Upload
wissam-az
View
465
Download
1
Tags:
Embed Size (px)
Citation preview
Wissam Abouzgheib, MD, FCCPWissam Abouzgheib, MD, FCCP
Pulmonary / Critical Care and Interventional Pulmonary / Critical Care and Interventional PulmonaryPulmonary
Sparks Health System, Fort Smith, ARSparks Health System, Fort Smith, AR
Dyspnea in Dyspnea in Lung cancerLung cancer
DisclosuresDisclosures NoneNone
56 y.o male presented with significant dyspnea and abnormal
CXR
56 y.o male presented with significant dyspnea and abnormal CXR
56 y.o male presented with significant dyspnea and abnormal CXR
56 y.o male presented with significant dyspnea and abnormal CXR
DefinitionDefinition Subjective experience of breathing Subjective experience of breathing
discomfort that consists of discomfort that consists of qualitatively distinct sensations that qualitatively distinct sensations that vary in intensity.vary in intensity.
Derives from interaction among Derives from interaction among multiple physiologic, psychological multiple physiologic, psychological and environmental factors and environmental factors
May induce 2May induce 2ndaryndary physiological and physiological and behavioral responsesbehavioral responses
PrevalencePrevalence Common and prevalence increases Common and prevalence increases
as death approachesas death approaches 70% last 6 wks of life 70% last 6 wks of life 60% of pts at diagnosis 60% of pts at diagnosis 90% advanced disease90% advanced disease
Dyspnea in terminally ill cancer patients. Chest 89:234-236
EtiologiesEtiologies
In advanced cancer: usually In advanced cancer: usually multifactorial multifactorial
Majority of underlying causes Majority of underlying causes irreversible irreversible
Palliative treatments partially successful Palliative treatments partially successful Important to reverse what is reversible Important to reverse what is reversible Relatively small improvement in Relatively small improvement in
different parameters may give different parameters may give significant reliefsignificant relief
Burden/BenefitBurden/Benefit
Burden/Benefit of the intervention for Burden/Benefit of the intervention for the patient needs to be evaluated by the patient needs to be evaluated by themthem
If extra visits to hospital are required, If extra visits to hospital are required, will the relief provided exceed the will the relief provided exceed the exhaustion incurred?exhaustion incurred?
InvestigateInvestigate Should be investigatedShould be investigated
Certain causes easily identifiable and Certain causes easily identifiable and reversiblereversible
Minimal interventionMinimal intervention
Rapid symptom improvement Rapid symptom improvement
EtiologiesEtiologies
Co-morbidities Cancer
Treatment
Co-morbiditiesCo-morbidities Infection/pneumoniaInfection/pneumonia
Increased dead space: COPD, Increased dead space: COPD, pulmonary vascular diseasepulmonary vascular disease
Resp muscle weakness: myasthenia Resp muscle weakness: myasthenia gravis, lambert-Eatongravis, lambert-Eaton
Cancer relatedCancer related AnemiaAnemia CachexiaCachexia Lymphangitic spreadLymphangitic spread Tumor obstructing an airwayTumor obstructing an airway Malignant pleural effusionMalignant pleural effusion Trapped lung Trapped lung Pulmonary embolismPulmonary embolism Conditions affecting chest wall compliance: hepatomegaly, Conditions affecting chest wall compliance: hepatomegaly,
ascites, pleural diseasesascites, pleural diseases Pulmonary congestion: SVCO, pericardial effusionPulmonary congestion: SVCO, pericardial effusion AnxietyAnxiety
Treatment-Treatment-relatedrelated Infection/pneumoniaInfection/pneumonia
DeconditioningDeconditioning
AnemiaAnemia
Pulmonary fibrosis Pulmonary fibrosis
Clinical Management Clinical Management
Non Non Pharmacological Pharmacological interventionsinterventions
Pharmacological Pharmacological interventionsinterventions
Treatable conditions - Treatable conditions - PneumoniaPneumonia
CAP and MDR pathogensCAP and MDR pathogens
Broad spectrum then deescalate Broad spectrum then deescalate
Initial management: Therapeutic Initial management: Therapeutic thoracentesisthoracentesis
MPEs inevitably re-accumulateMPEs inevitably re-accumulate Pleurodesis : Medical pleuroscopy vs Pleurodesis : Medical pleuroscopy vs
chest tube slurry talc pleurodesischest tube slurry talc pleurodesis Advanced disease = poor Advanced disease = poor
performance status performance status
Treatable conditions Treatable conditions Malignant pleural effusionMalignant pleural effusion
Treatable conditions Treatable conditions Malignant pleural effusionMalignant pleural effusion
Medical Pleuroscopy Medical Pleuroscopy availableavailable
Diagnostic and Diagnostic and therapeutic therapeutic
Lung / breast > slurry Lung / breast > slurry talctalc
Perceived more Perceived more comfortable and less comfortable and less painfulpainful
Treatable conditions Treatable conditions Malignant pleural effusionMalignant pleural effusion
Chest 2005;127;909-915
QuickTime™ and aYUV420 codec decompressor
are needed to see this picture.
