555
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Bronchodilators
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Theophylline(12)
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A non-selective phosphodiesterase (PDE) inhibitor with
antiinflammatory and bronchodilatory effects
Improves dyspnea
Improves FEV1
24 hour sustained release preparation may be given once before
bedtime without disturbing sleep (13)
Is now used less because of narrow therapeutic range and risks
of toxicity. ? Resurgence due to antiinflammatory effects and
lower serum levels (<10mg/L).(35a)
On the horizon, “Cilomilast and roflumilast are selective PDE4
inhibitors that are currently in pre-registration and phase III
clinical trials, respectively, for the treatment of COPD (cilomilast
and roflumilast) and for treatment of asthma (roflumilast).”(35)
12. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 903
13. Chest, Vol 110, 648-653
35. Curr Opin Investig Drugs. 2006 May;7(5):412-7
35a. American Journal of Respiratory and Critical Care Medicine Vol. 167. pp. 813-818, (2003)
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Bronchodilators
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Leukotriene Receptor Antagonists
 Zafirlukast
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(Accolade®)–
Has bronchodilation effect in COPD and asthma
There is no additive effect when added to inhaled steroids (34)
May reduce pulmonary hypertension in COPD(35)
 Montelukast
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(Singulair®)
There is long term benefit in elderly COPD patients with
moderate to severe disease(36)
34. Pulm Pharmacol Ther. 2000;13(6):301-5
35. Chin Med J (Engl). 2003 Mar;116(3):459-61
36. Respir Med. 2004 Feb;98(2):134-8
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Antiinflammatories
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Corticosteroids in the treatment of COPD / Dyspnea
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Short term oral corticosteroids:
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Acute exacerbation of COPD
Long term inhaled corticosteroids:
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Reduces all cause mortality in moderate to severe COPD(14)
Not a first line drug in mild COPD(15)
Long term oral corticosteroids:
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Only in those not responding to inhaled corticosteroids
Sometimes beneficial in hospice patients with malnutrition
Identification of those who will benefit from long term use:
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Remains controversial
One method:
 Check FEV1 then give a trial of 20-40 mg prednisone per day for 14
days, then repeat the FEV1. A ≥ 20% increase indicates the patient
will benefit from inhaled steroids(16)
14. Thorax. 2005 Dec;60(12):992-7. Epub 2005 Oct 14
15. Curr Opin Pulm Med. 2004 Mar;10(2):113-9
16. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 903
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Antiinflammatories
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Nebulized Indomethacin
 May
be of value in reduction of mucus
secretions in bronchiectasis and chronic
bronchitis(52,53)
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Inhibits production of a proteolytic enzyme,
neutrophil elastase
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May have long term beneficial effect on progression of
bronchiectasis
 Dyspnea
was improved(52)
52. Am Rev Respir Dis. 1992 Mar;145(3):548-52
53. Eur Respir J. 1995 Sep;8(9):1479-87
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Oxygen
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Indications
O2 saturation ≤ 89% with or without dyspnea
 Those with dyspnea relieved by O2 despite the resting
oxygen saturation.
 Resting
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Studies have shown ↑ survival with use of long
term oxygen, as well as improvement in health
related quality of life measures including
dyspnea (17,18)
The level of O2 saturation does not correlate with
the degree of dyspnea (17)
17. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 903
18. Curr Opin Pulm Med. 2004 Mar;10(2):120-7
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Oxygen
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Beware!
 Patients
on oxygen with high oxygen
saturation and confusion or lethargy may
have C02 retention
Treat with discontinuation or reduction in oxygen
flow and close observation
 Titrate to the flow of oxygen that does not cause
the confusion or lethargy
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31
Palliative Care of Dyspnea
Treatment – Pharmacologic - Opioids
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Meta-analysis concludes that opioids in modest
doses are effective in treating dyspnea(28)
Dose – as little as 2.5 mg of MS q4h(29)
Sustained release morphine reduces dyspnea(27)
(Don’t start on the sustained release forms.)
27. BMJ. 2003 Sep 6;327(7414):523-8
28. Thorax. 2002 Nov;57(11):939-44
29. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 904
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Opioids
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No clear evidence that inhaled morphine is
effective in the relief of dyspnea(30)
30. Eur Respir J. 1997 May;10(5):1079-83
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Anxiolytics
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Benzodiazepines
 Scant
literature on the use of benzodiazepines in the
treatment of dyspnea but they are commonly used (19,
20)
 Opioids
are first line anxiolytic drugs for dyspnea
secondary to advanced disease of any cause(21)
19. Q J Med. 1980 Winter;49(193):9-20
20. Am J Hosp Palliat Care. 1998 Nov-Dec;15(6):322-30
21. Can Fam Physician. 2003 Dec;49:1611-6.
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Anxiolytics
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Buspirone (BuSpar®)
 Conflicting
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reports of its effect on dyspnea(22,23)
Concerns about respiratory depression in COPD
patients receiving anxiolytics is unfounded.(24)
Anxiolytics can be beneficial in some patients
with dyspnea, even those without appreciable
anxiety.(24)
22. Respiration. 1993;60(4):216-20
23. Chest. 1993 Mar;103(3):800-4
24. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 904
35
Palliative Care of Dyspnea
Treatment – Pharmacologic - Mucolytics
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N-Acetylcysteine (Mucomyst®) by mouth
or inhalation will help patients with
excessive or viscous mucous clear these
secretions
 Effect
on dyspnea has not been studied
 Evidence is conflicting as to its reduction of
COPD exacerbations(31,32)
31. Lancet. 2005 Apr 30-May 6;365(9470):1552-60
32. Eur Respir J. 2003 May;21(5):795-8
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Palliative Care of Dyspnea
Treatment – Pharmacologic - Mucolytics
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Additional agents that may assist in mucolysis and
expectoration of thick sputum:
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Normal or hypertonic saline nebulizations
Inhaled mannitol powder (66)
Inhaled atropine
Corticosteroids
β2 agonists
Indomethacin
Theophylline
Glycerol guaiacolate

