Dyspnea & cough

Objectives Definition of dyspnea prevalence of dyspnea in palliative care Causes of dyspnea Medical management (Treatment of underlying cause) Non-pharmacological and symptom management Briefly review cough

an uncomfortable awareness of breathing Dyspnea an uncomfortable awareness of breathing

“…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

70% incidence in last 6 weeks of life severe/very severe dyspnea - 50% in last week of life less than 1/2 were offered effective treatment 70% incidence in hospice survey 50% based on family and friends perceptions

Causes of dyspnea Direct Tumour causes Indirect Tumour causes Treatment-related causes

Direct Tumour Causes Parenchymal Lymphangitic carcinomatosis Obstruction Pleural effusion Pericardial effusion Superior ven cava obstruction Ascites, hepatomegaly Tumour microemboli

Indirect Tumour Causes Cachexia Electrolyte imbalances Infections Anemia Pulmonary Embolism Paraneoplastic syndromes Aspiration

Treatment-Related Causes Surgery Radiation pneumonitis / fibrosis Chemotherapy-induced pulmonary fibrosis (bleomycin) Chemotherapy-induced cardiomyopathy (adriamycin, cyclophosphamide) Neutropenic infection

Managing the dyspneic palliative patient Disease specific Non-specific, symptom-oriented

Disease specific management Tumour treatment - chemo/radiation, hormone Infection - antibiotics CHF - Lasix SVCO - steroids, diuretics, radiation, anticoagulation Pleural effusion - thoracentesis Pulmonary Embolism - anticoagulation Airway obstruction - steroids, radiation, tracheostomy

Disease-specific medications Corticosteroids Obstruction, SVCO, Lymphangitic carcinomatosis, radiation pneumonitis Furosemide CHF, Lymphangitic carcinomatosis Antibiotics Anticoagulation Pulmonary embolism, svco Bronchodilators

Non-specific, non-pharmacological calm reassurance sitting up / semi-reclined open window fan

Non-specific, pharmacological Oxygen Opioids chlorpromazine benzodiazepines

Opioid management Multiple central effects that lead to subjective improvement in dyspnea Opioid selection and titration is similar to pain management Dyspnea = Pain

Dyspnea Crisis Sudden onset or rapid worsening of dyspnea Often an imminently terminal event (minutes -hours) Pulmonary embolism Fulminant pneumonia Upper airway obstruction Hemoptysis

Managing Dyspnea Crisis Aggressively pursue comfort remain on site until comfortable Ideally use intravenous route (subcutaneous usually adequate) Employ non-specific measures: reassurance oxygen Opioids sedatives (mehotrimeprazine, chlorpromazine, benzodiazepines)

Opioids in Dyspnea Crisis q10-15m iv push with escalating doses

10-15mins 5 mg 10 mg 20 mg e.g. Morphine

Consider the use of crisis Medications Midazolam 5-10 mg SC Methotrimeprazine 12.5-25 mg SC Opioid Double baseline dose

Congestion in the final hours Antisecretory scopolamine 0.3-0.6mg sc q1h prn glycopyrrolate 0.2-0.4 mg sc q1h prn Atropine 0.4-0.8mg sc q1h prn 1% eyedrops several drops q1h sl prn

Cough Defense mechanism to clear excess secretions and foreign material from airways

Causes of Cough postnasal drip, asthma, gerd, infection, acei, smoking, bronchiectasis, bronchitis, interstitial lung disease, etc.

cough is one of the most common initial symptoms in lung cancer Prevalence of 45% at diagnosis 39-80% receiving chemotherapy or radiotherapy for lung cancer 22-37% prevalence in patients with other cancers A comparative survey revealed that end-stage heart failure patients at a heart failure clinic had more cough than persons identified as terminally ill by a palliative care team (44% versus 26%)

Treatment of Cough Environmental humidification, supplemental oxygen, avoid irritants (perfume, smoke) Local treatment radiotherapy to cancer

Opioids Work by raising the threshold of the medullary cough centres Dextromethorphan NMDA antagonist with conflicting results on efficacy possible central inhibition of cough centre secondary to its syrup form which soothes the pharynx Benzonatate acts peripherally by anesthetizing pulmonary stretch receptors

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