Treatable conditions Treatable conditions Malignant pleural effusionMalignant pleural effusion
Pleurx Catheter : minimally Pleurx Catheter : minimally invasive, outpt procedure, invasive, outpt procedure, easily managed @ home or easily managed @ home or hospice hospice
Effective, relief of dyspnea Effective, relief of dyspnea > 90 % pts> 90 % pts
Pleurodesis can be Pleurodesis can be achieved in 42-58% within achieved in 42-58% within 4 wks 4 wks
Easily removableEasily removable
Curr Opin Pulm Med 2002
20-30% lung cancer during course of 20-30% lung cancer during course of diseasedisease
Bronchial > tracheal but more seriousBronchial > tracheal but more serious Endobronchial tumor, extrinsic
compression, or combination Endobronchial interventions quicker
than radiation or PDT
Treatable conditions Treatable conditions Central Airway ObstructionCentral Airway Obstruction
Electrocautery, APC, Nd-Yag,cryotherapy Debulking : certainly improves dyspnea but
? survival compared with historical controls Debulking alone unlikely affects survival Rapid / effective restoration of airway
patency and elimination of associated high morbidity and mortality of CAO were more likely responsible for this survival advantage.
Treatable conditions Treatable conditions Central Airway ObstructionCentral Airway Obstruction
20 pts20 pts ProspectiveProspective Absence of Absence of
concurrent therapyconcurrent therapy Nd-Yag laser, Nd-Yag laser,
Cryotherapy, stents, Cryotherapy, stents, laser and mechanical laser and mechanical debulking debulking
Treatable conditions Treatable conditions Central Airway ObstructionCentral Airway Obstruction
Respiration 2008;76:421–428
QuickTime™ and aYUV420 codec decompressor
are needed to see this picture.
Superior Vena Cava Superior Vena Cava syndrome syndrome
Facial and upper Facial and upper thoracic edemathoracic edema
Often associated with Often associated with dyspnea and coughdyspnea and cough
Traditional trts: EBRT Traditional trts: EBRT ± ± chemo, 60-75 % reponse chemo, 60-75 % reponse rate 2 weeks laterrate 2 weeks later
Endovascular stenting Endovascular stenting 95-100% relief of 95-100% relief of obstruction within 72 hrs obstruction within 72 hrs
Ann Thorac Surg. 2003
Non Pharmacological Non Pharmacological interventionsinterventions
Eclectic range of interventionsEclectic range of interventions Not systematically validated Not systematically validated self initiated self initiated Promotes self efficacyPromotes self efficacy
The fanThe fan Facial cooling 2nd and 3rd branchesFacial cooling 2nd and 3rd branches Reduces sensation of dyspneaReduces sensation of dyspnea CheapCheap SmallSmall Self initiatedSelf initiated
Am Rev Respir Dis. 1987 Jul;136(1):58-61.
