1. Managementn of RespiratorySymptoms in Cancer Patients
F. Soltaninejad MD
Pulmonologist

2. Breathlessness

3. Background 54%-76% of advanced cancer patients experience dyspnea
more than 65% of lung cancer patients have cough at the time of diagnosis
35% of cancer patients develop death rattle at the end of life

4. Breathlessness
Breathlessness is an uncomfortable sensation or awareness of breathing.
Subjective – measuring lung function does not correlate with sensation or severity of breathlessness
A complex experience of mind and body that is likely to progress with disease severity
Significant correlation with impaired quality of life and poor survival. Effects Patients and Carers.
A common complex distressing symptom at the end of life

5. Dyspnea
Dyspnea is a frequent symptom in advanced cancer patients with the highest prevalence in lung cancer (up to 74%) increasing in the terminal phase (up to 80%) with major impact on the quality of life of the patient and his or her family.

6. Dyspnea Dyspnea can be described along three dimensions:
air hunger—the need to breathe while being unable to increase ventilation
effort of breathing—physical tiredness associated with breathing
chest tightness—the feeling of constriction and inability to breathe in and out

7. Psychological Aspect of Breathlessness

8. Assessment of breathlessness
Listen/Observe
What does it mean to the patient / carer?
Onset
Triggers / What eases it?
Levels of significance – during activity, in
different positions, at rest
Pattern of breathing, colour, respiratory rate
Are they anxious?
Oxygen saturations

9. Assessment of dyspnea History Physical examinations
Paraclinic assessment: ( complete blood count, electrolytes, creatinine, oximetry and full blood gas assessment, electrocardiogram, brain natriuretic peptide or chest X-ray and computed tomography scan )

10. Manage reversible causes optimally according to patients wishes
Consider active treatment of:
Infection
Pleural effusion
Pneumothorax
Pericardial effusion
Airway obstruction
Anaemia
CHF

11. Non Pharmacological Management
Positioning
Airflow - use of fan /window
Relaxation / Distraction/ Reassurance
Energy conservation / Pacing
Controlled Breathing techniques
Loose clothing
Mouth Care

12. Comfortable Positions if short of breath

13. Breathing Techniques
Start with position of ease Relax shoulders / upper chest Diaphragmatic ‘tummy’ breathing Breath out twice as long as breath in Pursed lips on breathing out if needed

14. Pacing activities Encourage activity Allow time for tasks
Starting and stopping with rest intervals
Inspiration: expiration ratio during activity
Use of aids – stair lift etc
Adapting functional tasks

16. Management of dyspnea Oxygen therapy
Oxygen therapy is recommended in hypoxemic patients
Oxygen therapy is suggested not to be used in nonhypoxemic patients

18. Management of dyspnea
Noninvasive positive pressure ventilation (NPPV) is suggested to be used in patients with hypoxemia and hypercapnea

19. Management of dyspnea
High-flow nasal cannula oxygen therapy is suggested to be used in patients with hypoxemia that is refractory to standard oxygen therapy

20. Management of dyspnea Opioids
Systemic morphine is recommended to be used in cancer patients with dyspnea
Systemic oxycodone is suggested to be used, as alternative to morphine
Systemic fentanyl is suggested not to be used
Systemic codeine/dihydrocodeine is suggested to be used

22. Management of dyspnea Benzodiazepines
Benzodiazepines are suggested not to be used alone
Benzodiazepines are suggested to be used in combination with opioids

24. Management of dyspnea Corticosteroids
Systemic corticosteroids are suggested not to be used routinely without consideration of dyspnea etiology.
Systemic corticosteroids are suggested to be used in patients with lymphangitis carcinomatosa, radiation pneumonitis, superior vena cava syndrome, major airway obstruction.

25. other drugs
Neuroleptics such as phenothiazines and antidepressants and buspirone are reputed to exert some antidyspnoeic efficacy as mood-enhancing medication; nevertheless, this has not yet been proven.

26. Management of malignant pleural effusion
Thoracentesis with drainage of pleural effusion is recommended
Pleurodesis should be performed in cancer patients with dyspnea caused by malignant pleural effusion, if patients meet all the following conditions: (1) repeated thoracentesis is required to relieve dyspnea, (2) patient’s general condition is tolerable for pleurodesis, and (3) a monthly prognosis is expected.

27. Management of cough
Morphine/codeine/dihydrocodeine and dextromethorphan are suggested to be used.
Gabapentin/pregabalin and nebulized lidocaine are suggested not to be used.

28. Recommended dosages for antitussives
Dextromethorphan mg tds/qds
Codeine mg qds
Morphine (oramorph) 5 mg (single dose trial of oramorph; if effective 5-10 mg slow release morphine bd)
Diamorphine 5-10 mg CSCI/24 hrs
Methadone linctus Single dose 2 mg (2 mL of 1 mg/mL solution)
Dihydrocodeine 10 mg tds
Hydrocodone 5 mg bd
Prednisolone 30 mg daily for 2 weeks

29. End of life secretions Often referred to as ‘death rattle’
Caused when a patient’s coughing and swallowing reflex is impaired or absent, causing fluids to collect
Not easily relieved by drug therapy once established
Treatment should therefore be started at first sign of rattle

30. Non-pharmacological management of secretions
Re-positioning of the patient by tilting side to side, or tipping bed ‘head up’ to reduce noise
Management of halitosis with frequent mouth care
Discrete management of oral secretions mouth care – oral hygiene
Suction not advised, except when secretions are excessive
Reassurance to family that the noise is due to secretions, and not causing suffocation, choking or distress
Reduce oral fluids if at risk of aspiration

31. Pharmacological management of secretions
Hyoscine Butylbromide (Buscopan) mg/24hr s/driver, prn dose SC 20mg
If not effective, discuss with palliative care team who may consider
Glycopyronium Bromide (Glycopyrolate) mcg/24hr s/driver or prn dose 200mcg
Point: Hyoscine Hydrobromide was historically drug of choice, but not currently recommended due to side effects of sedation and confusion

32. Thank you for listening