1. Breathlessness in the ED
Palliative care workshop for EM residents
July 29, 2015

2. Disclosures No disclosures
Any brand names I use, it is because that is what they are most commonly referred to/used at LGH. There may be other brands but this is the one I am most familiar with

3. Case “CTAS 1 to the resus room”
mid 70s female in acute respiratory distress
Has been placed on O2 by FM by EHS but despite this still only has O2 sats of 88% and significant WOB
Hx of severe COPD, on home O2 and max medical therapy. Frequent hospitalizations in past 3 months and steadily declining, now fully bed bound at home due to symptoms
What do you do next?
FM = facemask

4. What is dyspnea?
Definition of dyspnea: subjective awareness of having difficulty breathing. Key is that it is subjective. Experienced when sensory cortex perceives a difference between ventilatory demand and the ability of the body to meet that demand. Variable presentation (intermittent, exertional, progressive, constant). However, also important to ask in palliative patients who are presenting to ED for reasons other dyspnea (palliative ROS). Generally affects quality of life and often associated with anxiety, low mood, fatigue and insomnia.

5. “I feel like I am suffocating.”
“I am afraid and feel like I am drowning.”
“I have a tightness in the chest”

6. Total dyspnea
We will focus mostly on the physical, but keep in mind the other factors. Refer for appropriate help as these are not ED issues.

7. Assessment of dyspnea: unfortunately objective parameters (O2 sats, blood gases, etc) don’t correlate well with dyspnea. Patient self-report is key.
caregivers rated the intensity of dyspnea as higher than the patients did. Nurses on the other hand rated the intensity of dyspnea as lower.
physiologic parameters that were weakly associated were higher heart rate, supplemental oxygen use and Respiratory distress Observation Scale (RDOS, looks at HR, RR,  accessory muscle use, paradoxical breathing, restlessness, grunting, nasal flaring, fearful facial displays)

8. Can use the Borg scale or a , numerical rating scale (0-10), visual analog scale. Alternatively can ask about how the symptoms affect quality of life

9. Don’t worry about the details on this slide
Don’t worry about the details on this slide. I am not going to discuss all the possible causes of dyspnea. How to diagnosis and treat these problems is covered elsewhere during your residency training. Today, the focus is on how to to manage the palliative patient with dyspnea
Of note, in palliative patients, there is not always a clear cause found. one study found that 24% of cancer patients with dyspnea had no clear underlying cause. causes of dyspnea are often multifactorial and include systemic causes such as cachexia and asthenia (lack of energy: from a- (without) + sthenos (strength)
Not on the list, but in cancer patients also think of SVCS

10. CHF: 65% will have some dyspnea COPD: 90% will have some dyspnea IPF
Cancer pts: lung, GI (esophagus), Breast, ENT, lung mets most common to have symptoms
CHF: 65% will have some dyspnea
COPD: 90% will have some dyspnea
IPF
Motor diseases: ALS, MS
Any patient with a life-threatening illness
These are the common palliative presentations of dyspnea
any cancer patient can develop symptoms, especially as disease advances.
Other examples of life threatening illnesses: CRF, HIV, dementia

11. When to think of palliative care?
Cancer, especially if metastatic or if lung, esophagus or ENT cancer
Advanced COPD: on home 02
CHF with EF <25%
Other significant co-morbidities
Recurrent ED visits/admissions for same problem in last 3 months
Poor functional status: ie ECOG 3 or 4
Pt expresses wish for comfort care or DNR
Surprise question
ECOG 3 - >50% of time in chair or bed, needs help with ADLs
Surprise question: “would you be surprised if this patient died in the next 12 months?”

12. If your patient meets these criteria, take the time to explore goals of care with the patient before proceeding with further testing and treatment. Once the goals of care are established, this can help you determine which tests to do (if any) and which treatments to offer.
Ask what can I do to help this patient feel better and will this help them to achieve their goals (ie SHOULD I do these tests or offer certain treatments)? Examples include draining a pleural effusion, antibiotics for pneumonia, ventilatory support, etc.

13. Goals of Care
Concurrently treat the symptom while addressing the underlying cause (if appropriate)
Outcomes are better when a palliative approach is adopted earlier in the disease process
Once those causes are no longer treatable, managing the symptom becomes the main priority
I would argue we should treat all dyspnea symptomatically while we investigate and treat the underlying cause – just like you would give analgesia for pain in the ED
Study in patients with stage 4 lung cancer found that those referred earlier to palliative care had better quality of life and actually lived longer.
In many cases, treating the underlying cause will also treat the dyspnea, however there are circumstances when this is not possible or appropriate.
Discuss concept of refractory dyspnea: does not respond to treatment of underlying medical problem

14. Treatment success is defined by the goals you set and not by the cure

15. Non-pharmacologic options
fans directed towards face, open windows, cold compresses on face can help
pulmonary rehab
Acupuncture
breathing training (upright forward leaning position, controlled breathing, pursed-lip breathing)
relaxation strategies
walking aides
Good evidence for fans directed towards face
Pulmonary rehab is supervised/directed physical conditioning combined with education and can help maintain function and may help improve symptoms. For ambulatory patients so Also not applicable to many palliative patients.
Acpuncture: Mechanism not understood but may be due to release of endogenous opioids. Mixed results from trials.

