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Dorothy House Hospice Care BREATHLESSNESS MANAGEMENT MANAGEMENT TOOLBOX TOOLBOX TOOLBOX TOOLBOX Modified for Motor Neurone Disease Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge Jeanne Burnett / Karen Tudge 30 30 th th April 2014 April 2014 30 30 April 2014 April 2014

BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

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Page 1: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Dorothy House Hospice Care

BREATHLESSNESSMANAGEMENTMANAGEMENT

TOOLBOXTOOLBOXTOOLBOX TOOLBOX

Modified for Motor Neurone DiseaseModified for Motor Neurone Disease

Jeanne Burnett / Karen TudgeJeanne Burnett / Karen Tudge3030thth April 2014April 20143030 April 2014April 2014

Page 2: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Breathlessness can be an interaction between physical, emotional and psychological factors, not just a symptom of disordered breathingbreathing

Breathlessness in MND is slightly different and is a combination of reduced respiratory function due to:

1 Progressive weakness of respiratory muscles1.Progressive weakness of respiratory muscles 2.Anxiety related to general progression of the disease and possibly fear for the future

Our aim is to teach some simple coping strategies at the earliest opportunity which can be patient or helper ledopportunity, which can be patient or helper led

Page 3: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

OverviewOverview• 70% of patients having cancer experience breathlessness at some

point due to disease or treatments but SOB either on exertion or atpoint due to disease or treatments but SOB either on exertion or at rest is common in many other conditions including progressive neurological conditions such as MND

• Patients with COPD or Heart Failure may become breathless periodically (episodic breathlessness) or have continuous breathlessness and each is managed differentlyg y

• Patients with MND can have both episodic breathlessness due to anxiety and continuous breathlessness due to disease progression

• Many people get chest infections which can cause breathing difficulties- this can be an additional and frequent occurrence in MND

• Breathlessness is often reported as the most distressing symptom after pain and for patients with MND ranks alongside the fear of chokingchoking

Page 4: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Tools to try:Tools to try:

• Comfort Zone• Positioning• Positioning• Fan/moving air• Breathing techniques• Calming Hand technique• Acupressure

S b d• Seabands• Pacing activity• Exercise• Exercise

Page 5: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Comfort ZoneComfort Zone

Page 6: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

SittingSitting

Page 7: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

LyingLying

Page 8: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

StandingStanding

Page 9: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

WheelchairsWheelchairs

Positioning in a suitable wheelchair may improve respiratory function tilt in space wheelchairs can be positioned so as tofunction- tilt in space wheelchairs can be positioned so as to maximise head support and allow maximal costal expansion-therefore use of collars for neck support may not be necessary

Page 10: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Use of a fanUse of a fan

Page 11: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Breathing TechniquesBreathing Techniques

In general terms:

• Aim to slow the rate of rapid shallow breathing• Encourage a longer out breath:Encourage a longer out breath:• Try 3:5 - count to 3 on the in breath and 5 on the out

breath (smell the rose, blow out the candle)( , )• For patients with MND in later stages this may not be

feasible

Page 12: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Clearing Chest SecretionsClearing Chest SecretionsEffective coughing and positioning can encourage drainage of excessive or Huffing and panting may loosen g ginfected secretionsAcupuncture/acupressure/TENS may also help move secretions if applied to pertinent acupuncture points(St40, Sp9)

secretions before an attempt to cough

Gentle pressure on the ribs or breast bone may help move secretionsp p p ( p )

Page 13: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Visualisation and DistractionVisualisation and DistractionFinding ways to aid relaxation may be helpful, e.g. listening to music/story tapes/radio or watching T.V.Enjoyable hobbies may also be beneficial e.g. painting, knitting and crafts if physical ability allows

Page 14: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

The Calming HandThe Calming Hand

Burnett and Blagbrough (2010) ‘The Calming Hand’ in Oxford Textbook of Palliative Medicine 4th Edition, Oxford: Oxford University Press

Page 15: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Acupressure Techniques to aid Respiratory Management

All 361+ acupuncture points have specific actions• Many acupuncture points can help with breathing y p p p g

difficulties (references available but currently little research related specifically to MND)

