1. Breathlessness
Dr Brian Ensor May 2016

2. Morning Star
Jon Barlow Hudson 2

3. Attend
Understand
Therapy
Plan 3

4. Attend
Understand
Therapy
Plan 4

5. Subjective experience of breathing discomfort
Dyspnoea
Subjective experience of breathing discomfort
Intensity component
Unpleasant component
Functional component 5

6. Roles Communication Whaikorero MND Independence Driving Toileting
Decision making 6

7. Language
Exhaustion
Air Hunger
Tightness
Choking 7

8. Measurement Research? Clinical? Intensity Unpleasantness Functional
Mastery
Research?
Clinical? 8

9. Total Dyspnoea Physical Psychological Existential (Social)
(Abernathy, A. P., & Wheeler J. L. (2008) Total dyspnoea. Current opinion in supportive and palliative care 2(2), ) 9

10. Respiratory Distress Observation Scale © Margaret L Campbell PhD RN, 19/2/2009
Variable
0 points
1 point
2 points
Total
Heart rate per minute
< 90
90 – 109
>110
Respiratory rate / minute
<18
19 – 30
> 30
Restlessness
None
Occassional
Frequent
Paradoxical abdominal movt
Present
Grunting
Nasal flaring
Presenet
Look of fear
Eyes wide open, facial muscles tense, brow furrowed, mouth open, teeth together 10

11. What is normal breathing?
That depends…
Triggers that can alter breathing patterns
pain fear
Snoring URTI
posture
Excitement dancing
asthma 11

12. “It's funny, but you never really think much about breathing
“It's funny, but you never really think much about breathing. Until it's all you ever think about.” ― Tim Winton, Breath 12

13. “Normal” breathing at rest
80% diaphragmatic movement, 20 % chest, inhale and exhale via nose
10-14 breaths/minute
Inspiration:expiration 1:1.5, slight pause end of exhale
Gentle inhale, effortless exhale
Feel minimal muscle activity, easy, smooth.. 13

14. Source: Alison McConnell,Respiratory Muscle Training; Theory and Practice, Elsevier, Oxford, 2013)14

15. Symptoms of disordered breathing in the healthy person.15

16. The Guardian by Cezary Stulgis accessed at brisstreet.com
Physiology
The Guardian by Cezary Stulgis accessed at brisstreet.com 16

17. Dyspnoea is a mismatch
“Respiratory motor centres receive and process the information according to the ventilator requirements of the body. A ventilator ‘command’ is then given, and an ascending copy of descending motor activity sent to perceptual areas (corollary discharge).
If ventilator demand exceeds the capacity for ventilation, there is an ensuing imblanace between the motor driver to breathe as sensed by the corollary discharge and afferent feedback from mechanoreceptors of the respiratory system.
This is variously referred to as…. efferent-reafferent dissociation, neuroventilatory dissociation, …...”
Currow et al 2013 Breathlessness – current and emerging mechanisms, measurement and management: A discussion from an EAPC workshop. Pall Med 27(10) 17

18. What the brain (cortex) expects, is not what it feels it is getting.
Dyspnoea is a mismatch
What the brain (cortex) expects, is not what it feels it is getting. 18

19. Exercise, Hyperthermia
Motor Cortex
Homeostasis
Brain Stem
CO2, O2, pH
Exercise, Hyperthermia
Ventilatory Pump 19

20. Brain Stem Breathing Agonal breathing Cheyne Stokes
Kussmaul (acidotic)
Apnoeic
Ondine’s curse
NB: Brain stem circuits are serotinergic 20

21. Exercise, Hyperthermia
Sensory Cortex
Motor Cortex
Corollary discharge
Effort demanded
Brain Stem
CO2, O2, pH
Exercise, Hyperthermia
Ventilatory Pump 21

22. Exercise, Hyperthermia
Afferent discharge
Results achieved
Sensory Cortex
Motor Cortex
Multiple Receptors
Brain Stem
CO2, O2, pH
Exercise, Hyperthermia
Ventilatory Pump 22

23. Multiple Receptors CO2, O2, pH
Muscle receptors – stretch & spindle, ergo
Lung receptors, J receptors, C fibre, irritant
Pressure receptors, blood vessels, lung
Nociceptors
Thermoreceptors (face, oropharynx) 23

24. Motor Cortex Brain Stem Ventilatory Pump Multiple Other Receptors
CO2, O2, pH
Exercise, Hyperthermia
Ventilatory Pump 24