16. Surgical interventions to consider

17. Malignant pleural effusion

18. Tunneled catheter (PleurX)
improved QoL, shorter hospital stays, fewer repeat procedures and lower cost (vs Talc pleurodesis)
risks of pleurodesis: pain, fever, talc embolization, empyema, adult respiratory distress syndrome, and respiratory failure
To look after PleurX in community - arrange for community nursing. Frequency of drainage varies, some need daily. generally drain cc at a time.

19. Bronchial stenting has been shown to be beneficial in those with malignant central respiratory obstruction. 80% of patients report improvement in symptoms.
Of note, steroids and chemotherapy and radiation therapy can also be considered.

20. Lets talk about O2 and its role in refractory dyspnea:
In those that are not hypoxic, it is less clear. Studies have had mixed results. A 2008 meta-analysis concluded that oxygen failed to improve symptoms in those cancer patients with mild dyspnea or who were not hypoxic.
Additional oxygen is not a benign intervention: it may limit quality of life due to functional restriction from tubing/tanks/concentrators, irritation from nasal cannula, expense if patients do not meet criteria for home O2.
Interestingly, one study compairing O2 by NP vs air by NP found benefit in both groups. Placebo effect vs relief from blowing air (like a fan)

21. If patients do not meet criteria, consider a trial of 1
If patients do not meet criteria, consider a trial of 1. If it does help, will usually see any benefits within a couple of days.

22. Home O2 criteria
Arterial oxygen saturation (SpO2) less than 88% for 6 min
Ambulatory Desaturation to less than 88% for 1 min
clear benefit for supplemental O2 in those that are hypoxemic, both in terms of quality of life and survival benefit.
There is also criteria based on PaO2, but this is generally an unnecessary test in palliative patients

23. O2 delivery systems Nasal Prongs (NP) : 1-6 lpm , 22-40% Fi02
Simple Mask (SM) : 5-12 lpm, 35-50% FiO2
Non Rebreather Mask : 15lpm, 60-90% Fi02
High Flow Face Mask : up to 95 % Fi02
High Flow Nasal Prongs (HFNP) : 100% Fi02 with very high flowrates
Bi-Level Positive Airway Pressure (Bipap) : set Fi02 plus ventilatory support ( aka non invasive ventilation )
Nasal prongs are most comfortable and practical for home environment.
I am going to talk about HFNP and BiPAP as ethically this is more challenging.

24. High Flow Nasal Prongs
Allow close to 100% FiO2 while being more comfortable than NIPPV. Allows patients to communicate. Washes out anatomic deadspace, therefore decreasing work of breathing (not as much as NIPPV). Helps with mucus clearing (another potential advantage over NIPPV). Provides a small amount of PPV, although unclear if this is clinically significant (therefore NIPPV probably better for CHF, COPD)
One study looking at patients with acute resp failure found that HFNP was significantly better tolerated than NiPPV and HFFM while maintaining similar respiratory parameters (only difference was a PaO2 which was lower than NIPPV but higher than HFFM). Overall discomfort was highest with NIPPV.
Recent FLORALI trial found a trend towards fewer intubations with HFNP in patients with acute resp failure (82% were pneumonia failure).

25. NIVPP
for those with COPD and CHF who want life prolonging therapy, we know that it works.
There is evidence (cochrane review, most data from single RCT) that for patients with ALS, non-invasive ventilation significantly prolongs survival and improves or maintains quality of life in people with ALS. Survival and some measures of quality of life were significantly improved in the subgroup of people with better bulbar function, but not in those with severe bulbar impairment.
Little research to see if whether NIPPV improves quality of life in those who are palliative. One study looking at cancer patients with severe dyspnea found that NIPPV relieved symptoms faster than O2 via other means and >50% of these patients (all felt to have terminal cancers) survived to hospital discharge. However, other evidence suggests that if cancer patients are intubated, survival is below 25%.