• Pressure on these points can be as effective as true acupuncture using needlesTh t ti t i t th L M idi d• The most pertinent points are on the Lung Meridian and Bladder Meridian but also on the Conception Vessel (midline with points on the sternum)(midline with points on the sternum)

• Uses: Acupressure can be used to relieve breathlessness and/or to clear secretionsbreathlessness and/or to clear secretions

Page 16: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Th L Ch l (L )The Lung Channel (Lu)

Page 17: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

The Bladder Channel (Bl)

Page 18: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

The Conception Vessel (CV)The Conception Vessel (CV)

Page 19: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

AcupressureAcupressure• ‘Acupressure’ means applying any form of pressureAcupressure means applying any form of pressure

over an acupuncture point (e.g. finger pressure or use of ‘Seabands’)

• Pressure on relevant acupuncture points has been shown to help relieve symptoms of breathlessness andshown to help relieve symptoms of breathlessness and other respiratory symptoms e.g. cough (references are available)

• Acupressure can be self-administered or carried out by h l d tli d i th t f lid ill ta helper and as outlined in the next few slides will not

interfere with any other treatments and can do no harm

Page 20: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Acupressure 2Acupressure 2There are many ways to apply acupressure, but the two easiest are:

• Fingertip pressure over one point• Stroking over a series of associated points (sometimes

called a meridian, line or channel)

The following slides show some examples of both techniques being used to help with breathlessness:techniques being used to help with breathlessness:

Page 21: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Stroking the Lung MeridianStroking the Lung Meridian

Using the palm of the handUsing the palm of the hand, firmly stroke down the arm and off the thumb

This is best done by a carer but can be a self help technique

If the arm is also supported on a pillow this will be even more peffective

Page 22: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Acupressure to acupoint Lu5 may help to relieve a dry or productive cough:Lu 5 is in the centre of the cubital fossa lateral to the Biceps tendon

Page 23: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Thumb HoldAcupressure to acupoint Lu11 may relieve breathlessness

This is an easy technique to use whilst active or struggling to catch breath e g when climbingbreathlessness

Lu 11 is at the base of the thumb nailstruggling to catch breath e.g. when climbing stairs or to reduce symptoms of breathlessness associated with anxiety

Page 24: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Bladder Meridian Conception Vessel

Acupressure to acupoint Bl13 may Acupressure to acupoint CV17 may relieve the feeling of a tight chestp p y

relieve breathlessness Bl 13 is either side of T3 spinous process

g gCV 17 is in the centre of the sternum at the nipple line – use pressure with the side of the handprocess the side of the hand

Page 25: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Clearing secretions with acupressure

• From a TCM perspective secretions are defined as ‘Damp’ or ‘Phlegm’ depending on duration of presence and originand origin

• Both can be cleared effectively with acupuncture, acupressure or TENSacupressure or TENS

• This can be useful for patients with MND who may not be able to cough effectively and may not tolerate be ab e o coug e ec e y a d ay o o e a edrainage positioning

• St 40, Sp9 are two accessible pertinent points on the p p plower limbs

Page 26: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

St 40 and Sp9St 40 and Sp9• St 40 is halfway between

kl d k t fi• Sp 9 is under the medial 

ankle and knee two finger widths lateral to the crest of the tibia

condyle of the tibia

of the tibia

Page 27: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Using ‘Seabands’ to apply acupressure for Breathlessness Management

Page 28: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

PC6PC6This is also known as the sea sickness or nausea pointnausea pointIt is located three fingers width above the wrist crease on the palm side of the forearm Using Seabands for prolonged periods on

Seabands should not be used on an arm at risk of lymphoedema

Using Seabands for prolonged periods on this point can be very relaxing as well as reducing symptoms of nausea or breathlessness

Page 29: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

H7H7This point is located in the hollow at the wrist

h li l fi id f h fAcupressure or ‘Seabands’ can be used on

crease on the little finger side of the forearmIt is a very useful point to reduce anxiety and palpitations which may be apparent during an episode of breathlessness or during a

this pointCaution for patients with a history of heart problems- discuss with therapist

an episode of breathlessness or during a panic attack, also used for insomnia

Page 30: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Lu9Lu9This acupoint is on the wrist crease at the base of the thumb

Finger acupressure here or ‘Seabands’ may be used to relieve breathing difficulties and cough.

