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Dyspnea in Palliative Care of Children. Mike Harlos MD, CCFP Medical Director, WRHA Palliative Care and St. Boniface General Hospital Palliative Care Section Head, Palliative Care, University of Manitoba Dept. of Family Medicine. DYSPNEA: An uncomfortable awareness of breathing. DYSPNEA:

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dyspnea in palliative care of children

Dyspnea in Palliative Care of Children

Mike Harlos MD, CCFP

Medical Director, WRHA Palliative Care and St. Boniface General Hospital Palliative Care

Section Head, Palliative Care, University of Manitoba Dept. of Family Medicine

slide3

DYSPNEA:

An uncomfortable awareness of breathing

slide4

DYSPNEA:

“...the most common severe symptom in the last days of life”

Davis C.L. The therapeutics of dyspnoea Cancer Surveys 1994 Vol.21 p 85 - 98

symptoms at the end of life in children with cancer
Symptoms At The End of Life in Children With Cancer

Hongo T. et al, Pediatrics International Feb 2003 p.60

symptoms at the end of life in children with cancer6
Symptoms At The End of Life in Children With Cancer

Wolfe J. et al, NEJM 2000; 342(5) p 326-333

end of life care in cystic fibrosis treatments received in last 12 hours of life
End-of-Life Care in Cystic Fibrosis:Treatments Received in Last 12 Hours of Life

Robinson,WM et al, Pediatrics 100(2) Aug.1997

Only 11% were noted to have titration of opioids at end of life specifically for dyspnea

slide8

HOW WELL ARE WE TREATING DYSPNEA IN THE TERMINALLY ILL?

Addington-Hall JM, MacDonald LD, Anderson HR, Freeling P.

Dying from cancer: the views of bereaved family and friends about the experience of terminally ill patients.Palliative Medicine 1991 5:207-214.

  • n = 80 Last week of life
  • severe / very severe dyspnea: 50%
    • less than ½ of these were offered
    • effective treatment
slide9

Causes of Dyspnea

in Cancer Patients

  • Direct tumor effects
  • Indirect tumor effects
  • Treatment-related
  • Unrelated to cancer
slide10

DIRECT TUMOR CAUSES

  • Parenchymal
  • Lymphangitic carcinomatosis
  • Obstruction
  • Pleural effusion / tumor
  • Pericardial effusion
  • Superior vena cava obstruction
  • Ascites, hepatomegaly
  • Tumor microemboli
slide11

INDIRECT CANCER CAUSES

  • Cachexia, respiratory muscle atrophy
  • Mineral & electrolyte imbalances
  • Infections
  • Anemia
  • Pulmonary embolism
  • Neurologic paraneoplastic syndromes
  • Aspiration
slide12

Cancer Treatment-Related Causes

Of Dyspnea

  • Surgery
  • Radiation pneumonitis / fibrosis
  • Chemotherapy-induced pulm. fibrosis (bleomycin)
  • Chemotherapy-induced cardiomyopathy
  • (adriamycin, cyclophosphamide)
  • Neutropenic infection
slide13

Approach To The Dyspneic Palliative Patient

  • Two basic intervention types:
  • Non-specific, symptom-oriented
  • Disease-specific
slide14

Simple Non-Specific Measures In Managing Dyspnea

  • calm reassurance
  • patient sitting up / semi-reclined
  • open window
  • fan
slide15

Non-Specific Pharmacologic Interventions In Dyspnea

  • Oxygen - hypoxic and ? non-hypoxic
  • Opioids - complex variety of central effects
  • Chlorpromazine - some evidence in adult literature; caution in children due to potential for dystonic reactions
  • Benzodiazepines - literature inconsistent but clinical experience extensive and supportive
slide16

TREAT THE CAUSE OF DYSPNEA -

IF POSSIBLE AND APPROPRIATE

  • Anti-tumor: chemo/radTx, hormone, laser
  • Infection
  • Anemia
  • CHF
  • SVCO
  • Pleural effusion
  • Pulmonary embolism
  • Airway obstruction
slide17

DISEASE-SPECIFIC MEDICATIONS

FOR DYSPNEA

  • Corticosteroids
          • obstruction: SVCO, airway
          • lymphangitic carcinomatosis
          • radiation pneumonitis
  • Furosemide
          • CHF
          • lymphangitic carcinomatosis
  • Antibiotics
  • Anticoagulation– pulm. embolus
  • Bronchodilators
  • Transfusion
opioids in dyspnea
Opioids in Dyspnea
  • Uncertain mechanism
  • Often patient already on opioids for analgesia; if dyspnea develops it will usually drive the titration
  • Dosage should be titrated empirically; may easily reach doses commonly seen in adults
  • May need rapid dose escalation in order to keep up with rapidly progressing distress
opioids and sedatives in dyspnea
Opioids and Sedatives in Dyspnea

* Cancer Pain Relief and Palliative Care in Children, W.H.O. 1998

¥ The Rainbows Children’s Hospice Guidelines 2002

‡ Principles and Practice of Pediatric Oncology 4th Ed.; Edited by Pizzo & Poplack

management of terminal secretions
Management of Terminal Secretions
  • Avoid deep suctioning… tends to cause increased secretions
  • “if you can see it, you can suction it”
  • Sometimes (approx. 5%) – it is not possible to completely relieve the secretions
  • Patient not likely to be aware of secretions when unresponsive and near death; family may need support in realizing this
a common concern about aggressive use of opioids in the final hours
A COMMON CONCERN ABOUT AGGRESSIVE USE OF OPIOIDS IN THE FINAL HOURS

How do you know that the aggressive use of opioids doesn't actually bring about or speed up the patient's death?

slide23

SUBCUTANEOUS MORPHINE IN

TERMINAL CANCER

Bruera et al. J Pain Symptom Manage. 1990; 5:341-344

slide24

Typically, with excessive opioid dosing one would see:

    • pinpoint pupils
    • gradual slowing of the respiratory rate
    • breathing is deep (though may be shallow) and regular
slide25

COMMON BREATHING PATTERNS IN THE FINAL HOURS

Cheyne-Stokes

Rapid, shallow

“Agonal” / Ataxic

slide26

DOCTRINE OF DOUBLE EFFECT

Wilkinson J. Oxford Textbook of Palliative Medicine 1993: p 497-8

Where an action, intended to have a good effect, can achieve this effect only at the risk of producing a harmful/bad effect, then this action is ethically permissible providing:

  • The action is good in itself.
  • The intention is solely to produce the good effect (even though the bad effect may be foreseen).
  • The good effect is not achieved through the bad effect.
  • There is sufficient reason to permit the bad effect (the action is undertaken for a proportionately grave reason).
slide27

Burdens

Benefits

Beneficial Effects

Side Effects

Mount B., Flanders E.M.; Morphine Drips, Terminal Sedation, and Slow Euthanasia: Definitions and Fact, Not AnecdotesJ Pall Care 12:4 1996; p 31-37

The principle of double effect is not confined to end-of-life circumstances

Good effects

Bad effects

slide28

The difference in aggressive opioid use in end-of-life circumstances is that the “bad effect” = Death

  • The doctrine of double effect exists to support those health care providers who may otherwise withhold opioids in the dying out of fear that the opioid may hasten the dying process
  • A problem with the emphasis on double effect is that there in an implication that this is a common scenario…. in day-to-day palliative care it is extremely rare to need to even consider its implications