Transcript Other Symptoms: Nausea and Vomiting, Dyspnea

Palliative Management Of:
• Nausea And Vomiting
• Dyspnea
• Secretions
• Delirium
Mike Harlos MD, CCFP, FCFP
Medical Director, WRHA Palliative Care
Professor, University of Manitoba Faculty of Medicine
MECHANISM OF NAUSEA AND VOMITING
• vomiting centre in reticular formation of medulla
• activated by stimuli from:
– Chemoreceptor Trigger Zone (CTZ)
• area postrema, floor of the fourth ventricle
• outside blood-brain barrier (fenestrated venules)
– Upper GI tract & pharynx
– Vestibular apparatus
– Higher cortical centres
Cortex
CTZ
GI
VOMITING
CENTRE
Vestibular
Stimuli Of Vomiting Pathways
Chemoreceptor
Trigger Zone
drugs
• opioids
• chemoTx
• etc...
biochemical
• Ca++
• renal failure
• liver failure
sepsis
radiotherapy
Vestibular
tumor
opioids
Cortical
anxiety
association
Peripheral
radiotherapy
chemotherapy
ICP
GI irritation
• inflammation
• obstruction
• paresis
• compression
PRINCIPLES OF TREATING NAUSEA & VOMITING
• Treat the cause, if possible and appropriate
• Environmental measures
• Antiemetic use:
–
anticipate need if possible
–
use adequate, regular doses
–
aim at presumed receptor involved
–
combinations if necessary
–
anticipate need for alternate routes
Stimulus
Area
Drugs,
Metabolic
Chemoreceptor
trigger zone
Motion,
Position
Vestibular
Organs
? Nonspecific
CNS
↑ ICP
Cerebral cortex
Dopamine
D2
5HT
5HT
Visceral
D2
Receptors
5HT
H1
Serotonin Histamine
M
H1
H1
M
D2
5HT
VOMITING
CENTRE
CB1
H1
M
Muscarinic
Effector
Organs
CB1
Cannabinoid
From: Nausea and vomiting associated with cancer chemotherapy:
drug management in theory and in practice
Arch. Dis. Child. 2004;89;877-880
E S Antonarakis and R D W Hain
Dyspnea
In
Palliative Care
DYSPNEA:
An uncomfortable
awareness of breathing
DYSPNEA:
“...the most common severe
symptom in the last days of life”
Davis C.L. The therapeutics of dyspnoea
Cancer Surveys 1994 Vol.21 p 85 - 98
Approach To The Dyspneic
Palliative Patient
Two basic intervention types:
1. Non-specific, symptom-oriented
2. Disease-specific
Simple Non-Specific Measures In
Managing Dyspnea
• calm reassurance
• patient sitting up / semi-reclined
• open window
• fan
Non-Specific Pharmacologic
Interventions In Dyspnea
• Oxygen - hypoxic and ? non-hypoxic
• Opioids - complex variety of central effects
• Chlorpromazine or Methotrimeprazine some evidence in adult literature; caution in
children due to potential for dystonic
reactions
• Benzodiazepines - literature inconsistent
but clinical experience extensive and
supportive
TREAT THE CAUSE OF DYSPNEA IF POSSIBLE AND APPROPRIATE
•
Anti-tumor: chemo/radTx, hormone, laser
•
Infection
•
Anemia
• CHF
•
SVCO
•
Pleural effusion
•
Pulmonary embolism
•
Airway obstruction
DISEASE-SPECIFIC MEDICATIONS
FOR DYSPNEA
• Corticosteroids
– obstruction: SVCO, airway
– lymphangitic carcinomatosis
– radiation pneumonitis
• Furosemide
– CHF
– lymphangitic carcinomatosis
• Antibiotics
• Anticoagulation – pulm. embolus
• Bronchodilators
• Transfusion
Opioids in Dyspnea
 Uncertain mechanism
 Comfort achieved before resp compromise; rate often
unchanged
 Often patient already on opioids for analgesia; if dyspnea
develops it will usually be the symptom that leads the
need for titration
 Dosage should be titrated empirically; may easily reach
doses commonly seen in adults
 May need rapid dose escalation in order to keep up with
rapidly progressing distress
A COMMON CONCERN ABOUT AGGRESSIVE USE
OF OPIOIDS IN THE FINAL HOURS
How do you know that the
aggressive use of opioids for pain or
dyspnea doesn't actually bring about
or speed up the patient's death?
SUBCUTANEOUS MORPHINE IN
TERMINAL CANCER
Bruera et al. J Pain Symptom Manage. 1990; 5:341-344
100
90
80
Pre-Morphine
70
Post-Morphine
60
50
40
30
20
10
0
Dyspnea
Pain
Resp. Rate
(breaths/min)
O2 Sat (%)
pCO2
Typically, with excessive opioid dosing one
would see:
• pinpoint pupils
• gradual slowing of the respiratory rate
• breathing is deep (though may be shallow) and regular
COMMON BREATHING PATTERNS