Of limited value
33. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 904
66. Respirology. 2005 Jan;10(1):46-56
37
Palliative Care of Dyspnea
Treatment – Pharmacologic - Antidepressants
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SSRIs; Tricyclics – In depressed patients with
endstage lung disease
 Beneficial
for anxiety
 Benefit for dyspnea is not conclusive (25,26)
25. Psychosomatics. 1998 Jan-Feb;39(1):24-9.
26. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 904
38
Palliative Care of Dyspnea
Treatment – Pharmacologic - Antibiotics
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Treatment of Exacerbations
 Antibiotics
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Fluoroquinolones (37,38)
Amoxicillin almost as effective and cheaper(39)
acting β2 agonists → long acting
 Short acting anticholinergics → long acting
 Oral prednisone → Inhaled corticosteroid
 Short
37. Clin Microbiol Infect. 2006 May;12 Suppl 3:42-54
38. Chest. 2004 Mar;125(3):953-64
39. American Family Physician Vol. 70/No. 4 (August 15, 2004)
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Palliative
Treatment of
Cough
Main Menu…
Palliative Care of Cough
Assessment
Many patients will not want the usual
diagnostic tests
 A thorough history and physical
examination is often our best and only tool
for assessing the cause of the cough
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ARS-3
41
Palliative Care of Cough
Assessment
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Causes
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Acute infections
Chronic Infections
Airways Disease
Cardiovascular
Parenchymal Disease
Irritant
Recurrent Aspiration
Drug Induced
Pleural Disease
Vocal Cord Disease
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Examples
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Pneumonia; Acute Bronchitis
Chronic bronchitis; Bronchiectasis
COPD; Asthma
LV failure; pulmonary edema
Interstitial Fibrosis
GERD; Foreign body
Stroke; Motor neuron disease
ACE Inhibitors; inhaled drugs
Pneumothorax; pleural effusion
Paralysis; nodules on cords
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 899
42
Palliative Care of Cough
Treatment of the Underlying Cause
Acute and chronic infections
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Diuretics, ACE inhibitors, ± βblockers
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Recurrent aspiration
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Postioning of patient;
swallowing evaluation → alter
food consistency
ENT evaluation and treatment
GERD
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Correct pneumothorax; drain
pleural effusion
Vocal cord dysfunction

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Discontinue drug
Pleural disease
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Bronchodilators and antiinflammatories
Left ventricular failure

