Transcript dyspnoea
Breathlessness Dr Brian Ensor May 2016 2 Morning Star Jon Barlow Hudson Attend Understand Therapy Plan 3 Attend Understand Therapy Plan 4 Dyspnoea Subjective experience of breathing discomfort Intensity component Unpleasant component Functional 5 component Roles Communication • Whaikorero • MND Independence • Driving • Toileting Decision making 6 Language • Exhaustion • Air Hunger • Tightness • Choking 7 Measurement • Intensity • Unpleasantness • Functional • Mastery 8 Total Dyspnoea • Physical • Psychological • Existential • (Social) (Abernathy, A. P., & Wheeler J. L. (2008) Total dyspnoea. Current opinion in supportive and palliative care 2(2), 110-113) 9 Respiratory Distress Observation Scale © Margaret L Campbell PhD RN, 19/2/2009 Variable Heart rate per minute Respiratory rate / minute Restlessness Paradoxical abdominal movt Grunting Nasal flaring Look of fear Total 10 0 points < 90 1 point 90 – 109 2 points >110 <18 19 – 30 > 30 None None Occassional Frequent Present None None None Present Presenet Eyes wide open, facial muscles tense, brow furrowed, mouth open, teeth together Total What is normal breathing? That depends… Triggers that can alter breathing patterns pain fear Snoring URTI posture Excitement dancing asthma 11 “It's funny, but you never really think much about breathing. Until it's all you ever think about.” ― Tim Winton, Breath 12 “Normal” breathing at rest • 80% diaphragmatic movement, 20 % chest, inhale and exhale via nose • 10-14 breaths/minute • Inspiration:expiration 1:1.5, slight pause end of exhale • Gentle inhale, effortless exhale • Feel minimal muscle activity, easy, smooth.. 13 14 Source: Alison McConnell,Respirat ory Muscle Training; Theory and Practice, Elsevier, Oxford, 2013) Symptoms of disordered breathing in the healthy person. 15 Physiology The Guardian by Cezary Stulgis accessed at brisstreet.com 16 Dyspnoea is a mismatch “Respiratory motor centres receive and process the information according to the ventilator requirements of the body. A ventilator ‘command’ is then given, and an ascending copy of descending motor activity sent to perceptual areas (corollary discharge). If ventilator demand exceeds the capacity for ventilation, there is an ensuing imblanace between the motor driver to breathe as sensed by the corollary discharge and afferent feedback from mechanoreceptors of the respiratory system. This is variously referred to as…. efferent-reafferent dissociation, neuroventilatory dissociation, …...” Currow et al 2013 Breathlessness – current and emerging mechanisms, measurement and management: A discussion from an EAPC workshop. Pall Med 27(10) 932-938 17 Dyspnoea is a mismatch What the brain (cortex) expects, is not what it feels it is getting. 18 Motor Cortex Homeostasis Brain Stem CO2, O2, pH Exercise, Hyperthermia 19 Ventilatory Pump Brain Stem Breathing • Agonal breathing • Cheyne Stokes • Kussmaul (acidotic) • Apnoeic • Ondine’s curse NB: Brain stem circuits are serotinergic 20 Sensory Cortex Motor Cortex Corollary discharge Effort demanded Brain Stem CO2, O2, pH Exercise, Hyperthermia 21 Ventilatory Pump Afferent discharge Results achieved Sensory Cortex Motor Cortex Multiple Receptors Brain Stem CO2, O2, pH Exercise, Hyperthermia 22 Ventilatory Pump Multiple Receptors • CO , O , pH • Muscle receptors – stretch & spindle, ergo • Lung receptors, J receptors, C fibre, irritant • Pressure receptors, blood vessels, lung • Nociceptors • Thermoreceptors 2 2 (face, oropharynx) 23 Motor Cortex Multiple Other Receptors CO2, O2, pH Exercise, Hyperthermia 24 Brain Stem Ventilatory Pump Motor Cortex Multiple Other Receptors CO2, O2, pH Exercise, Hyperthermia 25 Brain Stem Ventilatory Pump Dyspnoea is a mismatch 26 Dyspnoea is a mismatch Bridge Engine Engineering 27 Dyspnoea is a mismatch Bridge Engine Engineering 28 Dyspnoea is a mismatch Bridge Engine Engineering 29 Multiple Receptors • • • • • • 30 CO2, O2, pH Outcome Muscle receptors – stretch & spindle, ergo Lung receptors, J receptors, C fibre, irritant Pressure receptors, blood vessels, lung