“respiratory issues at end-of-life” jerry boltz, fnp ... respiratory issues at...
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E L N E C Geriatric Curriculum
“Respiratory Issues at End-of-Life”
Jerry Boltz, FNP
January 27, 2012
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CENLEEnd-of-Life Nursing Education Consortium
Module 3:
Nonpain Symptoms at the
End of Life
Geriatric Curriculum
Part I
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E L N E C Geriatric Curriculum
Common Respiratory Issues
Near the End of Life
• Dyspnea
• Cough
• Changes in respiratory rate & rhythm
• Increased Respiratory secretions
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E L N E C Geriatric Curriculum
Dyspnea: Definition
• Distressing shortness of breath, air hunger, or difficulty breathing
• Associated with anxiety, depression, and decreased quality of life
• Can be acute or chronic
• Sometimes occurs or worsens only with activity
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E L N E C Geriatric Curriculum
Dyspnea: A subjective Feeling
• Dyspnea refers to the sensation of
difficult or uncomfortable breathing. It
is a subjective experience perceived and
reported by an affected patient.
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E L N E C Geriatric Curriculum
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E L N E C Geriatric Curriculum
Dyspnea
Major Pulmonary CausesTumor Infiltration Pleural Effusion
Aspiration COPD
Pneumonia Bronchospasm
Pulmonary Embolism Pulmonary Fibrosis
Superior Vena Cava Syndrome
Thick Secretions caused by infectious diseases or
dehydration…
Thick secretions caused by Us? Later
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E L N E C Geriatric Curriculum
Dyspnea
• Major Cardiac causes
– Congestive Heart Failure
– Pulmonary edema
– Pulmonary Hypertension
– Pericardial Effusion
– Cardiac disease - arrhythmias
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E L N E C Geriatric Curriculum
Dyspnea
• Cancer Related Causes
– Metastatic disease from any primary site
– Obstruction of Bronchus
– Malignant Ascites
– Anemia (Anemia of chronic disease)
– Superior Vena cava Syndrome
– Pneumonectomy
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E L N E C Geriatric Curriculum
Dyspnea
• Major Neuromuscular Causes
– Amyotrophic Lateral Sclerosis (ALS)
– Muscular dystrophy
– Myasthenia Gravis
– Cerebrovascular Disease
– Trauma as a result of physical injury
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E L N E C Geriatric Curriculum
Dyspnea
Other causes
Generalized weakness
Anorexia Cachexia
Hyperventilation Anxiety
Uncontrolled Pain Hyperthyroid
Obesity Spiritual issues
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E L N E C Geriatric Curriculum
Assessment of Dyspnea
• Subjective report
• Clinical assessment
– Physical exam
– Diagnostic tests
Derby et al., 2010; Dudgeon, 2010
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E L N E C Geriatric Curriculum
Dyspnea Assessment
Subjective
• Dyspnea Assessment Is like a Pain
Assessment. The subjective report of the
patient is the only reliable indicator of this
symptom.
• The patient’s respiratory rate &
Oxygenation status Do Not always correlate
with the symptom of breathlessness.
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E L N E C Geriatric Curriculum
Subjective Report
• Impact on Function & Quality of Life
– Ability to sleep
– Ability to perform ADL’s (get dressed,
talk, eat, sleep, etc.)
• The patient may report breathlessness
in spite of good oxygenation status or
limited disease state.
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E L N E C Geriatric Curriculum
Clinical Assessment of Dyspnea
• Determine history of:
– Acute or chronic dyspnea
– Smoking
– Heart Disease or Lung Disease
– Concurrent Medical Conditions
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E L N E C Geriatric Curriculum
Clinical Assessment of Dyspnea
• Physical Examination
– Elevated Jugular Pressure
– Lung Sounds
– Respiratory Rate, Depth
– Use of Accessory Muscles
– Peripheral Edema
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E L N E C Geriatric Curriculum
Non-Pharmacologic Treatments
for Dyspnea
–Education, Education, Education
–Pursed lip breathing
–Energy conservation
–Fans, elevating head of the bed
–Prayer, Music,
–Calm environmentDudgeon, 2010
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E L N E C Geriatric Curriculum
Other Non-Pharmacologic
Treatments for Dyspnea
• Transfusion of PRBC’s
• Thoracentesis
• Paracentesis
• Radiation therapy to shrink tumor
• Stent tube placement to open an
occluded airway
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E L N E C Geriatric Curriculum
Oxygen Therapy for Dyspnea
• Effectiveness has not been
established by research
• Worth trying especially if oxygen
saturation is low
• Trial O2 2-6 L per nasal prongs;
reassess 2 hours after each change in
liter flow
Derby et al., 2010; Dudgeon, 2010;
Gallagher & Roberts, 2004; Pan, 2003
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E L N E C Geriatric Curriculum
Pharmacologic Treatment of
Dyspnea
– Opioids
– Bronchodilators
– Diuretics
– OtherClemens & Klaschik, 2007; Derby et al., 2010;
Dudgeon, 2010; Jacobs, 2003
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E L N E C Geriatric Curriculum
Opioids for Dyspnea
• Can be administered by oral, subcutaneous, sublingual, or intravenous routes
• Studies show that Opioids have a small, but positive effect on reducing dyspnea
• Significant respiratory depression is uncommon
• Nebulized opioids are no more effective than opioids given by other routes
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E L N E C Geriatric Curriculum
How do Opioids work for
Dyspnea?
Possible Mechanisms
– They interrupt the neural pathways that
give rise to the sensation of dyspnea
– They have a sedative & anxiolytic effect
to relieve the discomfort of dyspnea
– Vasodilatation – Reduce Preload
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E L N E C Geriatric Curriculum
What Opioids do not do
• Opioids do not relax the respiratory
muscles, allowing the patient to
breathe easier.
