Transcript Shortness of Breath and Secretions

Palliative Care:
Shortness of Breath and
Secretions
Hong-Phuc Tran, M.D.
Learning Objectives
• Understand pathophysiology of dyspnea
• Learn how to evaluate dyspnea
• Understand reversible causes / potential
contributors of shortness of breath
• Manage shortness of breath in terminally ill
patients
Introduction
• Shortness of breath is common in terminally ill
patients
• “Death rattle” (noisy breathing) occurs in 2392% of dying patients
– Patients lose ability to clear secretions as
mentation worsens
• Appropriate management of excessive secretions
is important in providing palliation
Pathophysiology of Dyspnea
• Multifactorial
▫ Increased work of breathing
▫ Chemical effects
 Medullary chemoreceptors sense hypercapnea
 Carotid and aortic body chemoreceptors sense
hypoxemia
▫ Neuromechanical association
 Mismatch between what brain desires for respiration
and sensory feedback brain receives
Evaluation of Dyspnea
• Patient’s self-report is most reliable measure
• Can have dyspnea with normal O2 saturation
• Physical exam findings
▫ Accessory muscle use
▫ Tachypnea
▫ Rhonchi, crackles, decreased breath sounds,
stridor
▫ Cyanosis (central or peripheral)
Examples of Some Reversible Causes /
Potential Contributors of Shortness of
Breath
• Bronchospasm
• Pleural effusion
• Anemia
• Airway obstruction
Management of Shortness of Breath (1)
First, treat underlying, reversible causes (if any)
Examples of Management of Some Reversible
Causes/
Potential Contributors of Shortness of Breath
• Bronchospasm
– Albuterol, ipratropium, steroids
• Pleural effusion
– Thoracentesis, pleurodesis, diuretics, catheter
drainage
• Anemia
– Transfusion
• Airway obstruction
– Steroids, Clean out tracheostomy tube (if present)
Management of Shortness of Breath (2)
• After treating reversible causes (if any), then
treat symptomatically
▫ Pharmacologic
 Opioids
 Benzodiazepines
 Anticholinergics
▫ Non-pharmacologic
Opioids (1)
• Most effective for alleviating dyspnea
▫ Exact mechanism unclear but thought to alter
perception of dyspnea
• Common Routes: oral, parenteral
• Unlikely to hasten death or cause addiction if
adhere to dosing guidelines
Opioids (2)
• Opioid naïve patients
– Start with Morphine 10 -15mg po q1hr prn or morphine
5mg SC q 30min prn
– Titrate to patient’s relief using standard opioid dosing
guidelines
• Opioid non-naïve patients
– Increase opioid dose by 25%
– Titrate to patient’s relief using standard opioid dosing
guidelines
– Once chronic dyspnea controlled, provide extended release
formulation and short acting formulation
 Short acting formulation: 10% of total dose of same opioid in
24 hr period, offered at q1hr prn
Benzodiazepines (1)
• Can relieve dyspnea associated with anxiety
• Potential side effects, especially in elderly
patients
– Increased risk of confusion, falls
• Can use conjunction with opioids without
causing respiratory depression when dosing
guidelines followed
Benzodiazepines (2)
• Common routes: oral, sublingual, subcutaneous
• Example of dosing for dyspnea
▫ Lorazepam 0.5 mg po / SL q 1 hr prn, titrate to
patient’s relief
▫ Once total dose in 24 hr period determined, then
can give 1/3 of total dose q8hrs
Anticholinergics (1)
• Dries excessive secretions
• Effective for patients with weak cough reflex
• Examples: Atropine, Hyoscyamine (Levsin),
Scopolamine, Glycopyrrolate (Robinul)
• Atropine, hyosyamine, scopolamine are equally
effective in treatment of death rattle
• Effectiveness of medications better at lower initial
rattle intensity
Anticholinergics (2)
• Atropine 1% ophthalmic drops
– 1-2 drops SL every 1 hr prn
• Scopolamine
– 1-3 transdermal patches q72hrs
– 0.1-0.4 mg SC / IV q4hrs
– 1080mcg/hr by continuous IV or SC infusion
• Hyoscyamine 0.125 mg PO / SL q8hrs prn
• Glycopyrrolate
– 0.4-1.0 mg daily by SC infusion
– 0.2 mg SC / IV q4-6hrs PRN
Non-pharmacologic Interventions
• Educate patients, families/caregivers
• Repositioning
– Turning patient on side, Elevate head of bed
• Suctioning
– Gentle, anterior (not deep) suctioning
• Increase airflow
– Fans, open windows, oxygen nasal cannula
– Stimulates V2 branch of trigeminal nerve, which has central
inhibitory effect on dyspnea
• Reduce room temperature without making patient too
cold
• Behavioral techniques
– Relaxation, Distraction
References & Suggested Readings
• EPEC (Education for Physicians on End-of-Life Care) :
http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/module-3
• Mercandante S, Villari P, Ferrera P. Refractory death rattle: deep aspiration
facilitates the effects of antisecretory agents. J Pain Symptom Manage. 2011
Mar;41(3):637-9.
• Pantilat SZ and Isaac M. End-of-life care for the hospitalized patient. Med Clin
North Am. 2008; 92(2): 349-70.
• Quaseem A 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 Intern Med. 2008 Jan
15;148(2):141-6.
• Shinjo T, Okada M. Atropine eyedrops for death rattle in a terminal cancer
patient. J Palliat Med. 2013 Feb;16(2):212-3.
• Wee B, Hillier R. Interventions for noisy breathing in patients near to death.
Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005177
• Wildiers H et al. Atropine, hyoscine butylbromide, or scopolamine are equally
effective for the treatment of death rattle in terminal care. J Pain Symptom
Manage. 2009 Jul;38(1):124-33