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UNDERSTANDING BREATHLESSNESS IN 10’ish MINUTES!

UNDERSTANDING BREATHLESSNESS IN 10’ish MINUTES!. Dr David Plume Macmillan GP Facilitator, Central Norfolk. Dyspnoea. Unpleasant awareness of difficulty in breathing Pathological when ADLs affected and associated with disabling anxiety Resulting in : physiological behavioural responses.

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UNDERSTANDING BREATHLESSNESS IN 10’ish MINUTES!

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  1. UNDERSTANDING BREATHLESSNESS IN 10’ish MINUTES! Dr David Plume Macmillan GP Facilitator, Central Norfolk

  2. Dyspnoea • Unpleasant awareness of difficulty in breathing • Pathological when ADLs affected and associated with disabling anxiety • Resulting in : physiological behavioural responses

  3. Dyspnoea • Breathlessness experienced by 70% cancer patients in last few weeks of life • Severe breathlessness affects 25% cancer patients in last week of life

  4. Causes of breathlessness-Cancer • Pleural effusion • Large airway obstruction • Replacement of lung by cancer • Lymphangitiscarcinomatosa • Tumour cell microemboli • Pericardial Effusion • Phrenic nerve palsy • SVC obstruction • Massive ascites • Abdominal distension • Cachexia-anorexia syndrome respiratory muscle weakness. • Chest infection

  5. Causes of Breathlessness-Treatment • Pneumonectomy • Radiation induced fibrosis • Chemotherapy induced • Pneumonitis • Fibrositis • Cardiomyopathy • Progestogens • Stimulates ventilation • Increased sensitivity to carbon dioxide.

  6. Causes of Breathlessness- Debility • Atelectasis • Anaemia • PE • Pneumonia • Empyema • Muscle weakness

  7. Causes of Breathlessness-Concurrent • COPD • Asthma • HF • Acidosis • Fever • Pneumothorax • Panic disorder, anxiety, depression

  8. Reversible causes of breathlessness! • Resp. Infection • COPD/Asthma • Hypoxia • Obstructed Bronchus/SVC • Lymphangitis Carcinomatosa • Pleural Effusion • Ascites • Pericardial Effusion • Anaemia • Cardiac Failure • PE

  9. Breathlessness Cycle PANIC

  10. Independent predictor of survival weeks days months Symptomatic drug treatment Non-drug treatment Correct the correctable Breathless on exertion Breathless at rest Terminal breathlessness

  11. Non-Drug Therapies • Explore perception of patient and carers • Maximise the feeling of control over the breathing • Maximise functional ability • Reduce feelings of personal and social isolation.

  12. Patient and Carer Perception • Meaning to patient and carer • Explore anxiety esp. fear of sudden death • Inform that not life threatening • State what is likely to/not to happen • Realistic goal setting • Help patient and carer adjust to loss of roles/abilities.

  13. Maximize control • Breathing control advice • Diaphragmatic breathing • Pursed lips breathing • Relaxation techniques • Plan of action for acute episodes • Written instructions step by step • Increased confidence coping • Electric fan • Complementary therapies

  14. Maximize function • Encourage exertion to breathlessness to improve tolerance/desensitise to breathlessness • Evaluation by physios/OT’s/SW to target support to need.

  15. Reduce feelings of isolation • Meet others in similar situation • Day centre • Respite admissions

  16. Breathlessness Clinic • Nurse lead • NNUH-Monday Afternoon • Lung cancer and mesothelioma • Referral by GP/SPCN/Palliative Medicine team/Generalist Consultants • PBL Day Unit-Wednesday, link with NNUH.

  17. Drug Treatment

  18. What do I give? • Bronchodilators work well in COPD and Asthma even if nil known sensitivity. • O2 increases alveolar oxygen tension and decreases the work of breathing to maintain an arterial tension. • Usual rules regarding COPD/Hypercapnic Resp. failure apply. • Opioidsreduce the vent.response to inc. CO2, dec O2 and exercise hence dec resp effort and breathlessness. • If morphine naïve-Start with stat dose of Oramorph 2.5-5mg or Diamorphine 2.5-5mg sc and titrate Repeated 4hrly as needed. • If on morphine already for pain a dose 100% or > of q4h dose may be needed, if less severe 25% q4h may be given • Benzodiazipines stat dose of Lorazepam 0.5mg SL, Diazepam 2-5mg or Midazolam 2.5-5mg sc Repeated 4hrly as needed

  19. Ongoing treatment A syringe driver should be commenced if a 2nd stat dose is needed within 24hrs • Diamorphine 10-20mg CSCI / 24hrs • Midazolam 5-20mg CSCI / 24hrs Remember to prescribe stats Review & adjust dose daily if needed

  20. Terminal Breathlessness • Great fear of patients and relatives • Treat appropriately- Opioid and sedative/anxiolytic- Diamorphine and midazolam-PRN and CSCI • If agitation or confusion -haloperidol or Nozinan • Some patients may brighten. • Sedation not the aim but likely due to drugs and disease.

  21. Respiratory Secretions (death rattle) • Rattling noise due to secretions in hypopharynx moving with breathing • Usually occurs within days-hours of death • Occurs in ~40% cancer patients (highest risk if existing lung pathology or brain metastases) • Patient rarely distressed • Family commonly are distressed • Treat early • Position patient semi-prone • Suction rarely helpful

  22. If secretions are present, two options. A) HyoscineButylbromide (Buscopan) Stat-20mg 1hrly CSCI-80-120mg/24 hrs B) Glycopyrronium Stat-0.4mg 4hrly CSCI-0.6-1.2mg /24 hrs Remember Stats at appropriate doses Review & adjust dose daily Respiratory Secretions

  23. All clear? Any Questions?

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