UNDERSTANDING BREATHLESSNESS IN 10’ish MINUTES! Dr David Plume Macmillan Palliative Care 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

Dysponea Breathlessness experienced by 70% cancer patients in last few weeks of life Severe breathlessness affects 25% cancer patients in last week of life

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

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

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

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

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

Breathlessness Cycle

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

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.

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.

Maximize control Breathing control advice Relaxation techniques 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

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

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

Drug Treatment

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. Opioids reduce 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

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

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.

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

Respiratory Secretions Absent Prescribe stat doses Hyoscine Hydrobromide 0.4mg 4hrly prn If 2 or more doses required in 24hrs, consider adding to CSCI Present Stat Hyoscine Hydrobromide 0.4mg sc Repeat 4hrly prn Start Hyoscine Hydrobromide 1.2mg CSCI / 24hrs Prescribe stats Review & adjust dose daily

Alternative anti-secretory agents These unlike Hyoscine Hydrobromide don’t cross the BBB and hence are less likely to cause sedation and confusion. Hyoscine Butylbromide stat dose 20mg 1hrly CSCI 80-120mg/ 24hrs Glycopyrronium stat dose 0.4mg 6hrly CSCI 0.6-1.2mg/ 24hrs

All clear? Any Questions?