Breathlessness

Dr Brian Ensor May 2016

Morning

Star

Jon

Barlow

Hudson2

Attend

Plan

UnderstandTherapy

3

Attend

Plan

UnderstandTherapy

4

Dyspnoea

Subjective experience of breathing discomfort

Intensity component

Unpleasant component

Functional component

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Roles

Communication

• Whaikorero

• MND

Independence

• Driving

• Toileting

Decision making

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Language

• Exhaustion

• Air Hunger

• Tightness

• Choking

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Measurement

• Intensity

• Unpleasantness

• Functional

• Mastery

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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)

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Variable 0 points 1 point 2 points Total

Heart rate per

minute

< 90 90 – 109 >110

Respiratory rate

/ minute

<18 19 – 30 > 30

Restlessness None Occassional Frequent

Paradoxical

abdominal movt

None Present

Grunting None Present

Nasal flaring None Presenet

Look of fear None Eyes wide open, facial

muscles tense, brow

furrowed, mouth open,

teeth together

Total

Respiratory Distress Observation Scale © Margaret L Campbell

PhD RN, 19/2/2009

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What is normal breathing?

That depends…

Triggers that can alter breathing patterns

pain fear

Snoring URTI

posture

Excitement dancing

asthma

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“It's funny, but you never really think much about

breathing. Until it's all you ever think about.”

― Tim Winton, Breath

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• 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..

“Normal” breathing

at rest

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Source: Alison

McConnell,Respirat

ory Muscle Training;

Theory and

Practice, Elsevier,

Oxford, 2013)

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Symptoms of

disordered

breathing

in the

healthy

person.

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Physiology

The Guardian by Cezary Stulgis

accessed at brisstreet.com

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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-reafferentdissociation, 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

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Dyspnoea is a mismatch

What the brain (cortex) expects, is not what it

feels it is getting.

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Motor

Cortex

Brain

Stem

CO2, O2, pH

Exercise,

Hyperthermia

Ventilatory

Pump

Homeostasis

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Brain Stem Breathing

• Agonal breathing

• Cheyne Stokes

• Kussmaul (acidotic)

• Apnoeic

• Ondine’s curse

NB: Brain stem circuits are serotinergic

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Motor

Cortex

Brain

Stem

CO2, O2, pH

Exercise,

Hyperthermia

Ventilatory

Pump

Sensory

Cortex

Corollary discharge

Effort demanded

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Motor

Cortex

Brain

Stem

CO2, O2, pH

Exercise,

Hyperthermia

Ventilatory

Pump

Sensory

Cortex

Multiple

Receptors

Afferent

discharge

Results

achieved

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Multiple Receptors

• CO2, O2, pH

• Muscle receptors – stretch & spindle, ergo

• Lung receptors, J receptors, C fibre, irritant

• Pressure receptors, blood vessels, lung

• Nociceptors

• Thermoreceptors (face, oropharynx)

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Motor

Cortex

Brain

Stem

CO2, O2, pH

Exercise,

Hyperthermia

Ventilatory

Pump

Multiple Other

Receptors

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Motor

Cortex

Brain

Stem

CO2, O2, pH

Exercise,

Hyperthermia

Ventilatory

Pump

Multiple Other

Receptors

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Dyspnoea is a mismatch

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Dyspnoea is a mismatch

Bridge

Engineering

Engine

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Dyspnoea is a mismatch

Bridge

Engineering

Engine

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Dyspnoea is a mismatch

Bridge

Engineering

Engine

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Multiple Receptors• CO2, O2, pH

Outcome

• Muscle receptors – stretch & spindle, ergo

• Lung receptors, J receptors, C fibre, irritant

• Pressure receptors, blood vessels, lungProcesses

• Nociceptors

• Thermoreceptors (face, oropharynx)

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CardioPulmonary causes of

dyspnoea• Obstruction / collapse / pneumothorax

• Tracheal

• Bronchial

• SVC

• Effusion

• Emboli

• Infection

• Heart failure

• Pericardial effusion, anaemia,...

