UNDERSTANDING UNDERSTANDING BREATHLESSNESS IN BREATHLESSNESS IN

10’ish MINUTES!10’ish MINUTES!

Dr David PlumeDr David Plume

Macmillan GP Facilitator, Macmillan GP Facilitator,

Central NorfolkCentral Norfolk

DyspnoeaDyspnoea

• Unpleasant Unpleasant awareness of awareness of difficulty in breathingdifficulty in breathing

• Pathological when Pathological when ADLs affected and ADLs affected and associated with associated with disabling anxietydisabling anxiety

• Resulting in :Resulting in :physiologicalphysiologicalbehavioural behavioural responsesresponses

DyspnoeaDyspnoea• Breathlessness experienced by Breathlessness experienced by 70%70%

cancer patients in last few weeks of lifecancer patients in last few weeks of life

• Severe breathlessness affects Severe breathlessness affects 25%25% cancer cancer patients in last week of lifepatients in last week of life

Causes of breathlessness-Causes of breathlessness-CancerCancer

– Pleural effusionPleural effusion– Large airway obstructionLarge airway obstruction– Replacement of lung by cancerReplacement of lung by cancer– Lymphangitis carcinomatosaLymphangitis carcinomatosa– Tumour cell microemboliTumour cell microemboli– Pericardial EffusionPericardial Effusion– Phrenic nerve palsyPhrenic nerve palsy– SVC obstructionSVC obstruction– Massive ascitesMassive ascites– Abdominal distensionAbdominal distension– Cachexia-anorexia syndrome respiratory muscle Cachexia-anorexia syndrome respiratory muscle

weakness.weakness.– Chest infectionChest infection

Causes of Breathlessness-Causes of Breathlessness-TreatmentTreatment

– PneumonectomyPneumonectomy– Radiation induced fibrosisRadiation induced fibrosis– Chemotherapy inducedChemotherapy induced

• PneumonitisPneumonitis

• FibrositisFibrositis

• CardiomyopathyCardiomyopathy

– ProgestogensProgestogens• Stimulates ventilationStimulates ventilation

• Increased sensitivity to carbon dioxide.Increased sensitivity to carbon dioxide.

Causes of Breathlessness- Causes of Breathlessness- DebilityDebility

– AtelectasisAtelectasis– AnaemiaAnaemia– PEPE– PneumoniaPneumonia– EmpyemaEmpyema– Muscle weaknessMuscle weakness

Causes of Breathlessness-Causes of Breathlessness-ConcurrentConcurrent

o COPDCOPDo AsthmaAsthmao HFHFo AcidosisAcidosiso FeverFevero PneumothoraxPneumothoraxo Panic disorder, anxiety, depressionPanic disorder, anxiety, depression

Reversible causes of Reversible causes of breathlessness!breathlessness!• Resp. InfectionResp. Infection• COPD/AsthmaCOPD/Asthma• HypoxiaHypoxia• Obstructed Bronchus/SVCObstructed Bronchus/SVC• Lymphangitis CarcinomatosaLymphangitis Carcinomatosa• Pleural EffusionPleural Effusion• AscitesAscites• Pericardial EffusionPericardial Effusion• AnaemiaAnaemia• Cardiac FailureCardiac Failure• PEPE

Breathlessness CycleBreathlessness Cycle

PANIC

Independent predictor of Independent predictor of survivalsurvival

Breathless on exertion

Breathless at rest Terminal breathlessness

Correct the correctable

Non-drug treatment

Symptomatic drug treatment

months weeks days

Is this Terminal Breathlessness?

Are there appropriate treatments that couldor should be tried at home?

Does this patient want and need transfer for investigations and treatment?

Consider transfer to hospital for investigation & treatment if:

Pre-SOB condition good

Acute onset SOB

Patient receiving ongoing disease modifying treatment

Manage at home if:

Burden of transfer for investigation & treatment too great

Consider Oral antibioticsNebulisersSteroidsOxygen

Non-Drug TherapiesNon-Drug Therapies

• Explore perception of patient and Explore perception of patient and carerscarers

• Maximise the feeling of control over Maximise the feeling of control over the breathingthe breathing

• Maximise functional abilityMaximise functional ability

• Reduce feelings of personal and Reduce feelings of personal and social isolation.social isolation.

Patient and Carer Patient and Carer PerceptionPerception• Meaning to patient and carerMeaning to patient and carer

• Explore anxiety esp. fear of sudden Explore anxiety esp. fear of sudden deathdeath

• Inform that not life threateningInform that not life threatening

• State what is likely to/not to happenState what is likely to/not to happen

• Realistic goal settingRealistic goal setting

• Help patient and carer adjust to loss of Help patient and carer adjust to loss of roles/abilities.roles/abilities.

Maximize controlMaximize control

• Breathing control adviceBreathing control advice– Diaphragmatic breathingDiaphragmatic breathing– Pursed lips breathingPursed lips breathing

• Relaxation techniquesRelaxation techniques• Plan of action for acute episodesPlan of action for acute episodes

– Written instructions step by stepWritten instructions step by step– Increased confidence copingIncreased confidence coping

• Electric fanElectric fan• Complementary therapies Complementary therapies

Maximize functionMaximize function

• Encourage exertion to Encourage exertion to breathlessness to improve breathlessness to improve tolerance/desensitise to tolerance/desensitise to breathlessnessbreathlessness

• Evaluation by physios/OT’s/SW to Evaluation by physios/OT’s/SW to target support to need.target support to need.