Drug induced (ACE inhibitors)
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Antibiotics
Asthma and COPD
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PPIs; metoclopramide;
positioning of patient
Post-nasal drip
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Decongestants; antihistamines
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 899
43
Palliative Care of Cough
Treatment – Protussive and Antitussive
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Protussive Treatments
 Measures
to improve cough effectiveness
and secretion clearance

Antitussive Treatments
 Measures
to prevent or eliminate cough
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 899
44
Palliative Care of Cough
Treatment – Protussive Treatments

Measures to make cough more effective(40)
hydration – po fluids; steam
inhalations; saline nebulizations
 Physiotherapy – only in select patients with
COPD and bronchiectasis (41)
 Adequate
Forced exhalations
 Airways vibrations
 Postural drainage
 Assisted cough techniques

40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 899
41. Chron Respir Dis. 2006;3(2):83-91
45
Palliative Care of Cough
Treatment – Protussive Treatments

Measures to make cough more effective(40)
 Pharyngeal
suctioning
 Mini-tracheostomy
 For thick, excessive, infected sputum
Steroids
 Antibiotics
 Inhaled mannitol powder or hypertonic saline (42,43)

40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 899
42. Cochrane Database Syst Rev. 2005 Jul 20;(3):CD001506
43. J Aerosol Med. 2002 Fall;15(3):331-41
46
Palliative Care of Cough
Treatment – Protussive Treatments

Increase of secretion clearance (40,44)
 Liquification
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of secretions
N-acetylcysteine
Recombinant human DNAse
Arginine – not as effective as N-acetylcysteine
Uridine-5'-triphosphate – useful for getting sputum samples
from mild chronic bronchitics (67)
 Bronchodilators

β2 – agonists (albuterol)
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 900
44. Expert Opin Pharmacother. 2004 Feb;5(2):369-77
67. Chest. 2002 Dec;122(6):2021-9
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Palliative Care of Cough
Treatment – Antitussive Treatments
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Antitussive Treatment
 Used
when cough is not reversible
 Used primarily for dry non-productive cough
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Opioids
Oral local anesthetics
Nebulized local
anesthetics

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Other antitussive agents
Antimuscarinics
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 900
48
Antitussive Treatment of Cough
ACP Medicine 2006
ARS-4
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Palliative Care of Cough
Treatment – Antitussive Treatments
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Opioids
 Morphine

Useful especially in the terminal patient
 Codeine

is the strongest antitussive (47)
is used widely
In its OTC form codeine has no more antitussive effect than
the demulcent vehicle (47)
 Dextromethorphan


– an opioid derivative
No analgesic effect in antitussive doses
As effective as codeine for cough suppression
45. Chest. 2006 Jan;129(1 Suppl):284S-286S
46. Pulm Pharmacol Ther. 2004;17(6):459-62
47. Thorax. 2004 May;59(5):438-40
50
Palliative Care of Cough
Treatment – Antitussive Treatments

Oral Local Anesthetics
 Benzonatate


(Tessalon Perles ®)
Peripheral acting / opiates largely central acting
Often effective in opiate resistant cough (47)
 Levodropropizine


– not available in USA
Widely used in Europe
Peripheral acting and useful in cancer related cough (47)
45. Chest. 2006 Jan;129(1 Suppl):284S-286S
46. Pulm Pharmacol Ther. 2004;17(6):459-62
47. Thorax. 2004 May;59(5):438-40
51
Palliative Care of Cough
Treatment – Antitussive Treatments

Nebulized Local Anesthetics
 Risk

is aspiration 2-4 hours after a treatment
Patient should not eat or drink for 1 hour after Rx
 Nebulized
lidocaine is effective in reduction of
cough (48, 49) (5mg/kg in normal saline)
 Bupivacaine and Lidocaine have been
associated with bronchoconstriction in
patients with reactive airways. Consider giving
with salmeterol (50)
48. Am J Emerg Med. 2001 May;19(3):206-7
49. Emerg Med J. 2005 Jun;22(6):429-32
50. Canadian Family Physician. May 2002
52
Palliative Care of Cough
Treatment – Antitussive Treatments

Other Antitussive Agents
 If
cause is bronchospasm, inflammation, or
tumor…
Theophylline
 β2 –agonists
 Anti-inflammatories