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Treatment of Dyspnoea

• Drain effusions or ascites

• Antibiotics

• Transfusion

• Heart failure treatment

• Stop ß-blockers

• Steroids (+/-)

• Radiotherapy / Chemo

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CAUSES OF DYSPNOEA

Muscle weakness, fatigue, effort of breathing

• Cachexia, MND, “inefficiencies”

Damaged lung or chest wall

Congestion, inflammation, BP issues, pain

Metabolic

• CO2 , O2, acidosis

Cortical

• Anxiety

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Management of (unfixable)dyspnoea

Alter input to the cortex (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

Get the chest moving, air moving across face and in lungs

Distraction

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Non-drug

Jo Graham

Physiotherapist

Acupuncturist

Tanya Loveard

Occupational Therapist

Tracey Smith

Occupational Therapist

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PositioningBreathing Recovery

• Forward lean sitting or standing with

forearms supported

• Try & keep back straight & relax your

head forward

Optimal Breathing Position

• Sitting upright with feet, back & arms

supported

http://www.cuh.org.uk/cms/addenbrookes-hospital/for-patients/patient-information-and-

consent-forms

Resting Position

• High side lying – rest your upper

arm on a pillow

Or

Sitting & relax forward onto pillows

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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 – useful to clear secretions

• Active Cycle Breathing Techniques (ACBT)

• Forced expiratory technique (FET)

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ACBT

Taken from: http://www.guysandstthomas.nhs.uk/resources/patient-

information/therapies/physiotherapy/active-cycles-of-breathing-techniques.pdf

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Energy Conservation

The 3 P’s of energy conservation:

• Planning

• Prioritising

• Pacing

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Anxiety Management

• Recognise triggers for anxiety

• Relaxation

• Visualisation

• Positive phrases

• Distraction

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Environmental

Assessment /Equipment

• Adapting patients environment

• Provision of equipment/aids

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Use of Handheld Fan

A handheld fan directed at the

face may reduce the sensation

of breathlessness

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Acupuncture

Two approaches

- Western or Traditional Chinese Medicine

Used for anxiety & breathlessness

Extensive use in UK Hospices focusing on ASAD

(anxiety, sickness & dyspnoea) points

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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

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Education/Reassurance

• Communication

• Imparting basic knowledge/use of handouts

• Carer involvement

• Breathless groups/clinics

Avoid overload of information

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Breathlessness Plans

• Quick reference summary of MDT

interventions

• Individually designed for each patient &

their carer

• Discuss plan with patient & their carer

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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

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

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Exercise

Exercise is inherent in all activities of daily

living

• Patients set own goals

• International move to individualised planned

exercise programme

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Summary

Effective symptom management

=

Patients participating in activities

they value

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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.

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General Drug Treatments

• Opioids

• oral or subcut

• Nebulised

• Long acting and short acting.

• Benzodiazepines (Anxiety)

• Oxygen

• Steroids

• Levomepromazine

• Furosemide nebulised

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Morphine

• Good evidence that low dose morphine relieves dyspnoea

• Pain reverses that relief

• Dose finding: 10mg to 30mg daily, long acting NNT=1.6

• Role of short acting morphine is reduced

• It is not depressing respiration

• Expectation that Oxycodone works in a similar fashion.

• Methadone used uncommonly

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Fentanyl

• Randomised double blinded studies show it

works (up to 350mcg prn sc)

• Nebulised vs subcut vs sublingual

• It is serotinergic

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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

dyspnoea, which requires consciousness. The

aim (arguably) is then respiratory depression,

requiring much bigger doses of opioids.55

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.

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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.

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Oxygen

• No better than room air for patients without

hypoxia.

• Hypoxic COPD patients gain some long term

survival benefit

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Miscellaneous

Levomepromazine

12.5 – 25mg prn q1h

Radiotherapy, oncology, pleural drains, surgery,

laser, cryotherapy,

Furosemide nebulised

Non Invasive Ventilation

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Summary

Effective symptom management

=

Comfortable at rest, and the ability to

get there.

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End of life

Tachypnoea / “struggling to breath”

Secretions

• Buscopan

• Aspiration / Reflux

• Pneumonic

• Cardiac

Grunting

• Purse lip breathing for the unconscious.

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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.

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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

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