The Palliation of The Palliation of Dyspnea in Dyspnea in

Far Advanced Far Advanced Lung CancerLung Cancer

Dr. Anna TowersDr. Anna Towers

Division of Palliative CareDivision of Palliative Care

McGill UniversityMcGill University

Palliation of dyspneaPalliation of dyspnea

Work of:Work of:

Dr. Sam Ahmedzai Dr. Sam Ahmedzai

Professor of Palliative MedicineProfessor of Palliative Medicine

Sheffield, UKSheffield, UK

Effect of palliative drugs on Effect of palliative drugs on respiratory muscles and respiratory muscles and

ventilatory activityventilatory activity

The benzodiazepine midazolam reduces The benzodiazepine midazolam reduces tidal volume and depresses ventilation by tidal volume and depresses ventilation by affecting the thoracoabdominal musclesaffecting the thoracoabdominal muscles

Opioids inhibit rib cage movementOpioids inhibit rib cage movement

Effect of opioids on the Effect of opioids on the medullary respiratory medullary respiratory

centrecentre

Opioids reduce the hypercapnic drive in the Opioids reduce the hypercapnic drive in the medullary centre (respiratory depression) medullary centre (respiratory depression)

(the hypercapnic drive = mathematical (the hypercapnic drive = mathematical relationship between ventilation and relationship between ventilation and ppCO2)CO2)

i.e. opioids render the the medullary centre less i.e. opioids render the the medullary centre less sensitive to rising sensitive to rising ppCO2 levelsCO2 levels

Effect of severe Effect of severe hypercapnea on dyspneahypercapnea on dyspnea Dyspnea may abate when the CO2 level Dyspnea may abate when the CO2 level

rises above 75 – this could be due to the rises above 75 – this could be due to the compensatory release of natural compensatory release of natural endorphinsendorphins

Patients with severe hypercapnea are Patients with severe hypercapnea are often somnolent (CO2 narcosis), partially often somnolent (CO2 narcosis), partially due to the above mechanismdue to the above mechanism

Clinical definition Clinical definition of dyspnea of dyspnea

Greek : Dys= bad or difficult Greek : Dys= bad or difficult

Pneo= breathingPneo= breathing

A A SUBJECTIVESUBJECTIVE sensation of difficulty in sensation of difficulty in breathing, not necessarily related to breathing, not necessarily related to exertion, that compels the individual to exertion, that compels the individual to increase his ventilation or decrease his increase his ventilation or decrease his activity activity (Ahmedzai)(Ahmedzai)

Effects of dyspnea Effects of dyspnea on the patienton the patient

Reduction in :Reduction in :quality of life, general function, activities of quality of life, general function, activities of daily livingdaily living

Although dyspnea is subjective, the Although dyspnea is subjective, the effects on function are objectively effects on function are objectively observableobservable

Terms often confused Terms often confused with dyspneawith dyspnea

Tachypnea (e.g. increased breathing rate Tachypnea (e.g. increased breathing rate caused by fever)caused by fever)

Hyperpnea (increased ventilation through Hyperpnea (increased ventilation through metabiolic acidosis e.g. diabetic metabiolic acidosis e.g. diabetic ketoacidosis)ketoacidosis)

Hyperventilation (Psychologically induced Hyperventilation (Psychologically induced increased respiration) increased respiration)

Patients’ description Patients’ description of dyspneaof dyspnea

““I feel like I am suffocating.”I feel like I am suffocating.” ““I am afraid and feel like I am drowning.”I am afraid and feel like I am drowning.” ““I have a tightness in the chest”I have a tightness in the chest”

Prevalence of dyspnea in Prevalence of dyspnea in terminal illnessterminal illness

70% of those in the last 6 weeks of life – 70% of those in the last 6 weeks of life – all diagnoses all diagnoses (National Hospice Study U.S.A.)(National Hospice Study U.S.A.)

60% of those with lung cancer 60% of those with lung cancer (St. Christopher’s Hospice, UK)(St. Christopher’s Hospice, UK)

Causes of dyspnea Causes of dyspnea in lung cancerin lung cancer

PulmonaryPulmonary PleuralPleural Thoracic cageThoracic cage Cardiac/ pericardialCardiac/ pericardial

Pulmonary causes of Pulmonary causes of dyspnea dyspnea

in lung cancerin lung cancer Airway collapse/ lung collapseAirway collapse/ lung collapse ThromboembolismThromboembolism PneumoniaPneumonia Lymphangitis carcinomatosaLymphangitis carcinomatosa Radiation fibrosisRadiation fibrosis Noncancer causes: COPD/asthmaNoncancer causes: COPD/asthma

Pleural causesPleural causes

Pleural effusionPleural effusion Pleural tumourPleural tumour

Impaired thoracic cage Impaired thoracic cage functionfunction

Respiratory muscle wasting in Respiratory muscle wasting in anorexia/cachexia syndrome, leading to anorexia/cachexia syndrome, leading to respiratory muscle fatiguerespiratory muscle fatigue

