palliative care approaches to symptom management in advanced respiratory disease: anxiety and...
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Palliative care approaches to symptom management in advanced respiratory disease: anxiety and breathlessness
Dr Jonathan MartinConsultant in Palliative Medicine, St Joseph's HospiceVisiting Fellow, Harris Manchester College, University of Oxford28th June 2013
Thanks to:Rebecca Jennings, St Joseph’s HospiceDr Sara Booth, Cambridge Breathlessness Intervention Service
Balance of Management Approaches
Pharm
NonPhNonPh
Pharm
NonPh
Pharm
Dyspnoea at rest
Non-
pharmacological
Pharmacological
Terminaldyspnoe
a
Wilcock, 1998
Non-pharmacological interventions are the most effective interventions currently available to palliate breathlessness in the mobile patient Booth et al 2011
Dyspnoea on exercise
Focus of non-pharmacological management in advanced disease is not on decreasing
breathlessness but helping individuals to feel more in control of their breathing and be as
independent as possible
Anxiety
Total dyspnoea
Physical Psychological
Spiritual Social
Cancer
Non-cancer
Therapy
Hopelessness
Fear
Loss of jobFatigue
Faith questioned
Why me? Isolation
Depression
Anxiety and breathlessness are probably linked
CBTThoughts
I might die
How will my wife cope?
Feelings
Fear/anxiety
Physical
Breathless
Deconditioned
Weight loss
Behaviours
Staying in the house
Not talking to wife
Not eating well
Vicious daisy
Fear / anxiety
I might die Breathless
How will my wife cope?
Not talking to wife
Staying at home
Deconditioned
Breathless
Not eating well
Weight loss
Anxiety (and depression)
• Non-drug treatments: good evidence for effect:– Pulmonary rehabilitation. (Withers 1999, Paz 2007, Coventry 2009)
– Cognitive behavioural therapy (CBT). (Coventry 2008, Heslop 2009, Kunik 2008, Livermore 2010) [N.B. No RCT evidence]
• Drug treatments: limited contradictory evidence in COPD:– TCAs, SSRIs (Lacasse 2004, Yohannes 2001)
Breathlessness
Non-pharmacological and Pharmacological Approaches Breathlessness
Non-pharmacological • Personalised
goals of care
• Symptom orientated
• Multidisciplinary Approach
• Maximise quality of life for patients and their families
• Involve patient and family in care planning
• Maximise physical function and emotional wellbeing
• Holistic
Pharmacological
* Beware the hypercapnic patient
- Education: Physiology and Anatomy
- Positioning
- Hand Held Fan
- Breathing Control Techniques
- Functional Exercise
- Walking Aid (4 wheel rollator)
-Maximise usual treatments as appropriate eg: inhalers
-Manage exacerbations actively as appropriate
-Consider oxygen for hypoxia*
-Cautious use of opioids* and benzodiazepines*
Non-pharmacological Management
Intervention Rationale Summary of Evidence
Education: simple anatomy and physiology of breathing
Empowers patient and carer to understand condition, why they become breathlessness. Reduces fear and promotes self management
Insufficient evidence Bausewein 2009
Positioning: Forward leanHigh sitting
Increase efficient use of accessory musclesOffload diaphragmImprove ventilation/ perfusion ratio
Limited. Recommended in clinical practice but further research needed. Booth et al 2011
Handheld Fan Stimulates nasal receptors altering the signal to brainstem respiratory complex and changing respiratory pattern Abernethey et al 2010
Strong evidence. Crossover RCT 51 patients with chronic breathlessness. Significant decrease in breathlessness measured on VAS when fan directed to cheeks vs leg (p=0.003) Galbraith et al 2010
Breathing Control Techniques
Promotes efficient breathing pattern, decrease distressing symptoms of hyperventilation
Moderate quality evidence to support Bausewein 2009 Cochrane Systematic Review
Compounded by variation in definition of techniques Booth et al 2011
Recovery breathing
• “Rescue breathing”• A three-part behaviour for use in distressing
dyspnoeic episodes– Positioning: to allow use of accessory muscles– Focus on breathing out– Use of a fan
Cambridge Breathlessness Intervention Service
Pharmacological Management
• Opioids• Oxygen• Benzodiazepines e.g. lorazepam• Antidepressants (direct & indirect)• Major tranquillizers e.g. levomepromazine• Others: furosemide, heliox, cannabinoids
Booth et al, Expert Review of Respiratory Medicine, 2009
Opioids• Consistent evidence of benefit (Jennings 2002, Abernethy 2003, Currow 2011)
• Safety:– Entrenched societal and professional misconceptions– No evidence for respiratory depression from low dose oral opioids– Some evidence for safety (Clemens 2008, Estfan 2007, Chan 2004)
– Some evidence against• Benefit may be limited to a few sensitive subjects (Pauwels 2001/2005)• Longer term adverse effects on endocrine system, falls and cognitive
function (Freynhagen 2013)
– Need adequately powered safety studies– Particular caution with:
• Type 2 respiratory failure – no data specifically relating to this group• Transdermal fentanyl
Opioids in Breathlessness
When should they be considered?• Use them for breathlessness at rest • Use them at the end of life• Consider them in anyone with severe SOB• Consider in moderate breathlessness after other
interventions
Breathlessness: opioid palliation
Two approaches:• Currow and colleagues start on 10mgs modified
release (Currow et al , 2010)
• Booth, Rocker and colleagues start on 1mg NR o.d. (Rocker et al, 2010)
Oxygen
• Individual assessment essential for use for dyspnoea– Some evidence in non-malignant disease – related to
desaturation on exercise and hypoxia at rest– Very little evidence in cancer that better than air – use
according to clinical benefit in an individual
• Use the fan first
Booth et al, Respiratory Med, 2004 Cranston et al, Cochrane Systematic Reviews, 2008
Benzodiazepines, buspirone
• Benzodiazepines:– Recent Cochrane review. (Simon 2010)
• Non-significant trend for benefit.
• Buspirone:– Anxiolytic and respiratory stimulant with
theoretical benefits (Smoller 1996)
– Two RCTs with conflicting results (Singh 1993, Argyropoulou 1993)
Could antidepressants work?
Possibly by:• By treating depression • By treating anxiety/panic disorder• By an effect on serotonin-mediated pathways in the
brainstem
Detecting and treating depression essential Brenes, Psychosom Med, 2003
Summary of the evidence
Good evidence for:• Pulmonary rehabilitation• Breathing training• Walking aids• Exercise• CBT• Fan• Opioids
Limited evidence for:• Benzodiazepines• Oxygen• Antidepressants