Nociceptors Thermoreceptors (face, oropharynx) Processes CardioPulmonary causes of dyspnoea • • • • • 31 Obstruction / collapse / pneumothorax • • • Tracheal Bronchial SVC Effusion Emboli Infection Heart failure • Pericardial effusion, anaemia,... Treatment of Dyspnoea • Drain effusions or ascites • Antibiotics • Transfusion • Heart failure treatment • Stop ß-blockers • Steroids • Radiotherapy / Chemo (+/-) 32 33 CAUSES OF DYSPNOEA Muscle weakness, fatigue, effort of breathing • Cachexia, MND, “inefficiencies” Damaged lung or chest wall Congestion, inflammation, BP issues, pain Metabolic • CO 2, Cortical O2, acidosis • Anxiety 34 Management of Alter input to the cortex (unfixable) dyspnoea (Capt James T Kirk) Reduce respiratory drive from brain stem Improve blood gases Reduce noxious input from peripheral receptors Make muscles stronger, more efficient Reduce pointless activity / anxiety Increase positive input from peripheral receptors 35 Get the chest moving, air moving across face and in lungs Distraction Non-drug Jo Graham Physiotherapist Acupuncturist Tanya Loveard Occupational Therapist Tracey Smith Occupational Therapist 36 Positioning Breathing Recovery • Forward lean sitting or standing with Resting Position • forearms supported • High side lying – rest your upper arm on a pillow Try & keep back straight & relax your head forward Or Optimal Breathing Position • Sitting upright with feet, back & arms supported http://www.cuh.org.uk/cms/addenbrookes-hospital/for-patients/patient-information-andconsent-forms 37 Sitting & relax forward onto pillows Breathing Retraining Simple Breathing Techniques • • • • Drop your shoulders Focus on breathing OUT Useful: pursed lips breathing or “phew” Centre the breath in the belly Other Techniques – • • 38 useful to clear secretions Active Cycle Breathing Techniques (ACBT) Forced expiratory technique (FET) ACBT 39 Taken from: http://www.guysandstthomas.nhs.uk/resources/patientinformation/therapies/physiotherapy/active-cycles-of-breathing-techniques.pdf Energy Conservation The 3 P’s of energy conservation: • • • 40 Planning Prioritising Pacing Anxiety Management • Recognise triggers for anxiety • Relaxation • Visualisation • Positive phrases • Distraction 41 Environmental Assessment /Equipment • Adapting patients environment • Provision of equipment/aids 42 Use of Handheld Fan A handheld fan directed at the face may reduce the sensation of breathlessness 43 Acupuncture Two approaches - Western or Traditional Chinese Medicine Used for anxiety & breathlessness Extensive use in UK Hospices focusing on ASAD (anxiety, sickness & dyspnoea) points 44 Acupressure • Can be used in conjunction with acupuncture • Patients can self massage points or press needles/seeds (left in situ) • Use of auricular(ear)points –these can be left in situ for 5-7 days 45 Education/Reassurance • Communication • Imparting basic knowledge/use of handouts • Carer involvement • Breathless groups/clinics Avoid overload of information 46 Breathlessness Plans • Quick reference summary of MDT interventions • Individually designed for each patient & their carer • Discuss plan with patient & their carer 47 Breathing Plan for David 1. Support yourself in your breathing recovery position 2. Try using your fan 3. Take 1-2 puffs of midazolam spray into the mouth 4. Take your Oxynorm 5. Focus on breathing out 6. Listen to your music or, if you are able, work on crossword 48 Continue with this for 15 minutes, then 7. If feeling no better, repeat the midazolam spray 8. Continue your focus on breathing out 9. If you feel no better after a further 15 minutes phone the hospice on 801-0006 for advice Exercise Exercise is inherent in all activities of daily living • Patients set own goals • International move to individualised planned exercise programme 49 Summary Effective symptom management = Patients participating in activities they value 50 References Bausewein, C., Booth, S., Gysels, M., & Higginson, I. (2008). Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of Systematic Reviews (Online), CD005623. doi:10.1188/12.CJON.320 Cooper, J. (Ed.).