Page 31: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Oxygen and NebulisersOxygen and NebulisersOxygen may be provided on medical advice

A nebulizer with saline may assist with secretion clearanceadvice

Additional oxygen is not always necessary Use of a fan can be even more

secretion clearance

Use of a fan can be even more effective for some people

Page 32: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Pacing ActivityPacing ActivitySh t i d f tl ti it• Short episodes of gentle activity followed by short rest periods will allow greater achievement without becoming excessively breathlessexcessively breathless

Stairs- general advice:• Going upstairs - stop halfway up• Going upstairs - stop halfway up,

regain breathing control and then continue

• It may help to have a chair on a y phalfway landing

• It may help to use the thumb hold technique or a hand held fan during this activity

• A stairlift may be more appropriate for patients with MND

Page 33: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Aids and AdaptationsAids and Adaptations

Breathlessness which is exacerbated by particular activities may be relieved by the appropriate use of aids e.g. bath aids, perching stool walking aids or small aids toperching stool, walking aids or small aids to assist with daily life

Page 34: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

ExerciseExerciseEvidence shows that the most important exercise to help with breathlessness generally is to maintain strength in the thighs e.g. Hip flexion/gentle marching, leg straightening sitting in the chair, or sit to standWith the physical limitations of MND this may not be possible in later stages

Page 35: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Assessment for BreathlessnessAssessment for Breathlessness

• The new BMT includes a section for assessment ofThe new BMT includes a section for assessment of breathlessness

• This includes a section to record triggers for SOB, gg ,previous coping strategies, subjective problems relating to SOB and objective observations

• It is useful to record which Toolbox techniques have been tried and if possible capture their perceived ff ti t i t f di ieffectiveness at various stages of disease progression

Page 36: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

SummarySummary

•   Being mildly breathless is not dangerous although it can be frightening. Episodic and/or continuous breathlessness is morefrightening. Episodic and/or continuous breathlessness is more worrisome

• Have equipment readily available f• Practice when well - familiarity will reassure

• Breathlessness does respond to non-pharmacological measures• They are easy to learn empower both patient and helper and areThey are easy to learn, empower both patient and helper and are

cost effectiveFor patients with MND any or all of these techniques may be helpful if d l id th d i d i t li d b thif used alongside the advice and equipment supplied by the neuro-respiratory specialists and cannot cause harm

Page 37: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

ReferencesReferencesB i C B th S G l M Hi i I (2008) ‘N h l i l• 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 Systemic Reviews 2008, Issue 2 Art No :CD005623 DOI:10 1002/14651858 CD005623 pub2Issue 2. Art.No.:CD005623.DOI:10.1002/14651858.CD005623.pub2

• Bausewein, C., Booth, S., Gysels, M., Kuhnbach, R., Higginson, I.J. (2010) ‘Effectiveness of a hand-held fan for breathlessness: a randomised controlled phaseEffectiveness of a hand held fan for breathlessness: a randomised controlled phase II trial.’ BMC Palliative Care 19, (9) 22

• Burnett, J., Blagbrough, M., (2010) ‘The Calming Hand and Breathlessness , , g g , , ( ) gManagement Toolbox.’ in Oxford Textbook of Palliative Medicine. 4 th Edition. Oxford: Oxford University Press 229–230

• Deadman, P., Al‐Khafaji, M., Baker, K. (2007) A Manual of Acupuncture. Hove: Journal of Chinese Medicine Publications 

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Medical Management Of DyspnoeaMedical Management Of Dyspnoea

•Teamwork•Trusting relationships•Address fears•Plan ahead, anticipate problems, preparationDr gs•Drugs:

-Opioids

-Benzodiazepines

- Night sedation

Page 39: BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX€¦ · BREATHLESSNESS MANAGEMENT TTOOLBOXOOLBOXTOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 3030thth AprilApril

Medical Management Of SecretionsMedical Management Of SecretionsReduced swallowing causing drooling is distressing:Reduced swallowing causing drooling is distressing:

• Anticholinergics:g- Atropine drops tds- Hyoscine (s/l, transdermal, s/cut)

• Tricyclic antidepressants: Amitriptyline• Propranolol 10mg tds• Glycopyrronium (subcut)• Glycopyrronium (subcut)

Salivary glands:y g- Botulinum toxin - Radiotherapy