1. Palliative care approaches to symptom management in advanced respiratory disease: anxiety and breathlessness
Dr Jonathan Martin
Consultant in Palliative Medicine, St Joseph's Hospice
Visiting Fellow, Harris Manchester College, University of Oxford
28th June 2013
Thanks to:
Rebecca Jennings, St Joseph’s Hospice
Dr Sara Booth, Cambridge Breathlessness Intervention Service

2. Palliative care needs of COPD patients
Heavy burden of symptoms.
(Fan 2007, Habraken 2009, Gardiner 2009)
Symptoms at least as severe as lung cancer.
(Edmonds 2001, Habraken 2009)
Impaired quality of life and emotional well being compared to lung cancer.
(Gore 2000)
Information needs also great.
(Randall Curtis 2002, 2008)

3. Information needs Qualitative study in 2009
Understanding of COPD poor:
Lack of awareness of progressive nature;
Lack of awareness that they might die of COPD.
Despite this the patients:
Were concerned that their disease might progress;
Were frightened that they would die of breathlessness or suffocation.
None had discussed these fears with any health care professional.
(Gardiner 2009)

4. Balance of Management Approaches
Non-pharmacological
NonPh
NonPh
NonPh
Non-pharmacological interventions are the most effective interventions currently available to palliate breathlessness in the mobile patient Booth et al 2011
Pharm
Pharm
Pharmacological
Pharm
Dyspnoea on exercise
Dyspnoea at rest
Terminal
dyspnoea
Wilcock, 1998 4

5. Focus of non-pharmacological management in advanced disease is not on decreasing breathlessness but helping individuals to feel more in control of their breathing and be as independent as possible

6. Anxiety

7. Anxiety and breathlessness are probably linked
Total dyspnoea
Physical
Psychological
Spiritual
Social
Cancer
Non-cancer
Therapy
Hopelessness
Fear
Loss of job
Fatigue
Faith questioned
Why me?
Isolation
Depression 7

8. CBT Thoughts I might die How will my wife cope? Physical Breathless
Deconditioned
Weight loss
Feelings
Fear/anxiety
Behaviours
Staying in the house
Not talking to wife
Not eating well 8

9. Vicious daisy Fear / anxiety I might die Breathless
How will my wife cope?
Weight loss
Fear / anxiety
Not talking to wife
Not eating well
Breathless
Staying at home
Deconditioned 9

10. Anxiety (and depression)
Non-drug treatments: good evidence for effect:
Pulmonary rehabilitation. (Withers 1999, Paz 2007, Coventry 2009)
Cognitive behavioural therapy (CBT). (Coventry 2008, Heslop 2009, Kunik 2008, Livermore 2010) [N.B. No RCT evidence]
Drug treatments: limited contradictory evidence in COPD:
TCAs, SSRIs (Lacasse 2004, Yohannes 2001) 10

11. Breathlessness

12. Non-pharmacological and Pharmacological Approaches Breathlessness
• Personalised goals of care
• Symptom orientated
Multidisciplinary Approach
Maximise quality of life for
patients and their families
Involve patient and family in
care planning
• Maximise physical function
and emotional wellbeing
• Holistic
Maximise usual treatments as appropriate eg: inhalers
Manage exacerbations actively as appropriate
Consider oxygen for hypoxia*
Cautious use of opioids* and benzodiazepines*
Education: Physiology and Anatomy
Positioning
Hand Held Fan
Breathing Control Techniques
Functional Exercise
Walking Aid (4 wheel rollator)
* Beware the hypercapnic patient

13. Non-pharmacological Management
Intervention
Rationale
Summary of Evidence
Education:
simple anatomy and physiology of breathing
Empowers patient and carer to understand condition, why they become breathlessness. Reduces fear and promotes self management
Insufficient evidence Bausewein 2009
Positioning: Forward lean
High sitting
Increase efficient use of accessory muscles
Offload diaphragm
Improve ventilation/ perfusion ratio
Limited. Recommended in clinical practice but further research needed Booth et al 2011
Handheld Fan
Stimulates nasal receptors altering the signal to brainstem respiratory complex and changing respiratory pattern
Abernethey et al 2010
Strong evidence. Crossover RCT 51 patients with chronic breathlessness. Significant decrease in breathlessness measured on VAS when fan directed to cheeks vs leg (p=0.003)
Galbraith et al 2010
Breathing Control Techniques
Promotes efficient breathing pattern, decrease distressing symptoms of hyperventilation
Moderate quality evidence to support
Bausewein 2009 Cochrane Systematic Review
Compounded by variation in definition of techniques Booth et al 2011