Steroids
 Sodium cromoglycate

40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
53
Palliative Care of Cough
Treatment – Antitussive Treatments

Other Antitussive Agents
 OTC
Marketed as Antitussive but Not Proven
Effective
Pseudoephedrine
 Dexbrompheniramine
 Guaifenesin

40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
54
Palliative Care of Cough
Treatment – Antitussive Treatments

Antimuscarinics
 Ipratropium

bromide
Good in chronic bronchitis

Reduces secretions without reduction in mucus viscosity
 Hyoscine
.2-.4mg sc prn or Glycopyrronium
bromide .2-.4 mg IM prn
Good for the death rattle and associated cough
 May cause ataxia and hallucinations in the elderly

40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
55
Palliative Care of Cough
Treatment – Antitussive Treatments

Antimuscarinics (68)
 Ophthalmic Atropine

1% drops
Give sublingually or po
 Scopolamine
Patch ®
Hyoscine in a patch
 Not effective for about 12 hours

68. AAHPC Fast Fact and Concept #109: Death rattle and oral secretions
56
Palliative Care of
Respiratory
Infections
Main Menu…
Palliative Care of Respiratory
Infections
Treatment – Establishing Goals

Above all - goals must be discussed and
formulated with the patient and family
 The
patient or POA may ultimately decide
against antibiotic therapy

If antibiotics are not chosen as a treatment,
symptomatic treatment of fever, dyspnea and
cough should be the plan
58
Palliative Care of Respiratory
Infections
Treatment – Antibiotic Selection
COPD with FEV1 < 50% (Most hospice
patients with end stage lung disease)
exacerbations should be treated with a
quinolone
 COPD with FEV1 > 50% use ampicillin,
tetracycline or trimethoprim/sulfa

51. ACP Medicine Chapter 14:Respiratory Medicine: III Chronic Obstructive Disease of the Lung
59
Palliative Care of Respiratory
Infections
Treatment – Antibiotic Selection

Bronchiectasis and Cystic Fibrosis
 Coverage
of anaerobic bacteria and
pseudomonas are important
 Antibiotics should be given in high doses,
sometimes rotated and for 3-4 week courses
Ciprofloxacin
 Metronidazole
 Augmentin

40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
60
Palliative Care of Respiratory
Infections
Treatment – Antibiotic Selection

Bronchiectasis and Cystic Fibrosis
 Nebulized
antibiotics
Gentamicin (300 mg bid)
 Tobramycin (300 mg bid)

40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
61
Palliative Care of
Hemoptysis
Main Menu…
Palliative Treatment of Hemoptysis
Assessment
Majority of cases are mild to moderate
 <20% are massive (> 500 cc per day)
 Most common causes

 Infection
~ 80%
TB
 Abscesses
 Bronchiectasis

 Malignancy
~ 20%
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
63
Palliative Treatment of Hemoptysis
Assessment


History and Physical Examination
Examination of the sputum

Presence of food particles



Purulent sputum


Hematemesis
T/E fistula
Infection
Laboratory and X-Ray Studies



Chest x-ray
CT with contrast
Bronchial artery or pulmonary artery arteriogram
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
64
Palliative Treatment of Hemoptysis
Treatment - Anticipatory

Anticipation - If resuscitation is or is not the goal
 Education
of patient, family and caregivers
 Goals must be established
 Dark colored towels
 Morphine
 Anxiolytics



Lorazepam
Diazepam
Midazolam
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
65
Palliative Treatment of Hemoptysis
Treatment of Massive Hemoptysis

If resuscitation is the goal…
 Patent airway + oxygen
 Intubation and ventilation if needed
 Position
 Lateral decubitus


Head down
Bleeding lung down
 Determine
the site of bleeding
 Avoid excessive manipulation
 Cough suppression (codeine 30-60 mg po q6h)
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
66
Palliative Treatment of Hemoptysis
Treatment of Massive Hemoptysis – Goal Resuscitation

If resuscitation is the goal…(continued)
 Immediate bronchoscopy
 If source identified, lavage with iced saline and adrenalin
(10cc of 1:10,000 dilution)
 Topical thrombin
 Balloon catheter tamponade
 Vasopressin
 Bronchial stent placement
 If source not found
 CT with contrast
 Bronchial or pulmonary angiography
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
67
Palliative Treatment of Hemoptysis
Treatment of Massive Hemoptysis – Goal Resuscitation