25. Motor Cortex Brain Stem Ventilatory Pump Multiple Other Receptors
CO2, O2, pH
Exercise, Hyperthermia
Ventilatory Pump 25

26. Dyspnoea is a mismatch 26

27. Dyspnoea is a mismatch
Bridge
Engine
Engineering 27

28. Dyspnoea is a mismatch
Bridge
Engine
Engineering 28

29. Dyspnoea is a mismatch
Bridge
Engine
Engineering 29

30. Multiple Receptors CO2, O2, pH Outcome
Muscle receptors – stretch & spindle, ergo
Lung receptors, J receptors, C fibre, irritant
Pressure receptors, blood vessels, lung Processes
Nociceptors
Thermoreceptors (face, oropharynx) 30

31. CardioPulmonary causes of dyspnoea
Obstruction / collapse / pneumothorax
Tracheal
Bronchial
SVC
Effusion
Emboli
Infection
Heart failure
Pericardial effusion, anaemia,... 31

32. Treatment of Dyspnoea Drain effusions or ascites Antibiotics
Transfusion
Heart failure treatment
Stop ß-blockers
Steroids (+/-)
Radiotherapy / Chemo 32

33. 33

34. CAUSES OF DYSPNOEA Muscle weakness, fatigue, effort of breathing
Cachexia, MND, “inefficiencies”
Damaged lung or chest wall
Congestion, inflammation, BP issues, pain
Metabolic
CO2 , O2, acidosis
Cortical
Anxiety 34

35. Management of (unfixable)dyspnoea
Alter input to the cortex (Capt James T Kirk)
Reduce respiratory drive from brain stem
Improve blood gases
Reduce noxious input from peripheral receptors
Make muscles stronger, more efficient
Reduce pointless activity / anxiety
Increase positive input from peripheral receptors
Get the chest moving, air moving across face and in lungs
Distraction 35

36. Non-drug Jo Graham Tanya Loveard Tracey Smith Physiotherapist
Acupuncturist
Tanya Loveard
Occupational Therapist
Tracey Smith 36

37. Positioning Resting Position Breathing Recovery
Forward lean sitting or standing with forearms supported
Try & keep back straight & relax your head forward
Optimal Breathing Position
Sitting upright with feet, back & arms supported
  consent-forms
High side lying – rest your upper arm on a pillow Or
Sitting & relax forward onto pillows 37

38. Breathing Retraining Simple Breathing Techniques
Drop your shoulders
Focus on breathing OUT
Useful: pursed lips breathing or “phew”
Centre the breath in the belly
Other Techniques – useful to clear secretions
Active Cycle Breathing Techniques (ACBT)
Forced expiratory technique (FET) 38

39. ACBT
Taken from: information/therapies/physiotherapy/active-cycles-of-breathing-techniques.pdf 39

40. Energy Conservation The 3 P’s of energy conservation: Planning
Prioritising
Pacing 40

41. Anxiety Management Recognise triggers for anxiety Relaxation
Visualisation
Positive phrases
Distraction 41

42. Environmental Assessment /Equipment
Adapting patients environment
Provision of equipment/aids 42

43. Use of Handheld Fan A handheld fan directed at the
face may reduce the sensation
of breathlessness 43

44. Acupuncture Used for anxiety & breathlessness
Two approaches
- Western or Traditional Chinese Medicine
Used for anxiety & breathlessness
Extensive use in UK Hospices focusing on ASAD (anxiety, sickness & dyspnoea) points 44

45. Acupressure Can be used in conjunction with acupuncture
Patients can self massage points or press needles/seeds (left in situ)
Use of auricular(ear)points –these
can be left in situ for 5-7 days 45

46. Education/Reassurance
Communication
Imparting basic knowledge/use of handouts
Carer involvement
Breathless groups/clinics
Avoid overload of information 46

47. Breathlessness Plans Quick reference summary of MDT interventions
Individually designed for each patient & their carer
Discuss plan with patient & their carer 47

48. Breathing Plan for David
1. Support yourself in your breathing recovery position 2. Try using your fan 3. Take 1-2 puffs of midazolam spray into the mouth 4. Take your Oxynorm 5. Focus on breathing out 6. Listen to your music or, if you are able, work on crossword
Continue with this for 15 minutes, then
7. If feeling no better, repeat the midazolam spray
8. Continue your focus on breathing out
9. If you feel no better after a further 15 minutes phone the hospice on for advice 48

