2 An uncomfortable awareness of breathing DYSPNEA:An uncomfortable awareness of breathing
3 “...the most common severe symptom in the last days of life” DYSPNEA:“...the most common severe symptom in the last days of life”Davis C.L. The therapeutics of dyspnoea Cancer Surveys 1994 Vol.21 p
4 National Hospice Study prospectiveIncidence: 70 % during last 6 wks. of lifeReuben DB, Mor V. Dyspnea in terminally ill cancer patients.Chest 1986;89(2):234-6.
5 National Hospice Study Dyspnea PrevalenceReuben DB, Mor V. Dyspnea in terminally ill cancer patients.Chest 1986;89(2):234-6.
6 HOW WELL ARE WE TREATING DYSPNEA IN THE TERMINALLY ILL? Addington-Hall JM, MacDonald LD, Anderson HR, Freeling P.Dying from cancer: the views of bereaved family and friends about the experience of terminally ill patients.Palliative Medicine :n = Last week of lifesevere / very severe dyspnea: 50%® less than ½ of these were offered effective treatment
7 CAUSES OF DYSPNEA IN PALLIATIVE CARE 1. Direct tumor effects2. Indirect tumor effects3. Treatment-related4. Unrelated to cancer
11 APPROACH TO THE DYSPNEIC PALLIATIVE PATIENT Two basic intervention types:1. Non-specific, symptom-oriented2. Disease-specific
12 SIMPLE MEASURES IN MANAGING DYSPNEA calm reassurancesitting up / semi-reclinedopen windowfan
13 NON-SPECIFIC PHARMACOLOGIC INTERVENTIONS IN DYSPNEA Oxygen - hypoxic and ? non-hypoxicOpioids - complex variety of central effectsChlorpromazine - start with 10 mg po q6hBenzodiazepines - literature inconsistent butclinical experience extensive
14 TREAT THE CAUSE OF DYSPNEA - IF POSSIBLE AND APPROPRIATE Anti-tumor: chemo/radTx, hormone, laserInfectionCHFSVCOPleural effusionPulmonary embolismAirway obstruction
16 DYSPNEA CRISIS Sudden onset / rapid worsening of dyspnea Often imminently terminal situation(minutes or hours)Examples:pulmonary embolismfulminant pneumoniaupper airway obstructionhemoptysis
17 APPROACH TO DYSPNEA CRISIS Aggressively pursue comfortRemain on site until comfortableIdeally use intravenous routeGenerally employ non-specific measures:calm reassuranceoxygenopioidspossibly sedatives:methoptrimeprazine, CPZ, benzodiazepines(lorazepam, midazolam)
18 q10 min. IV push with escalating doses Example using morphine IV push: OPIOIDS IN DYSPNEA CRISISq10 min. IV push with escalating dosesExample using morphine IV push:mgmgmgIf no better in 10 min.If no better in 10 min.
19 CONGESTION IN THE FINAL HOURS “Death Rattle”PositioningANTISECRETORYScopolamine mg SQ q1h prnAtropine mg SQ q1h prnGlycopyrrolate mg SQ q2h prnless likely to cause delirium, sedation? less effectiveConsider suctioning if secretions are:distressing, proximal, accessiblenot responding to antisecretory agents