1. TM The EPEC-O Project Education in Palliative and End-of-life Care - Oncology The EPEC TM -O Curriculum is produced by the EPEC TM Project with major funding provided by NCI, with supplemental funding provided by the Lance Armstrong Foundation.

2. EPEC  – Oncology Education in Palliative and End-of-life Care – Oncology Module 3j: Symptoms – Dyspnea Module 3j: Symptoms – Dyspnea

3. Dyspnea l Definition: uncomfortable awareness of breathing Dudgeon DJ. J Pain Symptom Manage. 1998. l Definition: uncomfortable awareness of breathing Dudgeon DJ. J Pain Symptom Manage. 1998.

4. Causes l Anxiety l Airway obstruction l Bronchospasm l Hypoxemia l Pleural effusion l Pneumonia l Pulmonary edema l Anxiety l Airway obstruction l Bronchospasm l Hypoxemia l Pleural effusion l Pneumonia l Pulmonary edema l Pulmonary embolism l Thick secretions l Anemia l Metabolic l Family / financial / legal / spiritual / practical issues

5. Dyspnea l Impact: one of most frightening symptoms

6. Prevalence / prognosis l Prevalence 21 to 90% in patients with life-threatening illness l Prognosis less than 6 months when no underlying treatment for malignancy is possible l Prevalence 21 to 90% in patients with life-threatening illness l Prognosis less than 6 months when no underlying treatment for malignancy is possible

7. Key points l Pathophysiology l Assessment l Management l Pathophysiology l Assessment l Management

8. Pathophysiology... l Respiratory center (medulla and pons)  Coordinates diaphragm, intercostal m, accessory m of respiration  Sensory input from: o Chemoreceptors (pO 2, pCO 2 ) o Mechanoreceptors (stretch, irritation) l Respiratory center (medulla and pons)  Coordinates diaphragm, intercostal m, accessory m of respiration  Sensory input from: o Chemoreceptors (pO 2, pCO 2 ) o Mechanoreceptors (stretch, irritation)

9. ... Pathophysiology l Work of breathing o Resistance (COPD, obstruction) o Weakened muscles (cachexia) l Chemical o Hypoxemia o Hypercarbia (small role in cancer) l Neuromechanical dissociation: o Mismatch between brain and sensory feedback l Work of breathing o Resistance (COPD, obstruction) o Weakened muscles (cachexia) l Chemical o Hypoxemia o Hypercarbia (small role in cancer) l Neuromechanical dissociation: o Mismatch between brain and sensory feedback

10. Assessment... l May be described as: o Shortness of breath o A smothering feeling o Inability to get enough air o Suffocation l May be described as: o Shortness of breath o A smothering feeling o Inability to get enough air o Suffocation

11. ... Assessment l The only reliable measure is patient self-report. l Respiratory rate, pO 2, blood gas determinations DO NOT correlate with the feeling of breathlessness. l The only reliable measure is patient self-report. l Respiratory rate, pO 2, blood gas determinations DO NOT correlate with the feeling of breathlessness.

12. Management l Treat the underlying cause, e.g. o Thoracentesis o Bronchial Stents l Symptomatic management o Oxygen o Opioids o Anxiolytics o Nonpharmacologic interventions l Treat the underlying cause, e.g. o Thoracentesis o Bronchial Stents l Symptomatic management o Oxygen o Opioids o Anxiolytics o Nonpharmacologic interventions

13. Opioids l Relief not related to respiratory rate l No ethical or professional barriers l Small doses l Central and peripheral action Bruera E, et al. Ann Int Med. 1993. Mazzocato C, et al. Ann Oncol. 1999. Allard P, et al. J Pain Symptom Manage. 1999. l Relief not related to respiratory rate l No ethical or professional barriers l Small doses l Central and peripheral action Bruera E, et al. Ann Int Med. 1993. Mazzocato C, et al. Ann Oncol. 1999. Allard P, et al. J Pain Symptom Manage. 1999.

14. Anxiolytics l Safe in combination with opioids when titrated cautiously o Lorazepam 0.5-2 mg PO q 1 h PRN until settled, then dose routinely q 4–6 h to keep settled l Safe in combination with opioids when titrated cautiously o Lorazepam 0.5-2 mg PO q 1 h PRN until settled, then dose routinely q 4–6 h to keep settled

15. Oxygen l Pulse oximetry not helpful l Potent symbol of medical care l Expensive l Fan may do just as well Bruera E, et al. Lancet. 1993. l Pulse oximetry not helpful l Potent symbol of medical care l Expensive l Fan may do just as well Bruera E, et al. Lancet. 1993.

16. ... Nonpharmacologic interventions... l Reassure, work to manage anxiety l Behavioral approaches, e.g., relaxation, distraction, hypnosis l Limit the number of people in the room l Open window Bredin J, et al. BMJ. 1999. l Reassure, work to manage anxiety l Behavioral approaches, e.g., relaxation, distraction, hypnosis l Limit the number of people in the room l Open window Bredin J, et al. BMJ. 1999.

17. ... Nonpharmacologic interventions... l Eliminate environmental irritants l Keep line of sight clear to outside l Reduce room temperature l Avoid chilling the patient l Eliminate environmental irritants l Keep line of sight clear to outside l Reduce room temperature l Avoid chilling the patient

18. ... Nonpharmacologic interventions l Introduce humidity l Reposition  Elevate the head of the bed  Move patient to one side or other l Educate, support the family l Introduce humidity l Reposition  Elevate the head of the bed  Move patient to one side or other l Educate, support the family

19. Specific situations... l Refractory dyspnea l Dyspnea at the end of life l Bronchospasm l Refractory dyspnea l Dyspnea at the end of life l Bronchospasm

20. ... Specific situations l Thick secretions l Pleural effusion l Anemia l Airway obstruction l Thick secretions l Pleural effusion l Anemia l Airway obstruction

21. Summary Use comprehensive assessment and pathophysiology-based therapy to treat the cause and improve the cancer experience.