Chest wall tumoursChest wall tumours

Pericardial causes Pericardial causes

Pericardial tumour, effusion, tamponadePericardial tumour, effusion, tamponade

Management of dyspneaManagement of dyspnea

DIAGNOSE AND TREAT DIAGNOSE AND TREAT REVERSIBLE CAUSES REVERSIBLE CAUSES

Common reversible Common reversible causescauses

Pleural effusionPleural effusion PneumoniaPneumonia Tumour mass or lymphangitis that can be Tumour mass or lymphangitis that can be

reduced with palliative oncologial reduced with palliative oncologial treatmentstreatments

Superior vena cava syndromeSuperior vena cava syndrome

SVC syndromeSVC syndrome

Superior vena cava syndrome is Superior vena cava syndrome is considered an oncological and palliative considered an oncological and palliative EMERGENCYEMERGENCY

Is usually very responsive to radiotherapy Is usually very responsive to radiotherapy and high-dose corticosteroidsand high-dose corticosteroids

Treatment should always be considered Treatment should always be considered unless prognosis is very short unless prognosis is very short

Treatment of carcinomatous Treatment of carcinomatous lymphangitislymphangitis

Palliative chemotherapyPalliative chemotherapy RadiotherapyRadiotherapy Where prognosis is very short: Where prognosis is very short:

High dose dexamethasone High dose dexamethasone

(Start with at least 12 mg per day and (Start with at least 12 mg per day and titrate down. Stop steroid if there is titrate down. Stop steroid if there is no no response after a 2-week trial.)response after a 2-week trial.)

General drug treatment General drug treatment for dyspneafor dyspnea

Inhaled or nebulized bronchodilatorsInhaled or nebulized bronchodilators Corticosteroids (usually at least 12 mg Corticosteroids (usually at least 12 mg

per day of dexamethasone is required)per day of dexamethasone is required) Respiratory sedatives (opioids, Respiratory sedatives (opioids,

nonopioids)nonopioids)

Respiratory sedativesRespiratory sedatives

Opioids (morphine, hydromorphone, Opioids (morphine, hydromorphone, fentanyl, oxycodone, methadone etc)fentanyl, oxycodone, methadone etc)

BenzodiazepinesBenzodiazepines

Palliative approachPalliative approach

Aim is to prolong (good quality) life, or to Aim is to prolong (good quality) life, or to improve quality of life where life cannot improve quality of life where life cannot be prolongedbe prolonged

Discuss treatable causes with patient Discuss treatable causes with patient and/or family and obtain consent to treatand/or family and obtain consent to treat

Consider the prognosis, adverse effects, Consider the prognosis, adverse effects, social considerations (such as the burden social considerations (such as the burden of travel from home etc)of travel from home etc)

Palliative oncological Palliative oncological treatments for dyspneatreatments for dyspnea

Aim for improved quality of life rather Aim for improved quality of life rather than life prolongationthan life prolongation

Palliative chemotherapyPalliative chemotherapy RadiotherapyRadiotherapy

external beam or brachytherapyexternal beam or brachytherapy Endobronchial laser therapyEndobronchial laser therapy Endobronchial stentEndobronchial stent

Respiratory sedativesRespiratory sedatives

Have the effect of suppressing respiratory Have the effect of suppressing respiratory awareness – with or without an effect on awareness – with or without an effect on ventilatory driveventilatory drive

Non-opioidsNon-opioids OpioidsOpioids

Respiratory sedatives: Respiratory sedatives: non-opioidnon-opioid

Benzodiazepines:Benzodiazepines: Lorazepam (Ativan) , midazolam)Lorazepam (Ativan) , midazolam)

Phenothiazines:Phenothiazines: (methotrimeprazine (Nozinan)(methotrimeprazine (Nozinan)

Respiratory sedatives: Respiratory sedatives: opioidopioid

Reduce anxietyReduce anxiety Reduce sensitivity to hypercapneaReduce sensitivity to hypercapnea Improve cardiac functionImprove cardiac function Reduce concurrent pain that may be a Reduce concurrent pain that may be a

factor in producing anxiety and sensation factor in producing anxiety and sensation of dyspneaof dyspnea

Respiratory sedatives: Respiratory sedatives: opioidopioid

Note: codeine does NOT reduce Note: codeine does NOT reduce breathlessnessbreathlessness

Most commonly used opioids to control Most commonly used opioids to control dyspnea:dyspnea: morphinemorphine hydromorphone (Dilaudid)hydromorphone (Dilaudid) Fentanyl patchFentanyl patch oxycodoneoxycodone

Nebulized opioidsNebulized opioids

Route of delivery being studiedRoute of delivery being studied Note: nebulized morphine may induce Note: nebulized morphine may induce

histamine release and bronchospasm in histamine release and bronchospasm in some patientssome patients

How to use opioids in How to use opioids in dyspnea managementdyspnea management

Use prn only if dyspnea is intermittent Use prn only if dyspnea is intermittent (aggravated by exertion, anxiety)(aggravated by exertion, anxiety)

Have patient control the prn medicationHave patient control the prn medication Give just enough to relieve dyspnea, Give just enough to relieve dyspnea,

aiming, if possible, to avoid sedationaiming, if possible, to avoid sedation If combined with a benzodiazepine, small If combined with a benzodiazepine, small

doses of opioid are usually sufficientdoses of opioid are usually sufficient