If resuscitation is the goal…(continued)
 Bronchial arterial embolization
 Successful in 70-100% of cases
 Especially good in those with dilated bronchial arteries
(bronchiectasis)
 Complications




Rebleeding - common
Anterior spinal artery infarction and paraplegia – 5%
Ischemic necrosis of the bronchus
Arterial dissection
 Surgical
resection of the bleeding tissue
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 901
68
Palliative Care of
Pulmonary
Hypertension and
Cor Pulmonale
Main Menu…
Palliative Care of Pulmonary
Hypertension and Cor Pulmonale

Clinical Manifestations
 Dependent
edema
 Right ventricular hypertrophy
 Right ventricular dilatation
ARS-5
70
Palliative Care of Pulmonary Hypertension and
Cor Pulmonale
Etiology and Pathophysiology


Most chronic pulmonary diseases can ultimately cause
pulmonary hypertension and cor pulmonale
Pathophysiology (56)

COPD – severe pulmonary hypertension only in a small
percentage of COPD patients

Hypoxia → constriction of pulmonary arterial vasculature –
However…





Chronic inflammation
Repeated hyperinflation of the lungs
Cigarette smoking
Pulmonary Emboli and Pulmonary Fibrosis


Poor correlation between arterial p02 and pulmonary artery pressure in
COPD
Obstruction of the pulmonary vasculature
Primary Pulmonary Hypertension

Etiology unknown
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 909
56. The Proceedings of the American Thoracic Society 2:20-22 (2005)
71
Palliative Care of Pulmonary Hypertension and
Cor Pulmonale
Pathophysiology

Pathophysiology of Edema in COPD










Exercise →
↑ right ventricular end diastolic pressure →
↑ stretching of the right atrium →
↑ sympathetic tone →
↑ renin angiotensin aldosterone production →
↑ renal distal tubular retention of water and sodium →
↑ edema (56)
C02 retention →
↑ renal proximal tubular sodium retention →
↑ edema
56. The Proceedings of the American Thoracic Society 2:20-22 (2005)
72
Palliative Care of Pulmonary Hypertension and
Cor Pulmonale
Treatment
Treat the underlying pulmonary disease
 Oxygen

 Long

 In

term oxygen therapy in COPD
Only produces a small decrease in pulmonary
artery pressure
acute exacerbations of COPD
Delivered with BiPAP , reduces pulmonary artery
pressure
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 909
73
Palliative Care of Pulmonary Hypertension and
Cor Pulmonale
Treatment

β2 – agonists

Reduce pulmonary artery pressure
 Increase right ventricular ejection fraction

Diuretics – the primary treatment of edema

Edema is secondary to –





Hypoxic renal dysfunction
Excessive release of pituitary hormones
Not caused by right heart failure
Caution: hypochloremic alkalosis → ↓ ventilation and C02 retention
Calcium Channel Blockers


Only short term effect on pulmonary hypertension
May produce ventilation-perfusion mismatch and worsen oxygen
saturation
 May produce systemic hypotension
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 909
74
Palliative Care of Pulmonary Hypertension and
Cor Pulmonale
Treatment

ACE Inhibitors
 Cause
systemic hypotension
 No improvement in pulmonary vascular
resistance, gas exchange or ventilatory
parameters
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 909
75
Palliative Care of
Primary
Pulmonary
Hypertension
Main Menu…
Palliative Care of Primary Pulmonary
Hypertension
Treatment

Endothelin antagonists
 Bosentan



Oral endothelin receptor blocker
Mild improvement in dyspnea
36 meter increase in 6 minute walking distance



(Tracleer®) (57) –
Approved for use in pulmonary arterial hypertension
May be used in patients with COPD and severe pulmonary
hypertension, but these patients are difficult to identify in an
end of life setting. Clinical trials are ongoing.(58)
Caution – Numerous drug interactions
57. U.S. Pharmacist Vol. No: 30:05 Posted: 5/16/05
58. Curr Opin Pulm Med. 2003 Mar;9(2):139-43
77
Palliative Care of Primary Pulmonary
Hypertension
Treatment

