1. Dyspnea & cough

2. 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

3. an uncomfortable awareness of breathing
Dyspnea
an uncomfortable awareness of breathing

4. “…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

5. 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

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

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

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

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

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

11. 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

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

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

14. Non-specific, pharmacological
Oxygen
Opioids
chlorpromazine
benzodiazepines

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

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

17. 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)

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

19. 10-15mins
5 mg
10 mg
20 mg
e.g.
Morphine

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

21. Congestion in the final hours
Antisecretory
scopolamine mg sc q1h prn
glycopyrrolate mg sc q1h prn
Atropine mg sc q1h prn
1% eyedrops several drops q1h sl prn

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

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

24. 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%)

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

26. 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

29. ?