MANAGEMENT OF

DYSPNOEA – EFFECTIVE

INTERVENTIONS

DR. YEAT CHOI LING

PALLIATIVE MEDICINE PHYSICIAN

HOSPITAL RAJA PERMAISURI BAINUN

IPOH

2nd JUNE 2012

What is Dyspnoea?

A subjective experience of breathing discomfort that vary in intensity, deriving from interaction among multiple physiological, psychological, social, and environmental factors and may induce secondary physiological and behavioural responses.

American Thoracic Society Statement1999

It can cause great distress to the patients, caregivers as well as their physicians.

Patient’s Experience of Dyspnoea

Can be very frightening!

Fear of each breath will be one’s last.

Patients use words such as suffocating, choking or tightness

to describe the sensation.

3 dimensions:

Air hunger – the need to breath while being unable to

increase ventilation

Effort of breathing – physical tiredness associated with

breathing

Chest tightness – the feeling of constriction and inability to

breath in and out WHO Pain & Palliative Care Communications Program 2009

What is Dyspnoea (cont…)

Objective measures e.g. RR, O2 saturation, blood

gasses and lung function test may not correlate

closely with the sensation of dyspnoea.

In the cancer population, dyspnoea occurs more

often in patients with lung cancer but not only

associated with lung cancer:

46% reported breathlessness

4% had lung cancer, 5.4% had lung

metastases Dudgeon DJ 2001

Prevalence of Dyspnoea

General cancer population at diagnosis: 15-55%

Prevalence increases closer to death, up to 70% cancer patient experiencing dyspnoea in the last 6 weeks of life.

Reuben 1986

Incidence of dyspnoea in advanced non-malignant diseases: COPD: 90-95%

Heart disease: 60-88%

AIDS: 11-62%

Renal disease: 11-62%

Anxiety and Dyspnoea

Anxiety may contribute to dyspnoea but may also arise from

dyspnoea. Dudgeon 1998; Driscoll M et al. 1999

Anxiety can aggravate dyspnoea leading to a progressive

spiral of exacerbated breathlessness and greater

psychological distress. WHO Pain & Palliative Care Communications Program 2009

Mdm AZ/51/teacher

Has been diagnosed to have breast cancer with

lung metastases and pleural effusion.

Referred to Palliative Care Team for continuing

management.

Upon review, she was on N/P O2 3L/min, breathless

with RR 40/min. ECOG 4. Lungs: Right pleural

effusion.

Mdm AZ/48/housewife (cont…)

Right pleural tapping was done.

She felt better but still dyspnoeic at rest, worsen with exertion.

Mdm AZ/48/housewife (cont…)

Started on aq. morphine 3mg 4hrly and PRN, with

bisacodyl 2tabs on.

However, noted patient ‘refused’ to take morphine.

“My husband told me not to take morphine…”

“Morphine causes confusion…”

Explanation and reassurance!

Mdm AZ/48/housewife (cont…)

Breathless score reduced from 7/10 to 4-5/10. Not

drowsy or sleepy. No nausea/vomiting. Has hard

stool.

Subsequently, aq. morphine was increased to 5mg

4hrly and PRN. Sy. Lactulose 15ml on was added.

Able to have art therapy session with occupational

therapist. Good appetite!

Mdm AZ/48/housewife (cont…)

A week later later…

c/o severe lethargy with giddiness. Noted pallor.

Transfused 2 pints PC.

Able to sit on chair for ½ hour and spend quality

time with family.

The Principle - Treat The Reversible

Causes

It is important to reverse what is reversible depending on the patient’s physical and psychological condition and personal preferences.