15. Recovery breathing “Rescue breathing”
A three-part behaviour for use in distressing dyspnoeic episodes
Positioning: to allow use of accessory muscles
Focus on breathing out
Use of a fan
Cambridge Breathlessness Intervention Service

16. Pharmacological Management
Opioids
Oxygen
Benzodiazepines e.g. lorazepam
Antidepressants (direct & indirect)
Major tranquillizers e.g. levomepromazine
Others: furosemide, heliox, cannabinoids
Booth et al, Expert Review of Respiratory Medicine, 2009 16

17. Opioids
Consistent evidence of benefit (Jennings 2002, Abernethy 2003, Currow 2011)
Safety:
Entrenched societal and professional misconceptions
No evidence for respiratory depression from low dose oral opioids
Some evidence for safety (Clemens 2008, Estfan 2007, Chan 2004)
Some evidence against
Benefit may be limited to a few sensitive subjects (Pauwels 2001/2005)
Longer term adverse effects on endocrine system, falls and cognitive function (Freynhagen 2013)
Need adequately powered safety studies
Particular caution with:
Type 2 respiratory failure – no data specifically relating to this group
Transdermal fentanyl 17

18. Opioids in Breathlessness
When should they be considered?
Use them for breathlessness at rest
Use them at the end of life
Consider them in anyone with severe SOB
Consider in moderate breathlessness after other interventions 18

19. Breathlessness: opioid palliation
Two approaches:
Currow and colleagues start on 10mgs modified release (Currow et al , 2010)
Booth, Rocker and colleagues start on 1mg NR o.d. (Rocker et al, 2010) 19

20. titration in non-cancer in the community
Opioid
titration in non-cancer
in the community
Week AM PM 1
1mg Oramorph
Nil 2 3
2mg Oramorph 4 5
5mg MST 6
Up to 1mg Oramorph prn 7
Up to 2mg Oramorph prn 8
Up to 3mg Oramorph prn 9
Up to 4mg Oramorph prn 10
Consider 5mg MST

21. Oxygen Individual assessment essential for use for dyspnoea
Some evidence in non-malignant disease – related to desaturation on exercise and hypoxia at rest
Very little evidence in cancer that better than air – use according to clinical benefit in an individual
Use the fan first
Booth et al, Respiratory Med, 2004
Cranston et al, Cochrane Systematic Reviews, 2008 21

22. Benzodiazepines, buspirone
Recent Cochrane review. (Simon 2010)
Non-significant trend for benefit.
Buspirone:
Anxiolytic and respiratory stimulant with theoretical benefits (Smoller 1996)
Two RCTs with conflicting results (Singh 1993, Argyropoulou 1993) 22

23. Cochrane review of benzodiazepines/dyspnoea
Seven studies : RCT/CCT: meta-analysis of 6
200 participants with advanced COPD & cancer
No significant impact : positive small trend
>drowsiness placebo, <drowsiness morphine
Recommend: 3rd/4th line treatment after non-pharmacological & morphine
Simon et al, 2010

24. Summary: benzodiazepines
Little evidence
Rather more for major tranquillisers
Preferable to achieve anxiety-reduction by non-pharmacological means except at the end of life
Subcutaneous opioid & benzodiazepine in severe SOB 24

25. Could antidepressants work?
Possibly by:
By treating depression
By treating anxiety/panic disorder
By an effect on serotonin-mediated pathways in the brainstem
Detecting and treating depression essential
Brenes, Psychosom Med, 2003 25

26. Summary of the evidence
Good evidence for:
Pulmonary rehabilitation
Breathing training
Walking aids
Exercise
CBT
Fan
Opioids
Limited evidence for:
Benzodiazepines
Oxygen
Antidepressants 26