(2003). Occupational Therapy in Oncology and Palliative Care.(3rd ed.) England. Whurr. Corner, J.& O”Driscoll, M.(1999). Development of a breathlessness assessment guide for use in palliative care. Palliative Medicine,13,375-384. Galbraith, S., Fagan, P., Perkins, P., Lynch, A., & Booth, S. (2010). Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. Journal of Pain and Symptom Management, 39(5), 831–8. doi:10.1016/j.jpainsymman.2009.09.024 http://www.cuh.org.uk/cms/addenbrookes-hospital/for-patients/patient-information-and-consent-forms . Filshie, J., Penn, K., Ashley, S., & Davis, C. L. (1996). Acupuncture for the relief of cancer-related breathlessness. Palliative Medicine, 10, 145–150. doi:10.1177/026921639601000209 Kumar. S.P., & Jim, A. ( S.2010). Physical therapy in palliative care: from symptom control; to quality of life- a critical review. Indian Journal of Palliative Care . 16.3.138-146. Lewis,L.K., Willaims, M.T., & Olds, T.S.(2012). The active cycle of breathing technique: A systematic review and meta analylsis. Respiratory Medicine 106. 155-172. Lim, J. T. W., Wong, E. T., & Aung, S. K. H. (2011). Is there a role for acupuncture in the symptom management of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led supportive care. Acupuncture in Medicine : Journal of the British Medical Acupuncture Society, 29(3), 173–9. doi:10.1136/aim.2011.004044 Maa, S.H, Gauthier, D., & Turner, M.(1997). Acupressure as an adjunct to a pulmonary rehabilitation program. Journal of Cardiopulmonary Rehabilitation.17.4 286-276. 51 General Drug Treatments • • • • • • 52 Opioids • • • oral or subcut Nebulised Long acting and short acting. Benzodiazepines (Anxiety) Oxygen Steroids Levomepromazine Furosemide nebulised Morphine • • • Good evidence that low dose morphine relieves dyspnoea Pain reverses that relief Dose finding: 10mg to 30mg daily, long acting NNT=1.6 • • • • 53 Role of short acting morphine is reduced It is not depressing respiration Expectation that Oxycodone works in a similar fashion. Methadone used uncommonly Fentanyl • Randomised double blinded studies show it works (up to 350mcg prn sc) • Nebulised vs subcut vs sublingual • It is serotinergic 54 Evidence Free Zone • Fentanyl will not treat tachypnoea from brainstem activation at the very end of life. • SSRIs may aggravate tachypnoea. • Consider anti-serotinergic medication: Nozinan, quetiapine. • End of life tachypnoea is different from 55 dyspnoea, which requires consciousness. The aim (arguably) is then respiratory depression, requiring much bigger doses of opioids. Benzodiazepines • Good anxiolytics • There may be a place of midazolam nasal spray • Consider long acting benzodiazepines • Remember cognitive / psychological interventions • Anxiety is not the cause of dyspnoea. 56 Evidence Free Zone • Anxiety is not the cause of dypsnoea in our population. • Dyspnoea is the cause of anxiety. • Admission is a very good intervention. 57 Oxygen • No better than room air for patients without hypoxia. • Hypoxic COPD patients gain some long term survival benefit 58 Miscellaneous Levomepromazine 12.5 – 25mg prn q1h Radiotherapy, oncology, pleural drains, surgery, laser, cryotherapy, Furosemide nebulised Non Invasive Ventilation 59 Summary Effective symptom management = Comfortable at rest, and the ability to get there. 60 End of life Tachypnoea / “struggling to breath” Secretions • Buscopan • Aspiration / Reflux • Pneumonic • Cardiac Grunting • Purse lip breathing for the unconscious. 61 Evidence Free Zone • Gross aspiration might deserve a naso-gastric tube, certainly not buscopan • Pneumonic secretions might deserve some gentamicin or steroids • I would choose to die hypovolaemic rather than in congestive failure • We might consider more aggressive treatment of tachypnoea, with opioids, and anti serotonin medications. 62 Multidisciplinary Team “An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial” Higginson I, Bausenwein C et al Lancet Respiratory Medicine Dec 2014 12 (12) 979-987 63 64 www.ReubenBloodmoney.com