1. UNDERSTANDING BREATHLESSNESS IN 10’ish MINUTES! Dr David Plume Macmillan GP Facilitator, Central Norfolk

2. Dyspnoea Unpleasant awareness of difficulty in breathing Unpleasant awareness of difficulty in breathing Pathological when ADLs affected and associated with disabling anxiety Pathological when ADLs affected and associated with disabling anxiety Resulting in : physiological behavioural responses Resulting in : physiological behavioural responses Dyspnoea PhysiologySocialEnvironmentalPsychology

3. Dyspnoea Breathlessness experienced by 70% cancer patients in last few weeks of life Breathlessness experienced by 70% cancer patients in last few weeks of life Severe breathlessness affects 25% cancer patients in last week of life Severe breathlessness affects 25% cancer patients in last week of life

4. Causes of breathlessness-Cancer –Pleural effusion –Large airway obstruction –Replacement of lung by cancer –Lymphangitis carcinomatosa –Tumour cell microemboli –Pericardial Effusion –Phrenic nerve palsy –SVC obstruction –Massive ascites –Abdominal distension –Cachexia-anorexia syndrome respiratory muscle weakness. –Chest infection

5. Causes of Breathlessness- Treatment –Pneumonectomy –Radiation induced fibrosis –Chemotherapy induced Pneumonitis Pneumonitis Fibrositis Fibrositis Cardiomyopathy Cardiomyopathy –Progestogens Stimulates ventilation Stimulates ventilation Increased sensitivity to carbon dioxide. Increased sensitivity to carbon dioxide.

6. Causes of Breathlessness- Debility –Atelectasis –Anaemia –PE –Pneumonia –Empyema –Muscle weakness

7. Causes of Breathlessness- Concurrent oCOPD oAsthma oHF oAcidosis oFever oPneumothorax oPanic disorder, anxiety, depression

8. Reversible causes of breathlessness! Resp. Infection Resp. Infection COPD/Asthma COPD/Asthma Hypoxia Hypoxia Obstructed Bronchus/SVC Obstructed Bronchus/SVC Lymphangitis Carcinomatosa Lymphangitis Carcinomatosa Pleural Effusion Pleural Effusion Ascites Ascites Pericardial Effusion Pericardial Effusion Anaemia Anaemia Cardiac Failure Cardiac Failure PE PE

9. Breathlessness Cycle Anxiety Amplified Panic Fear of impending death Breathlessness Fear of Dying Lack of understanding PANIC

10. Independent predictor of survival Breathless on exertion Breathless at rest Terminal breathlessness Correct the correctable Non-drug treatment Symptomatic drug treatment months weeksdays

11. Is this Terminal Breathlessness? Are there appropriate treatments that could or should be tried at home? Does this patient want and need transfer for investigations and treatment? Consider transfer to hospital for investigation & treatment if: Pre-SOB condition good Acute onset SOB Patient receiving ongoing disease modifying treatment Manage at home if: Burden of transfer for investigation & treatment too great ConsiderOral antibiotics Nebulisers Steroids Oxygen

12. Non-Drug Therapies Explore perception of patient and carers Explore perception of patient and carers Maximise the feeling of control over the breathing Maximise the feeling of control over the breathing Maximise functional ability Maximise functional ability Reduce feelings of personal and social isolation. Reduce feelings of personal and social isolation.

13. Patient and Carer Perception Meaning to patient and carer Meaning to patient and carer Explore anxiety esp. fear of sudden death Explore anxiety esp. fear of sudden death Inform that not life threatening Inform that not life threatening State what is likely to/not to happen State what is likely to/not to happen Realistic goal setting Realistic goal setting Help patient and carer adjust to loss of roles/abilities. Help patient and carer adjust to loss of roles/abilities.

14. Maximize control Breathing control advice Breathing control advice –Diaphragmatic breathing –Pursed lips breathing Relaxation techniques Relaxation techniques Plan of action for acute episodes Plan of action for acute episodes –Written instructions step by step –Increased confidence coping Electric fan Electric fan Complementary therapies Complementary therapies

15. Maximize function Encourage exertion to breathlessness to improve tolerance/desensitise to breathlessness Encourage exertion to breathlessness to improve tolerance/desensitise to breathlessness Evaluation by physios/OT’s/SW to target support to need. Evaluation by physios/OT’s/SW to target support to need.

