1. The Center for Palliative Care Education Palliative Management of Dyspnea in HIV/AIDS

2. Learning objectives Describe the primary causes of dyspnea at the end of life Explain the process of evaluating a patient’s dyspnea Give examples of treatments for dyspnea and their risks and benefits Consider the causes, evaluation and treatment of dyspnea in patients with HIV/AIDS Understand management of dyspnea during the last hours of life

3. Consider a case 42-year-old HIV positive man Presents with progressive dypnea over 6 months PMH otherwise unremarkable –Physical exam normal –Cutaneous Kaposi’s Sarcoma –CXR shows…

5. Outline Causes of severe dyspnea in palliative care Causes of dyspnea in HIV/AIDS patients Treatment options for dyspnea Dyspnea in the last hours of life

6. Causes of dyspnea Many pulmonary and non-pulmonary diseases can cause dyspnea: –Pulmonary: COPD, asthma, pneumonia, PE, lung cancer, lymphoma, pneumothorax, pleural effusion –Non-Pulmonary: Heart failure, anemia, acidosis First step to managing dyspnea is to diagnose and treat underlying cause

7. Some causes of dyspnea in HIV/AIDS Opportunistic Infections: PCP, Fungal, TB, Viral Pulmonary Kaposi’s Sarcoma Lymphoma HIV-Related Myopathy

11. Initial evaluation for dyspnea History, physical examination Chest x-ray Laboratory tests: CBC, chemistries, arterial blood gas Spirometry

12. Approach to managing dyspnea Identify the cause Treat what is treatable Manage with supportive measures

13. What kind of life-support do patients receive? Claessens, J Am Geratr Soc, 2000 p<0.05 all comparisons

14. What kind of life-support do patients want? Claessens, J Am Geratr Soc, 2000 p>0.05 all comparisons

15. Treatment of dyspnea Oxygen Opioids Benxodiazepines Anti-depressants Non-pharmacologic measures

16. Oxygen Many HIV+ patients with dyspnea do not have low O 2 saturations However, O 2 therapy may relieve symptoms of dyspnea Pro: Symptom relief, ease of use Con: Uncomfortable, burdensome, expensive

17. Oxygen Indication for oxygen therapy: –PaO 2 < 55 mmHgPaO 2 55-59 + a) p pulmonale, –b) clinical right heart failure, OR c) hct > 55% –SaO 2 < 89% –SaO 2 89% plus a, b, or c above –Treatment of dyspnea in hospice care

18. Opioids Primary pharmacologic therapy for dyspnea Important central effects of analgesia and euphoria that palliate dyspnea Choice of administration route (Patch, PO, parenteral) Intermittent vs. continuous dosing Pro: May be efficacious in improving breathlessness Con: Sedating, may cause respiratory depression, constipation

19. Trials of oral opiates for dyspnea in severe COPD Author- YearDrugDurationDyspnea Woodcock ’81dh-codeine 1 dose improved Johnson ’83dh-codeine 1 wkimproved Light ’89morphine1 dose improved Rice ’87codeine1 mono change Eiser ’91diamorph.2 wkno change Poole ’98MS-SR6 wkno change Manning, Resp Care, 2000; 45:1342

20. Other agents with little or no effect on dyspnea Nebulized opiates: –1 positive, 4 negative controlled trials Benzodiazepines: –1 positive, 3 negative controlled trials Buspirone: –1 positive trial, very small effect Phenothiazines: –1 positive, small effect; 1 negative trial

21. Depression and anxiety in severe COPD and stage III/IV lung cancer Gore, Thorax, 2000 p<0.01 all comparisons

22. Benzodiazepines Use may alleviate associated fear and anxiety Start at low dose and titrate to dyspnea reduction Once effective dose determined, schedule administration Q4-6H Variety of dosing routes available

23. Treating depression in COPD 12-week randomized controlled trial Two groups: –Nortriptyline vs placebo N=36 –Major depression (n=33) –Residual depression (n=3) Mean duration depression 39 months Borson, Psychosomatics 1992

24. Nortriptyline improves mood NT vs Placebo p=0.01

25. Nortriptyline (NT) improves anxiety and somatic symptoms Differential NT treatment effects: All p < 0.05

26. Nonpharmacologic interventions Minimize anxiety-producing factors in the environment Address concerns of family members and caregivers as well as the patient Relaxation techniques Fan/cool air Schwartzstein RM, et al (1987) Am Rev Respir Dis 136:58 -61

27. Dyspnea in the last hours of life Same treatment modalites: oxygen, opioids, and benzodiazepines Titrate opioid dose to patient’s respiratory signs Consider anticholinergic agent for management of secretions

28. Re-consider case 42-year-old man with HIV presents with progressive dypnea over 6 months PMH otherwise unremarkable –Physical exam normal –CXR consistent with KS

29. Summary Dyspnea is common and disabling Identify cause of dyspnea and treat underlying cause when possible Trial of symptomatic treatments –Oxygen, opiates Recognize and treat anxiety and depression Spend time communicating with patients and family

30. Contributors The primary author of this module is Elizabeth Knauft, MD, MS, University of Washington Department of Pulmonary and Critical Care Medicine Anthony Back, MDDirector J. Randall Curtis, MD, MPHCo-Director Frances Petracca, PhD Evaluator Liz Stevens, MSW Project Manager Visit our Website at uwpallcare.org Copyright 2003, Center for Palliative Care Education, University of Washington This project is funded by the Health Resources and Services Administration (HRSA) and the Robert Wood Johnson Foundation (RWJF).