Transcript What symptoms?

Objectives
By the end of this module you will

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
Non-Pain Symptom
Management
James Hallenbeck, MD
Assistant Professor of Medicine,
Stanford School of Medicine
Director, Palliative Care Services, VA Palo Alto
HCS
Definition 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
From the Patient’s
Perspective- a Symptom Is
What Is Bothersome
Disease As a Clue for the
Symptom
Disease process
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?
Symptom
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.
So WHY do we have
this disgusting problem?
Consider our Hungry Ancestors…
What protects this guy from
eating something poisonous?
A Final Pathway for Nausea
(Dopamine, Serotonin)
???
CTZ
CNS
(Intrinsic:
Substance P,
Achetylcholine,
Histamine)
VestibularApparatus
(Acetylcholine, Histamine)
VOMIT
CENTER
GI Tract
(Acetylcholine, Histamine, Serotonin,
Substance P & mechanoreceptors)
Pearl for the Day…
Receptor Affinity Common
Antiemetics
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
The lower the number,the stronger this agent is
Adapted from Perourka, Snyder
at blocking this receptor
Causes of Nausea and
Vomiting

Vestibular

Obstruction (Opioids)

Mind (Dysmotility)

Infection (irritation)

Toxins (taste and other senses)
V
Vestibular 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!
O
Obstruction




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
M
Mind

Mediates emotional, cognitive aspects of nauseaanxiety, memory, meaning
 Can be very powerful
 Manipulating taste and other senses often helpful
 Doc(s):
– Lorazapam (poor solo agent)
– Appetite stimulants

Megestrol, steroids, Cannibinoids
M
DysMotility

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)
I
Infection/Irritation

Mediated through chemoreceptorsacetylcholine, histamine, serotonin
 Gut and adjacent organ inflammation can
trigger
 DOC(s): Anticholinergic/antihistaminic
agents, such as promethazine
T
Toxins

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
Opioid Related Nausea
Via two mechanisms:

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)
No good evidence, rationale for using promethazine
5HT3
Antagonists

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
Dyspnea

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
Treating Dyspnea

In addition to what you already
know…
Local
– Low-dose opioids
– Fan, cool breeze

Central
– Low-dose opioids

Benzodiazepines for anxiety
 Address emotional, cognitive, spiritual
factors
SUMMARY

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