objectives have a better understanding of how physical and mental factors affect symptomatology be...
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ObjectivesObjectives
Have a better understanding of how physical and mental factors affect symptomatology
Be able to use this understanding in the treatment of patients suffering from nausea/vomiting and dyspnea
Incorporate skills and knowledge gained into your practice and teaching
By the end of this module you will
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Non-Pain Symptom Non-Pain Symptom ManagementManagement
James Hallenbeck, MD
Assistant Professor of Medicine,
Stanford School of Medicine
Director, Palliative Care Services, VA Palo Alto HCS
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Definition of a SymptomDefinition of a Symptom“A physical or mental phenomenon, circumstance or change of condition arising from accompanying a disorder and constituting evidence for it… specifically a subjective indicator perceptible to the patient and as opposed to an objective one (compare with sign).”
The New Shorter Oxford English Dictionary, cited by The Oxford Textbook of Palliative Medicine
Symptoms as clues, not experiences, not suffering
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From the Patient’s From the Patient’s Perspective- a Symptom Is Perspective- a Symptom Is
What Is BothersomeWhat Is Bothersome
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Disease As a Clue for the Disease As a Clue for the SymptomSymptom
Disease process Symptom
Questions to ask…
How does the disease give rise to the symptom through local, central effects?
What are emotional, cognitive and spiritual components of the patient’s illness?
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What Symptoms?What Symptoms?Constipation Diarrhea Peripheral Edema Nausea, vomiting Pruritus/itching Dyspnea Anxiety Anorexia Sleep disorders Cough Akathisia Dysphagia Anhedonia Death rattle/secretions Drooling Urinary Incontinence Rectal Incontinence Hiccups Flatulence Muscle spasms Confusion Memory Loss Visual problems Hearing loss Dysgeusia Colic Sexual dysfunction Polyuria Polydipsia Dizziness Dyspepsia Xerostomia Dry skin Dysarthria Dysphoria Dysuria Failure to thrive Fatigue Fear Fever Crying Hallucinations Halitosis Impotence Irritability Taste alterations Odor Mucositis Panic attacks Photosensitivity Restlessness Stomatitis Urinary frequency
N=53, Oxford Textbook of Palliative Medicine: Index, 1998.
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So WHY do we have this disgusting problem?
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Consider our Hungry Consider our Hungry Ancestors…Ancestors…
What protects this guy from eating something poisonous?
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A Final Pathway for Nausea
CTZ CNS
VOMIT
CENTER
VestibularApparatus GI Tract
(Dopamine, Serotonin) ???
(Acetylcholine, Histamine) (Acetylcholine, Histamine, Serotonin,Substance P & mechanoreceptors)
(Intrinsic:
Substance P, Achetylcholine, Histamine)
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Pearl for the Day…Pearl for the Day…
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Receptor Affinity Common Receptor Affinity Common AntiemeticsAntiemetics
The lower the number,the stronger this agent is
at blocking this receptor
Drug Dopamine 2 Musc. Chol. Histamine
Scopolamine >10,000 .08 >10,000
Promethazine 240 21 2.9
Prochlorperazine 15 2100 100
Chlorpromazine 25 130 28
Metoclopramide 270 >10,000 1,000
Haloperidol 4.2 >10,000 1,600
Adapted from Perourka, Snyder
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Causes of Nausea and Causes of Nausea and VomitingVomiting
Vestibular
Obstruction (Opioids)
Mind (Dysmotility)
Infection (irritation)
Toxins (taste and other senses)
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VVVestibular ApparatusVestibular Apparatus
Complaint of nausea with head movement
Mediated by acetylcholine and histamine receptors
DOC(s):– Promethazine (supp)– Scopolomine (patch, injection)– Cyclizine (oral, injection)
Most anticholinergic, antihistminic drugs will help!
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OOObstructionObstruction
Most common cause: constipation May be caused by external or internal obstruction
– In advanced malignant bowel obstruction external compression most common
May be mediated through both mechano and chemoreceptors
Doc(s) – True bowel obstruction
Controversy as to best drugs– Constipation- anti-constipation meds
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MMMindMind
Mediates emotional, cognitive aspects of nausea- anxiety, memory, meaning
Can be very powerful Manipulating taste and other senses often helpful Doc(s):
– Lorazapam (poor solo agent)– Appetite stimulants
Megestrol, steroids, Cannibinoids
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MMDysMotilityDysMotility
Multiple causes– Opioids– Anticholinergic drugs– Stomach/bowel compression, infiltration
Upper intestinal dysmotility-very common, under appreciated
Doc(s): Prokinetics:– Metoclopramide (upper only)– Cisapride (upper and lower gut)– Senna (lower only)
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IIInfection/IrritationInfection/Irritation
Mediated through chemoreceptors- acetylcholine, histamine, serotonin
Gut and adjacent organ inflammation can trigger
DOC(s): Anticholinergic/antihistaminic agents, such as promethazine
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TTToxinsToxins
Most important- drugs we give Various mechanisms of inducing nausea
– Local irritant NSAIDs
– Changing blood levels (via CTZ) opioids, ? SSRIs
– Toxic blood levels digoxin
Doc(s): depends on mechanism of action
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Opioid Related NauseaOpioid Related Nausea
Gut effect: Dysmotility of upper and lower gut– Doc(s): prokinetics
Effect on CTZ– Mediated through D2 receptor– Related to changing blood levels– Improves with steady state blood level– Doc(s): Haloperidol (po, inj.), Prochlorperizine (supp,
po)
Via two mechanisms:
No good evidence, rationale for using promethazine
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5HT3 5HT3 AntagonistsAntagonists
Useful for certain forms of chemotherapy related nausea
May have other special uses:– In CTZ related nausea, where dopamine
blockade contraindicated– ? Other refractory CTZ related causes– ? In certain GI cases
Very expensive currently
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DyspneaDyspnea
Common- 70% of dying patients in last six weeks of life
Traditional care for dyspnea largely palliative, as not curative– Focuses on lung physiology– Less attention to central processes
Pathophysiology of dyspnea poorly understood
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Treating DyspneaTreating Dyspnea
Local– Low-dose opioids– Fan, cool breeze
Central– Low-dose opioids
Benzodiazepines for anxietyAddress emotional, cognitive, spiritual
factors
In addition to what you already know…
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SUMMARYSUMMARY
Symptoms matter in their own right as expressions of patient suffering
Symptoms have their own “pathophysiology,”
As is true for treatment of disease, treatment of symptoms is tailored to this underlying physiology