Reduce feelings of isolationReduce feelings of isolation

• Meet others in similar situationMeet others in similar situation

• Day centreDay centre

• Respite admissionsRespite admissions

Breathlessness ClinicBreathlessness Clinic

• Nurse leadNurse lead

• NNUH-Monday AfternoonNNUH-Monday Afternoon

• Lung cancer and mesotheliomaLung cancer and mesothelioma

• Referral by GP/SPCN/Palliative Referral by GP/SPCN/Palliative Medicine team/Generalist ConsultantsMedicine team/Generalist Consultants

• PBL Day Unit-Wednesday, link with PBL Day Unit-Wednesday, link with NNUH.NNUH.

Drug TreatmentDrug Treatment

What do I give?What do I give?• BronchodilatorsBronchodilators work well in COPD and Asthma even if nil work well in COPD and Asthma even if nil

known sensitivity.known sensitivity.

• O2 O2 increases alveolar oxygen tension and decreases the work of increases alveolar oxygen tension and decreases the work of breathing to maintain an arterial tension. breathing to maintain an arterial tension. – Usual rules regarding COPD/Hypercapnic Resp. failure apply.Usual rules regarding COPD/Hypercapnic Resp. failure apply.

• OpioidsOpioids reduce the vent.response to inc. CO2, dec O2 and reduce the vent.response to inc. CO2, dec O2 and exercise hence dec resp effort and breathlessness. exercise hence dec resp effort and breathlessness. – If morphine naïve-Start with stat dose of If morphine naïve-Start with stat dose of Oramorph 2.5-5mgOramorph 2.5-5mg or or

Diamorphine 2.5-5mgDiamorphine 2.5-5mg sc and titrate Repeated 4hrly as needed. sc and titrate Repeated 4hrly as needed. – If on morphine already for pain a dose 100% or > of q4h dose may be If on morphine already for pain a dose 100% or > of q4h dose may be

needed, if less severe 25% q4h may be givenneeded, if less severe 25% q4h may be given

• BenzodiazipinesBenzodiazipines stat dose of stat dose of LorazepaLorazepam 0.5mg SL, m 0.5mg SL, DiazepamDiazepam 2-5mg or 2-5mg or MidazolamMidazolam 2.5-5mg sc 2.5-5mg scRepeated 4hrly as neededRepeated 4hrly as needed

Ongoing treatmentOngoing treatment

A syringe driver should be commenced if A syringe driver should be commenced if a 2a 2ndnd stat dose is needed within 24hrs stat dose is needed within 24hrs

• Diamorphine 10-20mg CSCI / 24hrsDiamorphine 10-20mg CSCI / 24hrs

• Midazolam 5-20mg CSCI / 24hrsMidazolam 5-20mg CSCI / 24hrs

Remember to prescribe statsRemember to prescribe statsReview & adjust dose daily if neededReview & adjust dose daily if needed

Terminal BreathlessnessTerminal Breathlessness

• Great fear of patients and relativesGreat fear of patients and relatives

• Treat appropriately- Opioid and Treat appropriately- Opioid and sedative/anxiolytic- Diamorphine and sedative/anxiolytic- Diamorphine and midazolam-PRN and CSCImidazolam-PRN and CSCI

• If agitation or confusion -haloperidol or If agitation or confusion -haloperidol or NozinanNozinan

• Some patients may brighten.Some patients may brighten.

• Sedation not the aim but likely due to Sedation not the aim but likely due to drugs and disease.drugs and disease.

Respiratory Secretions (death Respiratory Secretions (death rattle)rattle)• Rattling noise due to secretions in hypopharynx Rattling noise due to secretions in hypopharynx

moving with breathingmoving with breathing• Usually occurs within days-hours of deathUsually occurs within days-hours of death• Occurs in ~40% cancer patients (highest risk if Occurs in ~40% cancer patients (highest risk if

existing lung pathology or brain metastases) existing lung pathology or brain metastases)

• Patient rarely distressedPatient rarely distressed• Family commonly are distressedFamily commonly are distressed

• Treat earlyTreat early• Position patient semi-pronePosition patient semi-prone

• Suction rarely helpfulSuction rarely helpful

Respiratory SecretionsRespiratory Secretions• If secretions are present, two options.If secretions are present, two options.

• A) Hyoscine Butylbromide (Buscopan)A) Hyoscine Butylbromide (Buscopan)– Stat-20mg 1hrlyStat-20mg 1hrly– CSCI-80-120mg/24 hrsCSCI-80-120mg/24 hrs

• B) GlycopyrroniumB) Glycopyrronium– Stat-0.4mg 4hrlyStat-0.4mg 4hrly– CSCI-0.6-1.2mg /24 hrsCSCI-0.6-1.2mg /24 hrs

Remember Stats at appropriate doses Remember Stats at appropriate doses Review & adjust dose dailyReview & adjust dose daily