Pre-existing causes

Cause of Dyspnoea Treatment Options

Infection Antibiotics , chest

physiotherapy

Asthma / COAD Bronchodilators,

corticosteroids

Cardiac Failure Diuretics

Radiation induced lung

fibrosis

Corticosteroids

Direct causes from Malignancy

Causes of Dyspnoea Treatment Options

Large airway obstruction RT, brachytherapy, laser

therapy, stent,

corticosteroids

Lung parenchymal damage Opioids, oxygen

Lymphangitis carcinomatosis Corticosteroids, opioids,

oxygen

Pleural Effusion Pleural drainage /

Pleurodesis

Pericardial Effusion Pericardiocentesis

SVC Obstruction Corticosteroids,

radiotherapy, stent

Indirect causes from Malignancy

Causes of dyspnoea Treatment options

Ascites Paracentesis, diuretics

Cachexia and muscle

weakness

Positioning,

physiotherapy

Pulmonary embolism Oxygen, DVT prophylaxis,

anticoagulation

Anemia Blood transfusion

ASSESSMENT

What should be included in the clinical assessment of

dyspnoea?

1. A comprehensive history

The onset, exacerbating and relieving factors

2. Assess the intensity of dyspnoea with a scale

To establish a baseline measurement

A simple categorically (mild-moderate-severe) or numerically (0-10) scale can be used.

3. Assess concomitant physical and psychological symptoms

To evaluate its impact on quality of life

4. Physical examination

To look for possible causes such as a pleural effusion or an arrhythmia

Useful Tests

Investigations should be carefully selected to guide

specific treatment.

The burden/benefit of the intervention for the

patient needs to be evaluated.

1st line investigations include Hb, O2 saturation by

oximetry and CXR.

Oximetry is non-invasive, enables us to

differentiate whether the patient is hypoxemic or

not.

It is often not possible to reverse all causes of dyspnoea in

patients with advanced cancer.

At this point, dyspnoea is refractory and the primary goal

should be symptom palliation to decrease the sensation of

dyspnoea.

SYMPTOMATIC MANAGEMENT

Clinical Symptomatic Management

Effective management requires both pharmacological and non-

pharmacological approaches.

Pharmacological intervention

Opioids

Benzodiazepines

Inhaled drugs

Oxygen

Non-pharmacological interventions

Positioning

The fan

Breathing techniques

Anxiety-reduction training

Pulmonary rehabilitation

Non-invasive ventilation

PHARMACOLOGICAL

MANAGEMENT

Opioids

There is significant positive effect of opioids (oral and parenteral routes) on the sensation of breathlessness (P = 0.0008).

Jennings et al 2002

No evidence of respiratory depression (measured by

RR, O2 saturation or levels of CO2) when morphine

is carefully titrated for dyspnoea.

No excess mortality demonstrated with the use of

opioids in any studies. Sara Booth 2008

Opioids (cont…)

For opioid naïve patients, a starting dose of mist. morphine 2.5-5 mg is a reasonable choice. E.g. mist. morphine 2.5mg 4hrly

mist. morphine 2.5mg PRN for breakthrough dyspnoea

It is reasonable to increase the dose of regular morphine, orally or subcutaneously, by 25–50% to control dyspnoea.

It is important to monitor the side effects of drowsiness and RR during opioid titration.

Kin-Sang Chan et al 2004

Benzodiazepines (bzd)

Bzd enhance the action of the neurotransmitter GABA (Gamma Amino Butyric Acid) and reduce anxiety.

No evidence that bzd modify the sensation of dyspnoea as there is with opioids, but they are widely used, often empirically for anxiety.

Bzd may improve mood in patients with dyspnoea and help to lessen the intensity of the sensation.

Benzodiazepines (cont…)

Doses for oral bzd: Po diazepam 2 mg -5 mg on

Sl/po lorazepam 0.5 - 1 mg prn

Midazolam at low doses in addition to morphine may be used at the end of life (EoL): sc 5–10 mg in 24 h with 2.5–5.0 mg PRN.

Sara Booth et al 2008

Side effects bzd including delirium, falls and severe sedation.

Haloperidol may be used when patient fear is prominent at the EoL.

Nebulised Drugs

Saline May be helpful for breathlessness or to aid expectoration

Limited evidence but minimal risk

Bronchodilaotrs Consider a trial of bronchodilators e.g. nebulised salbutamol 2.5mg tds

Frusemide May relieve dyspnoea in cancer patients.