Anxiety-reduction trainingAnxiety-reduction training
Learning diaphragmatic Learning diaphragmatic breathingbreathing
Reducing hyperventilationReducing hyperventilation Relaxation techniqueRelaxation technique Self hypnosisSelf hypnosis Visualization and guided imageryVisualization and guided imagery DistractionDistraction ““Dyspnea not harmful” may Dyspnea not harmful” may
reduce anxietyreduce anxiety
Methods need to fit with Methods need to fit with patient’s and relative’s patient’s and relative’s philosophy of carephilosophy of care
Part of “dyspnea Part of “dyspnea management program”management program”
Physical Physical rehabilitationrehabilitation Pulmonary rehab reduces dyspnea Pulmonary rehab reduces dyspnea
and improves QOL COPD and improves QOL COPD Even severely disabledEven severely disabled No comparable research in cancerNo comparable research in cancer Exercise training associated with Exercise training associated with
reduction in lactate levels and reduction in lactate levels and minute ventilationminute ventilation
Non invasive ventilationNon invasive ventilation
Reserved for patients with Reserved for patients with “reversible cause and to prolong life “reversible cause and to prolong life in order to achieve a specific goalin order to achieve a specific goal
COPD data: NIV might have a role in COPD data: NIV might have a role in symptom control symptom control
Crit Rev Oncol Hematol. 2004 Aug;51(2):91-103.
Pharmacological management - Pharmacological management - OpioidsOpioids
Most case reports or seriesMost case reports or series
Jenings et al: metanalysis double Jenings et al: metanalysis double blinded, randomized, placebo blinded, randomized, placebo controlled trials controlled trials
Nebulized opioids = placeboNebulized opioids = placebo
Thorax. 2002 Nov;57(11):939-44. Review.
Pharmacological management - Pharmacological management - OpioidsOpioids
Thorax. 2002 Nov;57(11):939-44. Review.
QuickTime™ and a decompressor
are needed to see this picture.
Pharmacological management - Pharmacological management - OpioidsOpioids
Randomized, double blind, placebo controlled Randomized, double blind, placebo controlled crossover trial of sustained release morphine for crossover trial of sustained release morphine for the management of refractory dyspnea.the management of refractory dyspnea.
6/38 pts had cancer6/38 pts had cancer 20mg modified-release morphine 4 days followed 20mg modified-release morphine 4 days followed
by 4 days placebo or vice versa by 4 days placebo or vice versa 5-10% improvement in dyspnea over baseline all 5-10% improvement in dyspnea over baseline all
ptspts Better sleep during treatment periodBetter sleep during treatment period No respiratory depressionNo respiratory depression
BMJ. 2003 Sep 6;327(7414):523-8.
Phenothiazines and Phenothiazines and benzodiazepinesbenzodiazepines
No randomized controlled trialsNo randomized controlled trials Phenothiazines preferred- less resp depressionPhenothiazines preferred- less resp depression beneficial effects of morphine in controlling beneficial effects of morphine in controlling
baseline levels of dyspnea could be improved baseline levels of dyspnea could be improved with the addition of midazolam to the with the addition of midazolam to the treatment.treatment.
morphine (2.5 mg Q4hrs for opioid-naïve or a morphine (2.5 mg Q4hrs for opioid-naïve or a 25% increment over daily dose for pts receiving 25% increment over daily dose for pts receiving baseline opioids) plus midazolam (5 mg Q4hrs) baseline opioids) plus midazolam (5 mg Q4hrs) with morphine rescue doses (2.5 mg)with morphine rescue doses (2.5 mg)
J Pain Symptom Manage. 2006 Jan;31(1):38-47.
OxygenOxygen Mechanism uncertainMechanism uncertain Correction of hypoxemia may not Correction of hypoxemia may not
alleviate dyspneaalleviate dyspnea May be activation trigeminal nerveMay be activation trigeminal nerve Randomized trials suggest that both Randomized trials suggest that both
O2 and air can reduce dyspnea in O2 and air can reduce dyspnea in cancer patientscancer patients
HelioxHeliox Less dense than airLess dense than air When mixed with O2, reduces When mixed with O2, reduces
turbulent flow in narrowed airwaysturbulent flow in narrowed airways Reduces work of breathing and Reduces work of breathing and
improves alveolar ventilationimproves alveolar ventilation One randomized controlled trial, Heliox One randomized controlled trial, Heliox
reduced DOE and increased exercise reduced DOE and increased exercise capacity and SaO2 at rest and exertioncapacity and SaO2 at rest and exertion
Br J Cancer. 2004 Jan 26;90(2):366-71.
Inhaled Inhaled furosemidefurosemide Randomized, double-blined, placebo Randomized, double-blined, placebo
controlled in cancer patientscontrolled in cancer patients
No beneficial effectNo beneficial effect
Thorax. 2008 Oct;63(10):872-5. Epub 2008 Apr 11.
Thank youThank you