1. Dr Steve Plenderleith Consultant in Palliative Medicine Dyspnoea (Breathlessness) & Fear

2. Session Objectives To move our focus from “diagnosis” onto the causes and symptom of SOB. From “treatment” to thinking about how to manage the symptom. To increase your ability to help the patient to understand their breathlessness. To spend a couple of minutes considering Death Rattle.

3. Dyspnoea >1% of the population at any time. > 50% of EoL patients

4. Find princess alice 100% circle slide

5. The Problem Experienced in; 94% of chronic lung disease 83% of heart failure patients 70% of cancer patients in the last 6 weeks of life Palliative Care Main symptom in 21% of homecare patients in last week of life

6. Post-it Mayhem 60 seconds The condition causing the most SOB on your caseload. 1 Best treatments for SOB. 2

7. Physiology Nasal breathing 10 000litres per day Diaphragm main inspiratory muscle Expiration passive – normally! Midbrain Respiratory Centre > phrenic and IC nerves Neurogenic factors – conscious, limb receptors (proprioception?), pulmonary receptors (stretch & irritation), J receptors (congestion) Chemical factors Strongest pCO2 – detected in resp. centre; lost in COPD pO2 below 8kPa – N 11-13; carotid & aortic bodies H+ rise in respiratory acidosis > incr. ventilation

8. Physiology Airway Tone autonomic control via cholinergic vagal efferents Circadian rhythm 04:00hrs bronchioles tight Incr. Tone – cigarettes, dust, post infection, NSAID’s Decr. Tone – beta agonists

9. WHY AM I FEELING BREATHLESS

10. What is causing SOB ??

13. Causes MusculoskeletalAirwayObstructionLung Decreased Volume Increased Lung stiffness Decreased Alveolar gas exchange Increased Demand Tumouranaemia

14. Dyspnoea - MEANING Intensity less important than how unpleasant Likert scale Unpleasantness may depend upon meaning. The Admiral Graf Spee Social aspect How many die a social death long before they physically die. Being close to someone SOB is distressing.

15. Dyspnoea “Breathlessness, is as bad as the person experiencing it says it is”

16. Fear of Suffocation “I really should have shaved this morning”, thought Mable

18. Normal 1 dodgy lung 1 Lung

20. Management - MEDICAL Treat reversible causes Pleural Effusion Diaphragmatic Hernia ! Mesothelioma Invasive Tumour Sarcoid Masses

21. Management - MEDICAL Treat reversible causes  Pleural effusion  LRTI  Infection  Bronchospasm  Cardiac Failure  Anaemia  Obstruction – stent  SVCO  etc

22. So is oxygen the answer?

23. If O2 saturation is low.

24. BTS/NICE O2 guidance !!!! Currow et al. Does palliative home O2 improve dyspnoea?  Large 5862 patient cohort study, 92% cancer.  Baseline, 1 & 2 weeks O2 therapy.  No significant difference in dyspnoea overall or for any subgroup analysis.

25. Management - MEDICAL Treat reversible causes  etc O2 ? – only if low, pO2 <92% or <88% Risk of patient being a CO2 retainer  Over 65, smoker or ex, Hx. of bronchitis, obese.  Max saturation 92% and monitor  Chronis et al. AM Thor Soc 2007. Those not on long term O2. COPD Saturation improved. Cancer NAD. No clinical benefit proven for either AND O2 is seen to help – ?? fan effect

26. Management - Drug Treatment Nebulisers – Beta agonist or ipratroprium Opioids – long acting or patient controlled? Mahler et al.Eur Resp J 2009 naloxone Vs saline Abernethy et al. BMJ 2003 MST. NNT 1.5 Benzodiazepines Lorazepam – very patient controllable SL Diazepam – back ground anxiety control Midazolam – Syringe driver or SL No evidence Anti-depressants / Diuretics / Analgesics Nebulised - Saline

29. Our Aim

30. Fear of Breathlessness

31. Post-it Mayhem 2 List at least 5 non medicine FINGS you can use to HELP breathlessness

33. Fan or air (via window) O2 if OK Cool flannel Nebuliser or volumatic Oramorph & / or lorazepam Visualisation Controlled breathing (long breath out) The Panic Hand Phone a friend 999 Cool Drink Splint chest (sit up) Cool Room

34. Management - ANXIETY Reassurance / Explain Perception of breathlessness Patients don’t suffocate / choke – MND, All Non drug treatment Fans Cold water Physiotherapy – panic hand, chest breathing, rehabilitation Visualisation

35. New Stuff – horizon scanning Limbic system – emotion, long term memory – appears more active (functional MRI) in patients with dyspnoea associated affective distress. More scared?? Nebulised fentanyl being lipophilic is rapidly absorbed leading to Rx serum levels after 5 minutes Inhaled Fentanyl Citrate Improves Exercise Endurance During High- Intensity Constant Work Rate Cycle Exercise in Chronic Obstructive Pulmonary Disease. Jensen D et al. J Pain &Sympt Mx 43, 4, 2012, 706–719. BUT doesn’t decrease perception of dyspnoea. NIV may have a role in hypercapnoeic COPD Requires a very clear contract of goals of care in palliative patients.

36. New Stuff – horizon scanning Prednisolone 1mg/kg/day (max 60mg) may improve diuresis in CHF. Glucocorticoid effect BAD Mineralocorticoid effect GOOD So far nothing convincingly works for dyspnoea in Interstitial Lung Disease. Constant 19% –both 20% –breakthrough 61% dyspnoea. 68% <5/day. 88% <10minutes.

38. Drug Therapy Exercise Reduce Oxygen Use Alter Perception

39. Nibble Away Any Questions

40. Rattle “ The noisy secretions in a patient close to death” 51-92% Type 1 – salivary secretions – poor swallow Type 2 – Bronchial secretions – poor cough Pulmonary Oedema Infection – treat or not! Noisy tachypnoea

41. Rattle - Aims Stop that damn noise Patient Suffering Education It’s a sign

42. Rattle - treatment Glycopyrronium Minimal CVS, ocular or CNS effects 200microg stat 600 - 2400mg syringe driver or higher / 24hrs Less effective at clearing established secretions - anec. Cheap Hyoscine Hydrobromide Crosses blood brain barrier Sedation or aggitation 400 microg stat 1200 – 2400 microg syringe driver / 24hrs Best for clearing established secretions – anec. Expensive

43. Rattle - treatment Hyoscine butylbromide 30 – 120mg syringe driver / 24hrs No sedation Large volume needed in CSCI Short acting so less use PRN Cheap as chips Oral secretions Scopoderm patch Anti-cholinergic Atropine 1% eye drops Botox the salivary glands Suction – for oro-pharyngeal secretions only Diuretics?

44. Session Objectives To move our focus from “diagnosis” onto the causes and symptom of SOB. From “treatment” to thinking about how to manage the symptom. To increase your ability to help the patient to understand their breathlessness. To spend a couple of minutes considering Death Rattle.