Prostacyclin Analogs
 Epoprostenol
(Flolan®) and Treprostinil
(Remodulin®)


Improves exercise tolerance
Must be given as a continuous infusion
 Iloprost (Ventavis®)
 Inhaled
 Improves exercise tolerance
 Beraprost – Not available in
 Inhaled
 Improvement in symptoms
57. U.S. Pharmacist Vol. No: 30:05 Posted: 5/16/05
USA
78
Palliative Care of Primary Pulmonary
Hypertension
Treatment

Phosphodiesterase V Inhibitors

Sildenafil (Viagra®)


Improves exercise tolerance
Other phosphodiesterase V inhibitors are being evaluated


Tadalafil (Cialis®) – only once daily dosing
Anticoagulants

Warfarin –




To prevent microthrombi formation in pulmonary circulation
To prevent thrombophlebitis in the lower extremities
Keep INR at 1.5 - 2.5
Reduces progression of the disease and those symptoms that will
worsen with progression of the disease
57. U.S. Pharmacist Vol. No: 30:05 Posted: 5/16/05
79
Palliative Care of
Pulmonary
Fibrosis
Main Menu…
Palliative Care of Pulmonary Fibrosis
Treatment
Pneumoconioses – Most Common Cause
 Idiopathic Pulmonary Fibrosis

 Treatment
with interferon gamma-1b
Conflicting evidence of effectiveness (59,60)
 Metaanalysis suggests it does prolong life ( 61)


In general pulmonary fibrosis patients do
not retain CO2
 High
flows of oxygen may be used
59. Mayo Clin Proc. 2003 Sep;78(9):1082-7
60. Ann Pharmacother. 2005 Oct;39(10):1678-86. Epub 2005 Sep 13
61. Chest. 2005 Jul;128(1):203-6
81
Palliative Care of
Pulmonary Emboli
Main Menu…
Palliative Care of
Pulmonary Emboli
Most deaths from PE are a result of
inadequate prophylaxis
 Which end of life patients should receive
prophylaxis?

 End
stage cardiopulmonary patients
 Cancer patients with prothrombotic tumors
 Minimal data on prophylactic treatment VTE in
end of life outpatients
83
Palliative Care of
Pulmonary Emboli

Current VTE Prophylaxis
 Hydration
 Not crossing legs
 Traditional stockings probably
 Encouraging mobility
not effective
 Drug therapy
 Low molecular weight heparin is preferred



No prothrombin time needed
Once daily injection
Warfarin


INR should be 2-3
Difficult to regulate in the end of life patient because of other
drug therapies and fluctuating liver functions
84
Palliative Care of
Pulmonary Emboli

On the horizon…
 Ximelagatran
Oral medication
 As effective as low dose warfarin with enoxaparin
 Not yet approved because of potential
hepatotoxicity and ↑ incidence of coronary events

 Idraparinux
Once weekly injection
 In phase III trials

62. Semin Vasc Med. 2005 Aug;5(3):276-84
85
Palliative Care of
Stridor
Main Menu…
Palliative Treatment of Stridor

Causes
Infection – epiglottitis, diphtheria
 Tumor
 Aspirated objects











Thick sputum
Blood clots
Foreign bodies
Dislodged tumor particles
Crohn's Disease – rare – resistant to dexamethasone (54)
Diffuse Idiopathic Skeletal Hyperostosis (DISH) Forestier’s Disease –
from large cervical spine osteophytes compressing the trachea (55)
Achalasia – megaesophagus compression of trachea (56)
Myasthenia gravis – presenting with exertional stridor (57)
Psychogenic stridor (58)
Drug hypersensitivity – amphotericin (60)
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 902
54. Chest. 2006 Aug;130(2):579-81
55. J Laryngol Otol. 1999 Jan;113(1):65-7
56. Eur J Gastroenterol Hepatol. 1997 Nov;9(11):1125-8
57. Thorax. 1996 Jan;51(1):108-9
59. Gen Hosp Psychiatry. 1994 May;16(3):213-23
60. Ann Allergy Asthma Immunol. 2003 Nov;91(5):460-6
87
Palliative Treatment of Stridor
Treatment – Non-pharmacologic and Pharmacologic