IN THE FINAL HOURS
Cheyne-Stokes
Rapid, shallow
“Agonal” / Ataxic
Palliative Management
of Secretions
Secretions - Prevalence At Study Entry And In Last Month Of Life
UK Children’s Cancer Study Group/Paediatric Oncology Nurses Forum Survey
Goldman A et al; Pediatrics 2006; 117; 1179-1186
45
40
Any
35
Major Problem
30
25
20
15
10
5
0
Study Entrance
Last Month
Managing Secretions in Palliative Patients
 Factors influencing approach management:
 Oral secretions vs.. lower respiratory
 Level of alertness and expectations thereof
 Proximity of expected death
 “Death Rattle” – up to 50% in final hours of life
 At times the issue is more one of creating an environment less
upsetting to visiting family/friends
 Suctioning: “If you can see it, you can suction it”
Suctioning
Increased
Secretions
Mucosal
Trauma
CONGESTION IN THE FINAL HOURS
“Death Rattle”
• Positioning
• ANTISECRETORY: Scopolamine, glycopyrrolate
• Consider suctioning if secretions are:
 distressing, proximal, accessible
 not responding to antisecretory agents
Atropine Eye Drops
For Palliative Management Of Secretions
• Atropine 1% ophthalmic preparation
• Local oral effect for excessive salivation/drooling
• Dose is usually 1 – 2 drops SL or buccal q6h prn
• There may be systemic absorption… watch for
tachycardia, flushing
Delirium in
Palliative Care
Definition
Etiologically non-specific global cerebral
dysfunction associated with changes in LOC,
attention, thinking, perception, memory,
psychomotor behavior, emotion and the
sleep/wake cycle
DSM-IV Criteria
A. Change in consciousness with reduced ability to focus,
sustain or shift attention
B. Change in cognition (e.g., memory, disorientation,
change in language, perceptual disturbance) that is not
dementia
C. Abrupt onset (hours to days) with fluctuation
D. Evidence of medical condition judged to be etiologically
related to disturbance
Characteristics
 Abrupt onset
 Disorientation, fluctuation of symptoms
 Hypoactive vs.. hyperactive (restlessness, agitation,
aggression) vs. mixed
 Changes in sleeping patterns
 Incoherent, rambling speech
 Fluctuating emotions
 Activity that is disorganized and without purpose
Delirium Types
 Hypoactive
– confusion, somnolence,  alertness
 Hyperactive
– agitation, hallucinations, aggression
 Mixed (>60%)
– features of both
Prevalence of Delirium
 20% - 44% on admission to a palliative care unit (common reason
for admission)
 28% - 45% of patients developed delirium while on the palliative
care unit
 68% - 90% prior to death
 Lawlor et al (J Pall Care 1998)
– n = 103 pts
– 50% of episodes reversible
– Terminal delirium in 88%
– Hyperactive (5%) vs. hypoactive (47%)
– Mixed (48%) most common
Delirium versus Dementia
Delirium
Dementia
Abrupt onset
Insidious onset
Decreased/Fluctuating LOC
LOC intact, alert
Erratic behaviour
Consistent behaviour
Sleep/wake cycle change
Minimal changes
Reversible (theoretically)
Irreversible
Causes Of Delirium In Palliative Care
1. Tumour
• Primary, metastatic, leptomeningeal, paraneoplastic syndrome
2. Metabolic / physiologic
• hypercalcemia
• Hyponatremia (hypernatremia less commonly)
• ↑ or ↓ glucose
• anemia, hypoxia
• CO2
• Renal or liver failure
3. Infection – UTI, pneumonia, biliary tract, wounds
4. Medication administration – opioids, antiemetics (esp.
anticholinergic), sedatives, antisecretory
5. Medication / Drug withdrawal
6. Etc…..
Management Of Delirium In Palliative Care
1.
Environmental

Quite, private setting: single room if possible

Low lighting, calendar, clock, familiar objects

Minimal room changes with unnecessary distractions
2.
Fix the Fixable – if possible and appropriate
3.
Help family navigate complex choices and non-choices, dictated by how
the patient would guide care if that were possible
4.
Effective sedation – with frank discussion of anticipated course

If delirium irreversible, goal of care is sedation

Sedation does not hasten the dying process

Will facilitate meaningful visiting

Encourage communication, even though patient not interactive