Managementn of RespiratorySymptoms in Cancer Patients F. Soltaninejad MD Pulmonologist

Breathlessness

Background 54%-76% of advanced cancer patients experience dyspnea more than 65% of lung cancer patients have cough at the time of diagnosis 35% of cancer patients develop death rattle at the end of life

Breathlessness Breathlessness is an uncomfortable sensation or awareness of breathing. Subjective – measuring lung function does not correlate with sensation or severity of breathlessness A complex experience of mind and body that is likely to progress with disease severity Significant correlation with impaired quality of life and poor survival. Effects Patients and Carers. A common complex distressing symptom at the end of life

Dyspnea Dyspnea is a frequent symptom in advanced cancer patients with the highest prevalence in lung cancer (up to 74%) increasing in the terminal phase (up to 80%) with major impact on the quality of life of the patient and his or her family.

Dyspnea Dyspnea can be described along three dimensions: air hunger—the need to breathe while being unable to increase ventilation effort of breathing—physical tiredness associated with breathing chest tightness—the feeling of constriction and inability to breathe in and out

Psychological Aspect of Breathlessness

Assessment of breathlessness Listen/Observe What does it mean to the patient / carer? Onset Triggers / What eases it? Levels of significance – during activity, in different positions, at rest Pattern of breathing, colour, respiratory rate Are they anxious? Oxygen saturations

Assessment of dyspnea History Physical examinations Paraclinic assessment: ( complete blood count, electrolytes, creatinine, oximetry and full blood gas assessment, electrocardiogram, brain natriuretic peptide or chest X-ray and computed tomography scan )

Manage reversible causes optimally according to patients wishes Consider active treatment of: Infection Pleural effusion Pneumothorax Pericardial effusion Airway obstruction Anaemia CHF

Non Pharmacological Management Positioning Airflow - use of fan /window Relaxation / Distraction/ Reassurance Energy conservation / Pacing Controlled Breathing techniques Loose clothing Mouth Care

Comfortable Positions if short of breath

Breathing Techniques Start with position of ease Relax shoulders / upper chest Diaphragmatic ‘tummy’ breathing Breath out twice as long as breath in Pursed lips on breathing out if needed

Pacing activities Encourage activity Allow time for tasks Starting and stopping with rest intervals Inspiration: expiration ratio during activity Use of aids – stair lift etc Adapting functional tasks

Management of dyspnea Oxygen therapy Oxygen therapy is recommended in hypoxemic patients Oxygen therapy is suggested not to be used in nonhypoxemic patients

Management of dyspnea Noninvasive positive pressure ventilation (NPPV) is suggested to be used in patients with hypoxemia and hypercapnea

Management of dyspnea High-flow nasal cannula oxygen therapy is suggested to be used in patients with hypoxemia that is refractory to standard oxygen therapy

Management of dyspnea Opioids Systemic morphine is recommended to be used in cancer patients with dyspnea Systemic oxycodone is suggested to be used, as alternative to morphine Systemic fentanyl is suggested not to be used Systemic codeine/dihydrocodeine is suggested to be used

Management of dyspnea Benzodiazepines Benzodiazepines are suggested not to be used alone Benzodiazepines are suggested to be used in combination with opioids

Management of dyspnea Corticosteroids Systemic corticosteroids are suggested not to be used routinely without consideration of dyspnea etiology. Systemic corticosteroids are suggested to be used in patients with lymphangitis carcinomatosa, radiation pneumonitis, superior vena cava syndrome, major airway obstruction.

other drugs Neuroleptics such as phenothiazines and antidepressants and buspirone are reputed to exert some antidyspnoeic efficacy as mood-enhancing medication; nevertheless, this has not yet been proven.

Management of malignant pleural effusion Thoracentesis with drainage of pleural effusion is recommended Pleurodesis should be performed in cancer patients with dyspnea caused by malignant pleural effusion, if patients meet all the following conditions: (1) repeated thoracentesis is required to relieve dyspnea, (2) patient’s general condition is tolerable for pleurodesis, and (3) a monthly prognosis is expected.

Management of cough Morphine/codeine/dihydrocodeine and dextromethorphan are suggested to be used. Gabapentin/pregabalin and nebulized lidocaine are suggested not to be used.

Recommended dosages for antitussives Dextromethorphan 10-15 mg tds/qds Codeine 30-60 mg qds Morphine (oramorph) 5 mg (single dose trial of oramorph; if effective 5-10 mg slow release morphine bd) Diamorphine 5-10 mg CSCI/24 hrs Methadone linctus Single dose 2 mg (2 mL of 1 mg/mL solution) Dihydrocodeine 10 mg tds Hydrocodone 5 mg bd Prednisolone 30 mg daily for 2 weeks

End of life secretions Often referred to as ‘death rattle’ Caused when a patient’s coughing and swallowing reflex is impaired or absent, causing fluids to collect Not easily relieved by drug therapy once established Treatment should therefore be started at first sign of rattle

Non-pharmacological management of secretions Re-positioning of the patient by tilting side to side, or tipping bed ‘head up’ to reduce noise Management of halitosis with frequent mouth care Discrete management of oral secretions mouth care – oral hygiene Suction not advised, except when secretions are excessive Reassurance to family that the noise is due to secretions, and not causing suffocation, choking or distress Reduce oral fluids if at risk of aspiration

Pharmacological management of secretions Hyoscine Butylbromide (Buscopan) 60- 240mg/24hr s/driver, prn dose SC 20mg If not effective, discuss with palliative care team who may consider Glycopyronium Bromide (Glycopyrolate) 400-2400mcg/24hr s/driver or prn dose 200mcg Point: Hyoscine Hydrobromide was historically drug of choice, but not currently recommended due to side effects of sedation and confusion

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