Treatment







Postural manipulation
Heimlich maneuver – for acute onset stridor
Physiotherapy
Bronchoscopy or laryngoscopy
Tracheostomy
Stents
Medications



Dexamethasone 16 mg po qd for edema or inflammation
Oxygen / Helium 4:1 Mixture
Infliximab – for Crohn’s Disease (54)
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 902
54. Chest. 2006 Aug;130(2):579-81
88
Palliative Care of
Neuromuscular and
Restrictive Pulmonary
Disorders
Main Menu…
Palliative Care of Neuromuscular Disorders and
Restrictive Pulmonary Disease




Hypercapnia and sleep disorders are very
common in neuromuscular disorders
MS and ALS – bulbar disorders result in
dysphagia and frequent aspiration and
pneumonia
Long term anticoagulation is often prescribed for
thromboembolic prophylaxis
Glossopharyngeal breathing is a good technique
to improve ventilation in patients with high
cervical injuries
90
Palliative Care of Neuromuscular Disorders and
Restrictive Pulmonary Disease

Non-invasive mechanical ventilation
 Rocking
beds
 Abdominal pneumatic belts
 Negative pressure ventilators
 Nasal CPAP
91
Palliative Care of
Bronchiectasis and
Cystic Fibrosis
Main Menu…
Palliative Care of Bronchiectasis and
Pulmonary Fibrosis

Nebulized Deoxyribonuclease (DNAse)
 Hydrolysis
of extranuclear DNA that
accumulates with neutrophil degradation in
infected airways

Useful in cystic fibrosis and to a lesser extent in
bronchiectasis
40. Derek, D. et al. (2004). Oxford Textbook of Palliative Medicine, pp. 908
93
Palliative Care of
α-1 Antitrypsin
Deficiency
Main Menu…
Palliative Care of
α-1 Antitrypsin Deficiency

