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Management of Advanced Breathlessness

Dr Phil Wilkins, Norfolk and Norwich University Hospital and Priscilla Bacon Lodge, Norwich

Definitions of breathlessness and when it occurs

How to manage the symptom How to implement this

Overview

Breathlessness

Unpleasant awareness of difficulty breathing

“Inability to get enough air” “Smothering feeling” The only reliable measure is patient self-

report RR, pO2 + blood gases do not correlate

with the feeling of breathlessness

Breathlessness

COPD Interstitial Lung Disease Cancer (Primary and Secondary) Left Heart Failure (Anaemia, Muscular disorders,

Bronchiectasis, etc)

Conditions Causing End-stage Breathlessness

Conscious vs Unconscious Useful Concepts

Functions of breathing What the patient thinks What it is actually for

What happens when it goes wrong How should we manage it?

Breathing Regulation

Breathing Control

medullary central pattern

generator : brain stem

respiratory muscles

ventilation

Mechanical receptors: parenchyma,airwaysintercostal muscles + diaphragm

Chemoreceptors in aortic,carotid bodies + medulla

↑CO2 ↓O2

higher centres

Management

Optimise the treatment for the underlying disease first!

Important!

Influenced by: Mental state Posture Exercise Environmental temperature + humidity

High breathlessness score = low QOL score

Affects all aspects of ADL : physical, psychological and social

Cancer - affects 15% at diagnosis : 65% at some time during illness

Breathlessness

In malignant disease breathlessness is usually due to distortion and stimulation of mechanical receptors.

Blood gases are often normal

Fatigue, muscle weakness, phrenic nerve palsy and restrictive chest wall tumours can exacerbate breathlessness

Breathlessness

Drugs

ventilatory response to hypercapnia, hypoxia + exercise

Activation µ and opioid receptors tidal volume + respiratory rate

Breathing more efficient: improves exercise tolerance Reduces sensation of breathlessness Cortical sedative / anxiolytic Suppress cough reflex centre in brain stem

Opiates

Morphine does not cause CO 2 retention if used appropriately

Morphine breathlessness by about 20% Generally more beneficial in patients who

are breathless at rest

In opioid naïve patients: start with 2.5mg oramorph prn + titrate

In patients on morphine for pain increase dose by 30%

Morphine for Breathlessness

Anxiolytic + Respiratory sedative Use formulations with relatively longer half

life to avoid pronounced peaks & troughs which may lead to rebound anxiety Diazepam 2-5mg nocte Midazolam 2.5mg SC stat+ 5-10mg / 24 hrs

CSCI Clonazepam 0.25-2mg PO 12hrly

Panic attacks Lorazepam 0.5-1mg SL prn

* SSRI* Neuroleptic

Benzodiazepines

Non-pharmacological, non-interventional control of dyspnoea

Reassurance Breathing control Activity pacing Relaxation techniques Complementary therapies Psychological support

RCT 119 significant improvement at 8 weeks in dyspnoea score, ECOG status, emotional status

General Considerations

Posture Breathing techniques Anxiety Relaxation Pacing

Hand Held Fans

Shallow rapid breathing is ineffective and causes panic

Encourage slow, regular, deep breathing

Diaphragmatic breathing: consciously expand abdominal wall during inspiratory diaphragm descent

Pursed lip breathing :nasal inspiration + exhale though pursed lips

Breathing Retraining

Panic Attacks

Lack of understanding + fear

Increased respiratory rate

Increased anxiety Dyspnoea PANIC

Oxygen

Oxygen

No evidence of help if not hypoxic Can be prescribed for ‘palliative care’

Optimise the management of the underlying condition

Consider lifestyle / behavioural changes Breathlessness clinics for non-drug

management Drugs to modify the sensation

Opiates Benzodiazepines

(Oxygen)

Summary