49. Exercise Exercise is inherent in all activities of daily living
Patients set own goals
International move to individualised planned exercise programme 49

50. Summary = Effective symptom management
Patients participating in activities they value 50

51. References
Bausewein, C., Booth, S., Gysels, M., & Higginson, I. (2008). Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of Systematic Reviews (Online), CD doi: /12.CJON.320 Cooper, J. (Ed.).(2003). Occupational Therapy in Oncology and Palliative Care.(3rd ed.) England. Whurr. Corner, J.& O”Driscoll, M.(1999). Development of a breathlessness assessment guide for use in palliative care. Palliative Medicine,13, Galbraith, S., Fagan, P., Perkins, P., Lynch, A., & Booth, S. (2010). Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. Journal of Pain and Symptom Management, 39(5), 831–8. doi: /j.jpainsymman Filshie, J., Penn, K., Ashley, S., & Davis, C. L. (1996). Acupuncture for the relief of cancer-related breathlessness. Palliative Medicine, 10, 145–150. doi: / Kumar. S.P., & Jim, A. ( S.2010). Physical therapy in palliative care: from symptom control; to quality of life- a critical review. Indian Journal of Palliative Care Lewis,L.K., Willaims, M.T., & Olds, T.S.(2012). The active cycle of breathing technique: A systematic review and meta analylsis. Respiratory Medicine Lim, J. T. W., Wong, E. T., & Aung, S. K. H. (2011). Is there a role for acupuncture in the symptom management of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led supportive care. Acupuncture in Medicine : Journal of the British Medical Acupuncture Society, 29(3), 173–9. doi: /aim Maa, S.H, Gauthier, D., & Turner, M.(1997). Acupressure as an adjunct to a pulmonary rehabilitation program. Journal of Cardiopulmonary Rehabilitation 51

52. General Drug Treatments
Opioids
oral or subcut
Nebulised
Long acting and short acting.
Benzodiazepines (Anxiety)
Oxygen
Steroids
Levomepromazine
Furosemide nebulised 52

53. Morphine Good evidence that low dose morphine relieves dyspnoea
Pain reverses that relief
Dose finding: 10mg to 30mg daily, long acting NNT=1.6
Role of short acting morphine is reduced
It is not depressing respiration
Expectation that Oxycodone works in a similar fashion.
Methadone used uncommonly 53

54. Fentanyl
Randomised double blinded studies show it works (up to 350mcg prn sc)
Nebulised vs subcut vs sublingual
It is serotinergic 54

55. Evidence Free Zone
Fentanyl will not treat tachypnoea from brainstem activation at the very end of life.
SSRIs may aggravate tachypnoea.
Consider anti-serotinergic medication: Nozinan, quetiapine.
End of life tachypnoea is different from dyspnoea, which requires consciousness. The aim (arguably) is then respiratory depression, requiring much bigger doses of opioids. 55

56. Benzodiazepines Good anxiolytics
There may be a place of midazolam nasal spray
Consider long acting benzodiazepines
Remember cognitive / psychological interventions
Anxiety is not the cause of dyspnoea. 56

57. Evidence Free Zone
Anxiety is not the cause of dypsnoea in our population.
Dyspnoea is the cause of anxiety.
Admission is a very good intervention. 57

58. Oxygen No better than room air for patients without hypoxia.
Hypoxic COPD patients gain some long term survival benefit 58

59. Miscellaneous
Levomepromazine 12.5 – 25mg prn q1h Radiotherapy, oncology, pleural drains, surgery, laser, cryotherapy, Furosemide nebulised Non Invasive Ventilation 59

60. Summary = Effective symptom management
Comfortable at rest, and the ability to get there. 60

61. End of life Tachypnoea / “struggling to breath” Secretions Buscopan
Aspiration / Reflux
Pneumonic
Cardiac
Grunting
Purse lip breathing for the unconscious. 61

62. Evidence Free Zone
Gross aspiration might deserve a naso-gastric tube, certainly not buscopan
Pneumonic secretions might deserve some gentamicin or steroids
I would choose to die hypovolaemic rather than in congestive failure
We might consider more aggressive treatment of tachypnoea, with opioids, and anti serotonin medications. 62

63. Multidisciplinary Team
“An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial” Higginson I, Bausenwein C et al Lancet Respiratory Medicine Dec (12) 63

64. 64