“AAT replacement therapy is for enzyme
deficient patients with impaired FEV-1 (3565% of predicted value), who have quit
smoking and are on optimal medical
therapy but continue to show a rapid
decline in FEV-1 after a period of
observation of at least 18 months.”(63)
63. Treat Respir Med. 2005;4(1):1-8
95
Happy Trails from Lea County, NM
96
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Spiriva Cost
Spiriva vs. Serevent
Respiratory. 2006 Sep;11(5):598-602
Is a long-acting inhaled bronchodilator the first agent to use in stable chronic obstructive pulmonary disease?
Emerging drugs for the treatment of chronic obstructive pulmonary disease.
Pharmacologic treatment of chronic obstructive pulmonary disease: past, present, and future.
Names of leukotriene related drugs
Effect of Intravenous Magnesium Sulfate on Chronic Obstructive Pulmonary Disease
Addition of anticholinergic solution prolongs bronchodilator effect of beta 2 agonists
Comparison of the bronchodilating effect of salmeterol and zafirlukast in combination
Retrospective evaluation of systemic corticosteroids for the management of acute exacerbations
Efficacy and safety of inhaled corticosteroids in patients with COPD
Roflumilast for the treatment of chronic obstructive pulmonary disease
Corticosteroids and Chronic Obstructive Pulmonary Disease
Theophylline in chronic obstructive pulmonary disease: new horizons.
Corticosteroid resistance in chronic obstructive pulmonary disease: inactivation of histone deacetylase.
Inhaled corticosteroids and mortality in chronic obstructive pulmonary disease.
Inhaled corticosteroids in chronic obstructive pulmonary disease: is there a long-term benefit?
Health-related quality of life in individuals with chronic obstructive pulmonary disease.
Improving health-related quality of life in chronic obstructive pulmonary disease.
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Diazepam in the treatment of dyspnea in the 'Pink Puffer' syndrome.
The palliation of dyspnea in terminal disease More research needed
An approach to dyspnea in advanced disease. Opioids are first line drugs
Buspirone effect on breathlessness and exercise performance in patients with chronic obstructive pulmonary
disease.
Effects of buspirone on anxiety levels and exercise tolerance in patients with chronic airflow obstruction and mild
anxiety.
Sertraline effects on dyspnea in patients with obstructive airways disease
Randomized, double blind, placebo controlled crossover trial of sustained release morphine for the management
of refractory dyspnea
A systematic review of the use of opioids in the management of dyspnea
Disabling dyspnea in patients with advanced disease: lack of effect of nebulized morphine
Roflumilast for the treatment of chronic obstructive pulmonary disease
Effects of N-acetylcysteine on outcomes in chronic obstructive pulmonary disease (Bronchitis Randomized on
NAC Cost-Utility Study, BRONCUS): a randomized placebo-controlled trial
N-acetylcysteine reduces the risk of re-hospitalization among patients with chronic obstructive pulmonary disease
Short-term effects of montelukast in stable patients with moderate to severe COPD
Therapeutic responses in asthma and COPD. Bronchodilators Review of effects of PDE4 Inhibitors and LRAs
Long-term montelukast therapy in moderate to severe COPD--a preliminary observation
Current and future pharmacologic therapy of exacerbations in chronic obstructive pulmonary disease and asthma.
Should patients with acute exacerbation of chronic bronchitis be treated with antibiotics? Advantages of the use of
fluoroquinolones.
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Short-term and long-term outcomes of moxifloxacin compared to standard antibiotic treatment in acute
exacerbations of chronic bronchitis
Moxifloxacin vs. Alternatives for Chronic Bronchitis
Palliative Home Care for Advanced Lung Disease
Is there a role for airway clearance techniques in chronic obstructive pulmonary disease?
Nebulized hypertonic saline for cystic fibrosis
Osmotic stimuli increase clearance of mucus in patients with mucociliary dysfunction
Potential future therapies for the management of cough: ACCP evidence-based clinical practice guidelines
Potential new cough therapies.
Current and future drugs for the treatment of chronic cough
Comparison of lidocaine and bronchodilator inhalation treatments for cough suppression in patients with chronic
obstructive pulmonary disease.
Lidocaine inhalation for cough suppression
Effect of indomethacin on bronchorrhea in patients with chronic bronchitis, diffuse panbronchiolitis, or
bronchiectasis
In vivo study of indomethacin in bronchiectasis: effect on neutrophil function and lung secretion
Stridor in Crohn disease and the use of infliximab
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An unusual case of stridor due to osteophytes of the cervical spine: (Forestier's disease).
Myasthenia gravis presenting with stridor
Achalasia presenting as acute stridor
Psychogenic stridor
Amphotericin-induced stridor: a review of stridor, amphotericin preparations, and their immunoregulatory effects
Use of the Dumon Y-stent in the management of malignant disease involving the carina: a retrospective review of
86 patients
Thoracic embolotherapy for life-threatening hemoptysis: a pulmonologists perspective
Bronchial and non bronchial systemic artery embolization for life-threatening hemoptysis: a comprehensive review
Pulmonary hypertension and right heart failure in chronic obstructive pulmonary disease
Advances in the treatment of secondary pulmonary hypertension
Overview of treprostinil sodium for the treatment of pulmonary arterial hypertension
Sildenafil for pulmonary hypertension
Oral sildenafil is an effective and specific pulmonary vasodilator in patients with pulmonary arterial hypertension:
comparison with inhaled nitric oxide
Treatment of Pulmonary Hypertension
Interferon gamma-1b as therapy for idiopathic pulmonary fibrosis. An intra-patient analysis.
Interferon gamma-1b therapy for advanced idiopathic pulmonary fibrosis
Interferon gamma-1b in the treatment of idiopathic pulmonary fibrosis
Interferon-gamma1b therapy in idiopathic pulmonary fibrosis: a metaanalysis
Emphysema in alpha1-antitrypsin deficiency: does replacement therapy affect outcome?
Ximelagatran vs low-molecular-weight heparin and warfarin for the treatment of deep vein thrombosis: a
randomized trial.
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Is long-term low-molecular-weight heparin acceptable to palliative care patients in the treatment of cancer related
venous thromboembolism? A qualitative study.
Acceptability of low molecular weight heparin thromboprophylaxis for inpatients receiving palliative care: qualitative
study.
Treating patients with venous thromboembolism: initial strategies and long-term secondary prevention.
Inhaled mannitol for the treatment of mucociliary dysfunction in patients with bronchiectasis: effect on lung
function, health status and sputum.
Improved sputum expectoration following a single dose of INS316 in patients with chronic bronchitis.
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