Management of Advanced Breathlessness

{ Dr Phil Wilkins, Norfolk and Norwich University Hospital and Priscilla Bacon Lodge, Norwich

Overview

 Definitions of breathlessness and when it occurs  How to manage the symptom  How to implement this

Breathlessness

Breathlessness

 Unpleasant awareness of difficulty breathing  “Inability to get enough air”  “Smothering feeling”  The only reliable measure is patient self-report  RR, pO 2 + blood gases do not correlate with the feeling of breathlessness

Conditions Causing End-stage Breathlessness

 COPD  Interstitial Lung Disease  Cancer (Primary and Secondary)  Left Heart Failure  (Anaemia, Muscular disorders, Bronchiectasis, etc)

Breathing Regulation

 Conscious vs Unconscious  Useful Concepts  Functions of breathing  What the patient thinks  What it is actually for  What happens when it goes wrong  How should we manage it?

Breathing Control

Mechanical receptors: parenchyma,airways intercostal muscles + diaphragm Chemoreceptors in aortic,carotid bodies + medulla ↑CO2 ↓O2 medullary central pattern generator : brain stem respiratory muscles ventilation higher centres

Management

Important!

 Optimise the treatment for the underlying disease first!

Breathlessness

 Influenced by:  Mental state  Posture  Exercise  Environmental temperature + humidity  High breathlessness score = low QOL score  Affects all aspects of ADL :  physical, psychological and social  Cancer - affects 15% at diagnosis : 65% at some time during illness

Breathlessness

 In malignant disease breathlessness is usually due to distortion and stimulation of mechanical receptors.  Blood gases are often normal  Fatigue, muscle weakness, phrenic nerve palsy and restrictive chest wall tumours can exacerbate breathlessness

Drugs

Opiates

 ventilatory response to hypercapnia, hypoxia + exercise  Activation µ and  respiratory rate opioid receptors  tidal volume +  Breathing more efficient: improves exercise tolerance  Reduces sensation of breathlessness  Cortical sedative / anxiolytic  Suppress cough reflex centre in brain stem

Morphine for Breathlessness

  Morphine does not cause CO 2 retention if used appropriately Morphine  breathlessness by about 20%  Generally more beneficial in patients who are breathless at rest  In opioid naïve patients:  start with 2.5mg oramorph prn + titrate  In patients on morphine for pain increase dose by 30%

Benzodiazepines

   Anxiolytic + Respiratory sedative Use formulations with relatively longer half life to avoid pronounced peaks & troughs which may lead to rebound anxiety  Diazepam 2-5mg nocte  Midazolam 2.5mg SC stat+ 5-10mg / 24 hrs CSCI  Clonazepam 0.25-2mg PO 12hrly Panic attacks  Lorazepam 0.5-1mg SL prn   SSRI Neuroleptic

Non-pharmacological, non interventional control of dyspnoea       Reassurance Breathing control Activity pacing Relaxation techniques Complementary therapies Psychological support  RCT 119  significant improvement at 8 weeks in dyspnoea score, ECOG status, emotional status

General Considerations

 Posture  Breathing techniques  Anxiety  Relaxation  Pacing

Hand Held Fans

Breathing Retraining  Shallow rapid breathing is ineffective and causes panic  Encourage slow, regular, deep breathing  Diaphragmatic breathing: consciously expand abdominal wall during inspiratory diaphragm descent  Pursed lip breathing :nasal inspiration + exhale though pursed lips

Panic Attacks

Lack of understanding + fear Dyspnoea PANIC Increased anxiety Increased respiratory rate

Oxygen

Oxygen

 No evidence of help if not hypoxic  Can be prescribed for ‘palliative care’

Summary



Optimise the management of the underlying condition



Consider lifestyle / behavioural changes



Breathlessness clinics for non-drug management



Drugs to modify the sensation

 

Opiates Benzodiazepines

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(Oxygen)