1. { Management of Advanced Breathlessness Dr Phil Wilkins, Norfolk and Norwich University Hospital and Priscilla Bacon Lodge, Norwich

2.  Definitions of breathlessness and when it occurs  How to manage the symptom  How to implement this Overview

3. Breathlessness

4.  Unpleasant awareness of difficulty breathing  “Inability to get enough air”  “Smothering feeling”  The only reliable measure is patient self-report  RR, pO 2 + blood gases do not correlate with the feeling of breathlessness Breathlessness

5.  COPD  Interstitial Lung Disease  Cancer (Primary and Secondary)  Left Heart Failure  (Anaemia, Muscular disorders, Bronchiectasis, etc) Conditions Causing End-stage Breathlessness

6.  Conscious vs Unconscious  Useful Concepts  Functions of breathing  What the patient thinks  What it is actually for  What happens when it goes wrong  How should we manage it? Breathing Regulation

7. Breathing Control medullary central pattern generator : brain stem respiratory muscles ventilation Mechanical receptors: parenchyma,airways intercostal muscles + diaphragm Chemoreceptors in aortic,carotid bodies + medulla ↑CO2 ↓O2 higher centres

8. Management

9.  Optimise the treatment for the underlying disease first! Important!

10.  Influenced by:  Mental state  Posture  Exercise  Environmental temperature + humidity  High breathlessness score = low QOL score  Affects all aspects of ADL :  physical, psychological and social  Cancer - affects 15% at diagnosis : 65% at some time during illness Breathlessness

11.  In malignant disease breathlessness is usually due to distortion and stimulation of mechanical receptors.  Blood gases are often normal  Fatigue, muscle weakness, phrenic nerve palsy and restrictive chest wall tumours can exacerbate breathlessness Breathlessness

12. Drugs

13.  ventilatory response to hypercapnia, hypoxia + exercise  Activation µ and  opioid receptors  tidal volume + respiratory rate  Breathing more efficient: improves exercise tolerance  Reduces sensation of breathlessness  Cortical sedative / anxiolytic  Suppress cough reflex centre in brain stem Opiates

14.  Morphine does not cause CO 2 retention if used appropriately  Morphine  breathlessness by about 20%  Generally more beneficial in patients who are breathless at rest  In opioid naïve patients:  start with 2.5mg oramorph prn + titrate  In patients on morphine for pain increase dose by 30% Morphine for Breathlessness

15. Anxiolytic + Respiratory sedative Use formulations with relatively longer half life to avoid pronounced peaks & troughs which may lead to rebound anxiety Diazepam 2-5mg nocte Midazolam 2.5mg SC stat+ 5-10mg / 24 hrs CSCI Clonazepam 0.25-2mg PO 12hrly Panic attacks Lorazepam 0.5-1mg SL prn  SSRI  Neuroleptic Benzodiazepines

16. Non-pharmacological, non- interventional control of dyspnoea Reassurance Breathing control Activity pacing Relaxation techniques Complementary therapies Psychological support RCT 119  significant improvement at 8 weeks in dyspnoea score, ECOG status, emotional status

17. General Considerations  Posture  Breathing techniques  Anxiety  Relaxation  Pacing

18. Hand Held Fans

19.  Shallow rapid breathing is ineffective and causes panic  Encourage slow, regular, deep breathing  Diaphragmatic breathing: consciously expand abdominal wall during inspiratory diaphragm descent  Pursed lip breathing :nasal inspiration + exhale though pursed lips Breathing Retraining

20. Panic Attacks

21. Lack of understanding + fear Increased respiratory rate Increased anxiety Dyspnoea PANIC

22. Oxygen

23. Oxygen  No evidence of help if not hypoxic  Can be prescribed for ‘palliative care’

24.  Optimise the management of the underlying condition  Consider lifestyle / behavioural changes  Breathlessness clinics for non-drug management  Drugs to modify the sensation  Opiates  Benzodiazepines  (Oxygen) Summary