• This explanation could be easily be
misconstrued by patients and families.
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E L N E C Geriatric Curriculum
Is there a role for Anxiolytics in
Dyspnea?
• Sedation and reduction of anxiety are
“side effects” of Opioids. Like all side
effects, (except for constipation), These
side effects may disappear over time.
• If an anxiety component is identified,
anxiolytics may be helpful.
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E L N E C Geriatric Curriculum
Bronchodilators
• Albuterol (relaxes bronchial smooth
muscle by action on the Beta-2
receptors).
• Atrovent (Anti-cholinergic agent that
causes bronchodilation)
• Given by SVN is more effective than if
given by metered dose inhalers.
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E L N E C Geriatric Curriculum
Diuretics
• Reduce pre-load on the heart
• May reduce the sensation of dyspnea
that may be caused by congestive heart
failure.
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E L N E C Geriatric Curriculum
Other Pharmacologic treatments
• Chlorpromazine (Thorazine) – There is
some evidence that low doses of
Chlorpromazine (25mg q 4 hours) may
relieve the symptoms of dyspnea.
• Antibiotics – Pneumonia
• Steroids – Reduce inflammation
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E L N E C Geriatric Curriculum
Cough
• Cough is:
• A Common Symptom in
advanced disease
• Cough causes:
• Pain, Fatigue, Insomnia
Dudgeon, 2010
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E L N E C Geriatric Curriculum
Some Causes of Cough
•Post Nasal Drip Asthma
•Bronchitis Obstruction
•Pleural effusion P.E.
•Pneumothorax Allergens
•Cigarette Smoking
•Environmental irritants
•Medications (ACE Inhibitors)
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E L N E C Geriatric Curriculum
Assess the Type of Cough
• Acute Cough – Often caused by:
• Allergens, Environmental irritants, Post-
Nasal drip, GERD, Lung lesions, TB,
Pneumonia, Foreign Body
• Chronic Cough: Allergens, Chronic
diseases (COPD, Bronchitis, Airway
Inflammation)
• Nocturnal: GERD, Asthma, CHF
–
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E L N E C Geriatric Curriculum
Treatment Decisions
• Patient’s condition – Where are they
on the trajectory of their illness.
• Does the patient have a strong or a
weak cough?
• Suppress by night – Expectorate by
day
• Do we really want to dry it up?
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E L N E C Geriatric Curriculum
Pharmacologic Interventions
for Cough
• Suppressants/Anesthetics
• Expectorants
• Antibiotics
• Steroids
• AnticholinergicsLingerfelt et al., 2007
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E L N E C Geriatric Curriculum
Cough Suppressants
• Opiates
– Morphine Sulfate
– Codeine – Metabolized to Morphine
– Hydrocodone & Homatropine
– Opioids in general - Bind to opiate
receptors & suppress cough in the
medullary center
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E L N E C Geriatric Curriculum
Cough Suppressants
• Non-Opioid
– Dextromethorphan – Structurally related
to Codeine, Depresses Medullary cough
center.
– Benzonatate (Tessalon Perles)
Suppresses cough by topical anesthetic
action on the respiratory stretch
receptors
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E L N E C Geriatric Curriculum
Non-Pharmacologic Interventions for Cough
• Chest PT
• Humidifier
• Positioning
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E L N E C Geriatric Curriculum
Changes in Respiratory
Rate and Rhythm
• Education, Education, Education
• Autonomic Nervous System -
• “Normal” Respiratory rate 12 – 20
breaths per minute.
• The term “Normal” changes depending
on where the patient is at on their
“Journey”
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E L N E C Geriatric Curriculum
“They are Breathing So Fast!!
• Kussmaul Breathing – Deep Rapid
respirations – Acidosis – Blowing off
Carbon Dioxide. Body is trying to
maintain acid / base balance…
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E L N E C Geriatric Curriculum
Some Things to Think About When the Patient’s Respiratory Rate is Fast
and “labored”
Do we need to slow down the patient’s respiratory
rate?
How much Morphine (Opioid) does it take to slow
down a person’s respiratory rate?
Who are we treating when we try to slow down the
respiratory rate?
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E L N E C Geriatric Curriculum
Other “End of Life”
Breathing Patterns
• Apnea
• Cheyne Stokes Breathing
• Guppy Breathing
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E L N E C Geriatric Curriculum
“Death Rattle”
• “Death Rattle” – Now that is an
uncomfortable couple of words!
• “Increased Respiratory Secretions”
– Why is the terminology problematic?
– Who are treating?
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E L N E C Geriatric Curriculum
Non-Pharmacologic “Treatments”
• Education, Education, Education
– Tell family members what to expect
– Ask them not to feed their loved ones
unless they are wide awake, and able to
swallow.
• Patient Positioning
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E L N E C Geriatric Curriculum
Pharmacologic Treatments
• Scopolamine Patch – Crosses the blood
brain barrier - “Mad as a Hatter”.
• Glycopyrrolate
• Atropine drops
• Hyoscyamine
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E L N E C Geriatric Curriculum
Just a Thought
• Asking for Refills on these medications
should be a rare event.
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E L N E C Geriatric Curriculum
Key Nursing Roles
• # 1 Patient Advocacy
• “We all believe in patient determined
end of life care…As long as they agree
with our plan”
Charles von Gunten, M.D.
•
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E L N E C Geriatric Curriculum
Key Nursing Roles
• Patient/Family Teaching
• Assessment
• Pharmacologic treatments
• Non-pharmacologic treatments
• Presence