26. This applies to both HFNP and BiPAP. Using these can :
confuse care goals if not discussed carefully
challenging or impossible to initiate outside of acute care environments (e.g. at home, nursing home, or hospice facility)
difficult to stop once started

27. potential benefits (not well studied): symptom relief (decrease dyspnea and WOB), buys time (allows family members to arrive, time to cope with the deterioration), improved level of consciousness allowing for better communication.
downsides: NPPV is noisy, can be uncomfortable and frightening, can interfere with family intimacy, and can confuse care goals if not discussed carefully.  It can be challenging or impossible to initiate outside of acute care environments (e.g. at home, nursing home, or hospice facility) and difficult to stop once started

28. Situations to consider HFNP/BiPAP
Time-limited trial
Goal-limited trial
1- pt wants life prolonging treatment but not intubation/ventilation
NPPV is considered successful if it improves ventilation or oxygenation and provides support for the patient while the underlying cause of the respiratory failure is treated. More likely to help those with COPD and CHF vs cancer patients. It is important that this patient's dyspnea is well managed so that they are comfortable on NPPV; however, this patient may also be encouraged to tolerate some discomfort if the NPPV is improving ventilation or oxygenation. NPPV is discontinued when the patient is able to support ventilation and oxygenation without it, when NPPV is determined not to be working, or when the patient is not tolerating NPPV. Reasonable to do a time limited trial.
2- patients who want focus on comfort care
For patients who need sedating doses of opioids to be comfortable, and who articulate a strong preference to be as awake as possible, it is reasonable to offer NPPV if the patient is in an environment which can accommodate it (not always possible on a palliative unit) and the risks are acceptable to the patient, including the possibility that the dying process will be prolonged.  Reassure patients that you can alleviate their symptoms even if NPPV is unhelpful or intolerable. NPPV in this circumstance would only be considered successful if it improves the patient's symptoms of dyspnea or other distress without causing other troubling consequences. There is little evidence to show that NIPPV does in fact improve comfort or quality of life, therefore it is very important that symptoms are re-assessed frequently to see if the intervention is meeting the goals.
Goals of care must be clear to both the patient and the medical team. important to find out what is most important to the patient (pt values) and then determine the best medical treatment to accomplish those goals. Let’s call this a Goal limited trial.
For dying patients who wish to forestall death briefly for a specific goal, it is reasonable to start a trial of NPPV. Before initiating NPPV, it is important to discuss withdrawal of NPPV after the above goal has been achieved, and to caution the patient/family that NPPV might not be able to forestall death long enough as hoped.
If goal is symptom control, consider use of NIPPV to gain control of symptoms. Once this is done, then titrate meds up while decreasing oxygen to maintain patient comfort. Goals must be very clear for everyone.

29. Role of opioids in treatment of dyspnea:
opioids are gold standard in treatment of dyspnea – endorsed by numerous guidelines (ie American chest physicians, Canadian thoracic society)
Opioids are thought to decrease dyspnea by reducing minute ventilation, increasing ventilatory efficiency during exercise, reducing ventilatory responses to hypoxemia and hypercapnia, and effecting bronchoconstriction.
Systematic review found benefit for oral and parenteral opioids but not nebulised (although studies were poor quality). Evidence to suggest that long acting opioids work. For intermittent dyspnea, start with short acting opioid. If constant dyspnea, low dose (5-10 mg BID) of long acting opioid is a reasonable. One study found a NNT of 1.5 for a 10% reduction in symptoms and that 70% responded to low dose and the majority had a sustained (3 mo) response.
Case reports of using SL fentanyl for dyspnea.

30. Many are concerned about safety of opioids causing respiratory depression
Clemens et al showed that gradual titration of morphine reduced RR and dyspnea but did not have a significant effect on other respiratory parameters. This study and others have led the American college of chest physicans to recommend opioids for dyspnea management in their 2010 guidelines.
However, beware that opioids (especially morphine) have toxic metabolites that are renal cleared, so best to avoid morphine (and to a lesser extent hydromorphone) in those with renal failure.

31. Role for Benzodiazepines?
rational is that dyspnea and anxiety are connected, therefore treating anxiety will help dyspnea.
However, evidence if mixed.
2010 Cochrane review found there is no evidence for a beneficial effect of benzodiazepines for the relief of breathlessness in patients with advanced cancer and COPD. There is a slight but non-significant trend towards a beneficial effect but the overall effect size is small. Benzodiazepines caused more drowsiness as an adverse effect compared to placebo, but less compared to morphine. These results justify considering benzodiazepines as a second or third-line treatment within an individual therapeutic trial, when opioids and non-pharmacological measures have failed to control breathlessness.
One trial, Navigante 2006 Journal of Pain and symptom management, showed that SC Morphine and Midaz together were better than either alone. Morphine was better than midaz alone. No placebo group and patients were near end of life.
Another study by Navigante in 2010 (same journal) found that PO midaz (started at 2mg prn and titrated up) was better than morphine in ambulatory patients.
Beware using midaz in those with liver failure due to toxicity

32. Back to our case
Patient’s symptom are controlled with HFNP and opioids.
Goals of care are discussed with patient and family
Patient is clear that she does not want further life prolonging treatment
Symptoms are managed with opioids and midazolam
Patient passes away 2 days later on the palliative unit

33. Summary Determine patient’s values/goals of care
Investigate and treat underlying cause if appropriate
Oxygen has a role in palliative care, but only use it if it is helping to achieve the patient’s goals
Opioids are main treatment for refractory dyspnea and will not hasten death when used appropriately
Concept of total dyspnea – address other factors which may be contributing