UNDERSTANDING BREATHLESSNESS IN 10’ish MINUTES!

1. UNDERSTANDING BREATHLESSNESS IN 10’ish MINUTES! Dr David Plume Macmillan Palliative Care GP Facilitator, Central Norfolk

2. Dyspnoea • Unpleasant awareness of difficulty in breathing • Pathological when ADLs affected and associated with disabling anxiety • Resulting in : physiological behavioural responses

3. Dysponea • Breathlessness experienced by 70% cancer patients in last few weeks of life • Severe breathlessness affects 25% cancer patients in last week of life

4. Causes of breathlessness-Cancer • Pleural effusion • Large airway obstruction • Replacement of lung by cancer • Lymphangitis carcinomatosa • Tumour cell microemboli • Pericardial Effusion • Phrenic nerve palsy • SVC obstruction • Massive ascites • Abdominal distension • Cachexia-anorexia syndrome respiratory muscle weakness. • Chest infection

5. Causes of Breathlessness-Treatment • Pneumonectomy • Radiation induced fibrosis • Chemotherapy induced • Pneumonitis • Fibrositis • Cardiomyopathy • Progestogens • Stimulates ventilation • Increased sensitivity to carbon dioxide.

6. Causes of Breathlessness- Debility Anaemia • Atelectasis • PE • Pneumonia • Empyema • Muscle weakness

7. Causes of Breathlessness-Concurrent • COPD • Asthma • HF • Acidosis • Fever • Pneumothorax • Panic disorder, anxiety, depression

8. Reversible causes of breathlessness! • Resp. Infection • COPD/Asthma • Hypoxia • Obstructed Bronchus/SVC • Lymphangitis Carcinomatosa • Pleural Effusion • Ascites • Pericardial Effusion • Anaemia • Cardiac Failure • PE

9. Breathlessness Cycle

10. Independent predictor of survival weeks days months Symptomatic drug treatment Non-drug treatment Correct the correctable Breathless on exertion Breathless at rest Terminal breathlessness

12. Non-Drug Therapies • Explore perception of patient and carers • Maximise the feeling of control over the breathing • Maximise functional ability • Reduce feelings of personal and social isolation.

13. Patient and Carer Perception • Meaning to patient and carer • Explore anxiety esp. fear of sudden death • Inform that not life threatening • State what is likely to/not to happen • Realistic goal setting • Help patient and carer adjust to loss of roles/abilities.

14. Maximize control • Breathing control advice • Diaphragmatic breathing • Pursed lips breathing • Relaxation techniques • Plan of action for acute episodes • Written instructions step by step • Increased confidence coping • Electric fan • Complementary therapies

15. Maximize function • Encourage exertion to breathlessness to improve tolerance/desensitise to breathlessness • Evaluation by physios/OT’s/SW to target support to need.

16. Reduce feelings of isolation • Meet others in similar situation • Day centre • Respite admissions

17. Drug Treatment

18. What do I give? • Bronchodilators work well in COPD and Asthma even if nil known sensitivity. • O2 increases alveolar oxygen tension and decreases the work of breathing to maintain an arterial tension. • Usual rules regarding COPD/Hypercapnic Resp. failure apply. • Opioidsreduce the vent.response to inc. CO2, dec O2 and exercise hence dec resp effort and breathlessness. • If morphine naïve-Start with stat dose of Oramorph 2.5-5mg or Diamorphine 2.5-5mg sc and titrate Repeated 4hrly as needed. • If on morphine already for pain a dose 100% or > of q4h dose may be needed, if less severe 25% q4h may be given • Benzodiazipines stat dose of Lorazepam 0.5mg SL, Diazepam 2-5mg or Midazolam 2.5-5mg sc Repeated 4hrly as needed

19. Ongoing treatment A syringe driver should be commenced if a 2nd stat dose is needed within 24hrs • Diamorphine 10-20mg CSCI / 24hrs • Midazolam 5-20mg CSCI / 24hrs Remember to prescribe stats Review & adjust dose daily if needed

20. Terminal Breathlessness • Great fear of patients and relatives • Treat appropriately- Opioid and sedative/anxiolytic- Diamorphine and midazolam-PRN and CSCI • If agitation or confusion -haloperidol or Nozinan • Some patients may brighten. • Sedation not the aim but likely due to drugs and disease.

21. Respiratory Secretions (death rattle) • Rattling noise due to secretions in hypopharynx moving with breathing • Usually occurs within days-hours of death • Occurs in ~40% cancer patients (highest risk if existing lung pathology or brain metastases) • Patient rarely distressed • Family commonly are distressed • Treat early • Position patient semi-prone • Suction rarely helpful

22. Present Stat Hyoscine Hydrobromide 0.4mg sc Repeat 4hrly prn Start Hyoscine Hydrobromide 1.2mg CSCI / 24hrs Prescribe stats Review & adjust dose daily Absent Prescribe stat doses Hyoscine Hydrobromide 0.4mg 4hrly prn If 2 or more doses required in 24hrs, consider adding to CSCI Respiratory Secretions

23. Alternative anti-secretory agents • These unlike Hyoscine Hydrobromide don’t cross the BBB and hence are less likely to cause sedation and confusion. • Hyoscine Butylbromide • stat dose 20mg 1hrly • CSCI 80-120mg/ 24hrs • Glycopyrronium • stat dose 0.4mg 6hrly • CSCI 0.6-1.2mg/ 24hrs

25. All clear? Any Questions?