16. Reduce feelings of isolation Meet others in similar situation Meet others in similar situation Day centre Day centre Respite admissions Respite admissions

17. Breathlessness Clinic Nurse lead Nurse lead NNUH-Monday Afternoon NNUH-Monday Afternoon Lung cancer and mesothelioma Lung cancer and mesothelioma Referral by GP/SPCN/Palliative Medicine team/Generalist Consultants Referral by GP/SPCN/Palliative Medicine team/Generalist Consultants PBL Day Unit-Wednesday, link with NNUH. PBL Day Unit-Wednesday, link with NNUH.

18. Drug Treatment Dyspnoea SalbutamolOxygenBenzodiazepinesMorphine

19. What do I give? Bronchodilators work well in COPD and Asthma even if nil known sensitivity. Bronchodilators work well in COPD and Asthma even if nil known sensitivity. O2 increases alveolar oxygen tension and decreases the work of breathing to maintain an arterial tension. O2 increases alveolar oxygen tension and decreases the work of breathing to maintain an arterial tension. –Usual rules regarding COPD/Hypercapnic Resp. failure apply. Opioids reduce the vent.response to inc. CO2, dec O2 and exercise hence dec resp effort and breathlessness. Opioids reduce the vent.response to inc. CO2, dec O2 and exercise hence dec resp effort and breathlessness. –If morphine naïve-Start with stat dose of Oramorph 2.5-5mg or Diamorphine 2.5-5mg sc and titrate Repeated 4hrly as needed. –If on morphine already for pain a dose 100% or > of q4h dose may be needed, if less severe 25% q4h may be given Benzodiazipines stat dose of Lorazepam 0.5mg SL, Diazepam 2- 5mg or Midazolam 2.5-5mg sc Benzodiazipines stat dose of Lorazepam 0.5mg SL, Diazepam 2- 5mg or Midazolam 2.5-5mg sc Repeated 4hrly as needed

20. Ongoing treatment A syringe driver should be commenced if a 2 nd stat dose is needed within 24hrs Diamorphine 10-20mg CSCI / 24hrs Diamorphine 10-20mg CSCI / 24hrs Midazolam 5-20mg CSCI / 24hrs Midazolam 5-20mg CSCI / 24hrs Remember to prescribe stats Review & adjust dose daily if needed

21. Terminal Breathlessness Great fear of patients and relatives Great fear of patients and relatives Treat appropriately- Opioid and sedative/anxiolytic- Diamorphine and midazolam-PRN and CSCI Treat appropriately- Opioid and sedative/anxiolytic- Diamorphine and midazolam-PRN and CSCI If agitation or confusion -haloperidol or Nozinan If agitation or confusion -haloperidol or Nozinan Some patients may brighten. Some patients may brighten. Sedation not the aim but likely due to drugs and disease. Sedation not the aim but likely due to drugs and disease.

23. Respiratory Secretions (death rattle) Rattling noise due to secretions in hypopharynx moving with breathing Rattling noise due to secretions in hypopharynx moving with breathing Usually occurs within days-hours of death Usually occurs within days-hours of death Occurs in ~40% cancer patients (highest risk if existing lung pathology or brain metastases) Occurs in ~40% cancer patients (highest risk if existing lung pathology or brain metastases) Patient rarely distressed Patient rarely distressed Family commonly are distressed Family commonly are distressed Treat early Treat early Position patient semi-prone Position patient semi-prone Suction rarely helpful Suction rarely helpful

24. Respiratory Secretions If secretions are present, two options. If secretions are present, two options. A) Hyoscine Butylbromide (Buscopan) A) Hyoscine Butylbromide (Buscopan) –Stat-20mg 1hrly –CSCI-80-120mg/24 hrs B) Glycopyrronium B) Glycopyrronium –Stat-0.4mg 4hrly –CSCI-0.6-1.2mg /24 hrs Remember Stats at appropriate doses Review & adjust dose daily