Opioids No benefit so not for routine use

The Myth of Palliative Oxygen

Currently, no evidence shows palliative O2 relieves the sensation of dyspnoea in cancer patients unless they have hypoxemia (O2 Sat <90%), although the use of O2 remains a common practice.

Cochrane review showed no overall improvement of breathlessness in cancer patients when O2 breathing was compared to air breathing.

Cranston JM et al 2008

A small meta-analysis showed O2 did not provide symptomatic benefit for mildly- or non-hypoxemic patients with cancer.

Uronis HE et al 2008

The Myth of Palliative Oxygen (cont…)

Adverse effect of O2 therapy:

Worsens dry mouth and nostril,

with a risk of nosebleeds from

the nasal cannula

Reinforces sick role

Barrier to close contact

Costly

Hinders mobility due to rapid

dependence

The need to rely on a machine

Therefore, it should not be a knee

jerk reaction to start it.

The Role Of Corticosteroids

Corticosteroids work by decreasing inflammation in the

respiratory tract.

Corticosteroids are useful in:

upper airway obstruction related to the tumor

radiation pneumonitis

lymphangitis carcinomatosis

superior vena cava syndrome

Use cautiously because of side effects when used for long

periods e.g. hyperglycaemia, proximal myopathy and

psychotropic effects.

Oncology Interventions Dyspnoea due to lung parenchymal damage from infiltration,

lymphangitis carcinomatosis or recurrent malignant effusion may be treated with palliative chemotherapy.

Particularly useful in chemosensitive tumours such as breast, lung, colon cancers and lymphoma.

Bronchial obstruction causing dyspnoea may also be treated with palliative radiotherapy.

NON-PHARMACOLOGICAL INTERVENTIONS

Best Position

The ones that need the least energy or effort

Being tense in the body and gripping things wastes

energy and O2

The Fan

Facial cooling in the areas supplied by the CN V2 and V3 will reduce the sensation of breathlessness.

It is simple to use, no adverse effects, cheap and small.

There was significant

improvement in

dyspnoea with

handheld fan. Galbraith 2007

Breathing Techniques & Activity Pacing

Breathing control Diaphragmatic and pursed-lip breathing improved dyspnoea in

COPD patients. Hochstetter et al 2005

Activity pacing

Anxiety Reduction Training

Relaxation E. g. progressive muscular relaxation, visualization and guided

imagery.

Cognitive-behavioural therapy Patients with cancer-related dyspnoea often too ill both mentally and

physically to complete cognitive or behavioural programs.

Psychosocial support

Patient and Family Education

The ‘Breathlessness plan’:

1. Listen to patient (and their carers) experience during a dyspnoeic episode, to explain and address their fear.

2. Write a ‘dyspnoea plan’ with them to anticipate the possibility of a respiratory failure crisis.

This approach can have an immediate impact on patient anxiety as patients and carers start to exert some control over a difficult situation.

Booth S et al 2006

Dyspnoea At The Very End of Life…

Constant calming presence (education for carers is important). Just be there!

Increased air movement near face

Nurse patient in appropriate position

Good general care - bowels, mouth, skin, pain etc

Convert or start opioids as infusion

Add midazolam if anxious or panicky; Haloperidol for fear.

May need to increase sedation

Dry secretions if needed

Prescribe crisis drugs

Support to both caregivers and staffs

References 1. Sara Booth et al. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic

review of pharmacological therapy. Nature Clinical Practice Oncology February 2008: vol 5 :no 2.

2. Elaine Cachia et al. Breathlessness in cancer patients. European Journal of Cancer 2 0 0 8: 44: 1116 –1123.

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5. Kin-Sang Chan et al. Oxford Textbook Of Palliative Medicine 4th edition: Palliative medicine in malignant respiratory diseases. Pg 588-618.

6. Cranston JM et al. Oxygen therapy for dyspnoea in adults. Cochrane Database of Systematic Reviews 2008, Issue 3.

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