Palliative Care Shortness of Breath and Secretions Hong
Palliative Care: Shortness of Breath and Secretions Hong Phuc Tran, M. D.
Learning Objectives • Understand pathophysiology of dyspnea • Learn how to evaluate dyspnea • Understand reversible causes / potential contributors of shortness of breath • Manage shortness of breath in terminally ill patients
Introduction • Shortness of breath is common in terminally ill patients • “Death rattle” (noisy breathing) occurs in 23 92% of dying patients – Patients lose ability to clear secretions as mentation worsens • Appropriate management of excessive secretions is important in providing palliation
Pathophysiology of Dyspnea • Multifactorial ▫ Increased work of breathing ▫ Chemical effects �Medullary chemoreceptors sense hypercapnea �Carotid and aortic body chemoreceptors sense hypoxemia ▫ Neuromechanical association �Mismatch between what brain desires for respiration and sensory feedback brain receives
Evaluation of Dyspnea • Patient’s self report is most reliable measure • Can have dyspnea with normal O 2 saturation • Physical exam findings ▫ Accessory muscle use ▫ Tachypnea ▫ Rhonchi, crackles, decreased breath sounds, stridor ▫ Cyanosis (central or peripheral)
Examples of Some Reversible Causes / Potential Contributors of Shortness of Breath • Bronchospasm • Pleural effusion • Anemia • Airway obstruction
Management of Shortness of Breath (1) First, treat underlying, reversible causes (if any)
Examples of Management of Some Reversible Causes/ Potential Contributors of Shortness of Breath • Bronchospasm – Albuterol, ipratropium, steroids • Pleural effusion – Thoracentesis, pleurodesis, diuretics, catheter drainage • Anemia – Transfusion • Airway obstruction – Steroids, Clean out tracheostomy tube (if present)
Management of Shortness of Breath (2) • After treating reversible causes (if any), then treat symptomatically ▫ Pharmacologic �Opioids �Benzodiazepines �Anticholinergics ▫ Non pharmacologic
Opioids (1) • Most effective for alleviating dyspnea ▫ Exact mechanism unclear but thought to alter perception of dyspnea • Common Routes: oral, parenteral • Unlikely to hasten death or cause addiction if adhere to dosing guidelines
Opioids (2) • Opioid naïve patients – Start with Morphine 10 15 mg po q 1 hr prn or morphine 5 mg SC q 30 min prn – Titrate to patient’s relief using standard opioid dosing guidelines • Opioid non naïve patients – Increase opioid dose by 25% – Titrate to patient’s relief using standard opioid dosing guidelines – Once chronic dyspnea controlled, provide extended release formulation and short acting formulation �Short acting formulation: 10% of total dose of same opioid in 24 hr period, offered at q 1 hr prn
Benzodiazepines (1) • Can relieve dyspnea associated with anxiety • Potential side effects, especially in elderly patients – Increased risk of confusion, falls • Can use conjunction with opioids without causing respiratory depression when dosing guidelines followed
Benzodiazepines (2) • Common routes: oral, sublingual, subcutaneous • Example of dosing for dyspnea ▫ Lorazepam 0. 5 mg po / SL q 1 hr prn, titrate to patient’s relief ▫ Once total dose in 24 hr period determined, then can give 1/3 of total dose q 8 hrs
Anticholinergics (1) • Dries excessive secretions • Effective for patients with weak cough reflex • Examples: Atropine, Hyoscyamine (Levsin), Scopolamine, Glycopyrrolate (Robinul) • Atropine, hyosyamine, scopolamine are equally effective in treatment of death rattle • Effectiveness of medications better at lower initial rattle intensity
Anticholinergics (2) • Atropine 1% ophthalmic drops – 1 2 drops SL every 1 hr prn • Scopolamine – 1 3 transdermal patches q 72 hrs – 0. 1 0. 4 mg SC / IV q 4 hrs – 10 80 mcg/hr by continuous IV or SC infusion • Hyoscyamine 0. 125 mg PO / SL q 8 hrs prn • Glycopyrrolate – 0. 4 1. 0 mg daily by SC infusion – 0. 2 mg SC / IV q 4 6 hrs PRN
Non-pharmacologic Interventions • Educate patients, families/caregivers • Repositioning – Turning patient on side, Elevate head of bed • Suctioning – Gentle, anterior (not deep) suctioning • Increase airflow – Fans, open windows, oxygen nasal cannula – Stimulates V 2 branch of trigeminal nerve, which has central inhibitory effect on dyspnea • Reduce room temperature without making patient too cold • Behavioral techniques – Relaxation, Distraction
References & Suggested Readings • EPEC (Education for Physicians on End of Life Care) : http: //www. cancer. gov/cancertopics/cancerlibrary/epeco/selfstudy/module 3 • Mercandante S, Villari P, Ferrera P. Refractory death rattle: deep aspiration facilitates the effects of antisecretory agents. J Pain Symptom Manage. 2011 Mar; 41(3): 637 9. • Pantilat SZ and Isaac M. End of life care for the hospitalized patient. Med Clin North Am. 2008; 92(2): 349 70. • Quaseem A et al. Evidence based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Jan 15; 148(2): 141 6. • Shinjo T, Okada M. Atropine eyedrops for death rattle in a terminal cancer patient. J Palliat Med. 2013 Feb; 16(2): 212 3. • Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008 Jan 23; (1): CD 005177 • Wildiers H et al. Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manage. 2009 Jul; 38(1): 124 33
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