Transcript The Basics of Symptom Management

The Basics of Symptom Management:
Understanding, Assessment and Principles
Dr. Leah Steinberg
Learning Objectives:
• List several good on-line resources;
• Review the model of pain and symptom
management;
• Describe basic management of
– Constipation, Delirium, Dyspnea
• Appreciate the principles of symptom
management.
Cancer Care Ontario Guidelines
• www.cancercare.on.ca
• Palliative care tools
• Symptom management tools
Objective 2: Review from yesterday
• Assess – rectal exam
• Treat underlying causes
• Treat symptoms
– pharmacological and non-pharmacological
• Monitor
• Educate
Objective 3: Constipation
• Huge burden to patients
• Uncomfortable, AND
• Makes them stop using opioids
Constipation: Definition
• Infrequent, hard stools, difficult to pass
• Feeling of incomplete evacuation
• Not just infrequency
Multiple causes: we know these!
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Immobility
Disease
Neurologic abnormalities
Metabolic abnormalities (hypercalcemia)
Decreased intake
Medications (OPIOIDS, anticholinergics)
Weakness
Physical surroundings
Again, to manage – follow the steps
• Assess – rectal exam
• Treat underlying causes
• Treat symptoms
– pharmacological and non-pharmacological
• Monitor
• Educate
Management: Many products
• Know the classes of laxatives to use
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Stimulant (senna)
Lubricant (mineral oil)
Osmotic (lactulose)
Opioid antagonist (methylnaltraxone)
• Usually don’t recommend:
– Fibre or docusate
• Create a protocol for your practice
• Set up regular dosing of laxatives:
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Sennosides or bisacodyl: 2–4 tablets at bedtime to begin plus
Lactulose 30 mL at bedtime or
PEG 3350 powder 17 g once or twice daily
• Monitor daily.
• If no bowel movement by day 2:
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Increase sennosides by 2 tablets (can be given in two doses) and increase lactulose or PEG
3350 to 30 mL twice daily
• If no bowel movement by day 3:
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Perform rectal examination
• If stool in rectum:
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Use phosphate enema or bisacodyl suppository
• If no stool in rectum and no contraindication:
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Give oil enema followed by saline or tap water enema to clear
• Increase regular laxatives
• If problems continue:
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Do flat-plate radiograph of abdomen
Switch stimulant laxative
Use regular enemas
• Set up regular dosing of laxatives:
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Sennosides or bisacodyl: 2–4 tablets at bedtime to begin plus
Lactulose 30 mL at bedtime or
PEG 3350 powder 17 g once or twice daily
• Monitor daily.
• If no bowel movement by day 2:
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Increase sennosides by 2 tablets (can be given in two doses) and increase lactulose or PEG
3350 to 30 mL twice daily
• If no bowel movement by day 3:
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Perform rectal examination
• If stool in rectum:
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Use phosphate enema or bisacodyl suppository
• If no stool in rectum and no contraindication:
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Give oil enema followed by saline or tap water enema to clear
• Increase regular laxatives
• If problems continue:
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Do flat-plate radiograph of abdomen – Rule out Bowel obstruction
Switch stimulant laxative
Use regular enemas
Constipation Pearls!
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Prevent!!!
If not, treat aggressively
Myth: he’s not eating…
Regular laxatives if regular opioids
– Easier to decrease laxatives
Dyspnea:
• Frightening symptom
• Often linked with anxiety, fear
• Need lots of education and support for
patient with severe dyspnea
Prevalence of dyspnea
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50% - 70% of all cancer patients
60% of patients with NSCLC
Worsens as disease progresses
Prognostic indicator
– When patients are dysnpeic at rest, prognosis
is often in the range of weeks
Etiology
• Multifactorial:
• Dudgeon, Lertzman Dyspnea in the advanced cancer patient, JPSM
1998 Oct;16(4)
• Reviewed 100 pts to determine etiology
of dyspnea;
• Average number of potential causes = 5
Etiology: many many causes
From the Tumour itself;
• Compression
• Obstruction
• Carcinomatosis
Other Card/Resp Dx
• COPD
• CHF
Indirectly from tumour:
• Muscle weakness
• Anemia
• Thromboembolic
disease
• Effusions: pleural,
pericardial, peritoneal
• Infection
Again, to manage – follow the steps
• Assess: to diagnose
– Tachypnea is not dyspnea
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Reverse when you can
Treat the symptoms
Monitor
Educate
Treat underlying cause if possible:
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Antibiotics
Drain effusion: +/- Tenchkoff catheter
Radiotherapy
Stents
Transfusions
Non-pharmacological
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Education ++
Energy Conservation
Breathing techniques
Muscle strengthening
Cool air/fan
Positioning
Relaxation exercises
Pharmacological
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Opioids are mainstay
Methyltrimeprazine
Anxiolytics
Steroids
Inhalers/diuretics
Secretion management at EOL
Trial of oxygen
What about respiration compromise?
• 11 studies looked for evidence of
respiratory compromise – no clinically
relevant compromise found
• Again, related to opioid naive
Opioid dosages
• Opioid-naïve patients, mild dyspnea
– codeine 30 mg q 4 hr
– morphine 2.5 mg q 4 hr
• Opioid-naïve patients, moderate - severe
– morphine 2.5 - 5.0 mg q 4 hr (or equivalent)
– titrate 25 - 50% every 24 hrs
– in COPD, start low and go slower
Opioid dosages
• Opioid tolerant patients
– titrate baseline dose by 25 - 50 %
Anxiolytics: if anxiety a component
• Lorazepam 1 – 2 mg sl q 8 hrs prn
• Clonazpam 0.25 - 2.0 mg q 12 hr
• Midazolam 0.5 - 1.0 mg s/c or iv q 20
mins prn
Steroids
• Dexamethasone 4 – 16 mg daily
• Can give in one dose in the morning,
rather than qid
Dyspnea summary:
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Tachypnea is not dyspnea
Reverse when you can
Opioids are mainstay of medical therapy
Use non-pharmacological measures when
you can
Delirium
• Palliative care emergency!
• A delirious patient cannot express their
symptoms;
• Distressing for patient and family
• Remember:
– Hyperactive
– Hypoactive
Patient’s remember their delirium
50% of patients remember the experience –
It is frightening for them
To manage – follow the steps
• Assess: to diagnose
– Don’t forget to do physical exam
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Reverse when you can
Treat the symptoms
Monitor
Educate
Reverse when that is the goal
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Hydration
Opioid rotation
Bisphosponates
Stop medications if possible
Non-pharmacologic measures:
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Quiet room
Decrease stimulation
Light
Visible reminders of time and date
Verbal orientation of patient
But most importantly: TREAT IT
• Don’t leave patient untreated while
attempting to reverse:
• First line:
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Haloperidol 0.5 mg bid plus breakthrough
Risperidone 0.5 mg bid plus breakthrough
Olanzipine 2.5 mg bid plus breakthrough
If severely agitated, we use
Methyltrimeprazine
Delirium summary:
• Prevent it when possible
– PCUs may use daily screening tool (CAM)
• Reverse when possible
• Treat always
• Counsel patient after, if needed
SUMMARY
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Many symptoms
Don’t be overwhelmed
Use the model
Use the resources out there!
Opioids treat symptom of dyspnea
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Cochrane review
Mechanism unclear
Systemic naloxone increases dyspnea
Opioid receptors in tracheobronchial tree
and alveolar walls
• But, no clear role for nebulized though