1. Palliative Care: Shortness of Breath and Secretions Hong-Phuc Tran, M.D.

2. Learning Objectives Understand pathophysiology of dyspnea Learn how to evaluate dyspnea Understand reversible causes / potential contributors of shortness of breath Manage shortness of breath in terminally ill patients

3. Introduction Shortness of breath is common in terminally ill patients “Death rattle” (noisy breathing) occurs in 23- 92% of dying patients – Patients lose ability to clear secretions as mentation worsens Appropriate management of excessive secretions is important in providing palliation

4. Pathophysiology of Dyspnea Multifactorial ▫Increased work of breathing ▫Chemical effects  Medullary chemoreceptors sense hypercapnea  Carotid and aortic body chemoreceptors sense hypoxemia ▫Neuromechanical association  Mismatch between what brain desires for respiration and sensory feedback brain receives

5. Evaluation of Dyspnea Patient’s self-report is most reliable measure Can have dyspnea with normal O2 saturation Physical exam findings ▫Accessory muscle use ▫Tachypnea ▫Rhonchi, crackles, decreased breath sounds, stridor ▫Cyanosis (central or peripheral)

6. Examples of Some Reversible Causes / Potential Contributors of Shortness of Breath Bronchospasm Pleural effusion Anemia Airway obstruction

7. Management of Shortness of Breath (1) First, treat underlying, reversible causes (if any)

8. Examples of Management of Some Reversible Causes/ Potential Contributors of Shortness of Breath Bronchospasm – Albuterol, ipratropium, steroids Pleural effusion – Thoracentesis, pleurodesis, diuretics, catheter drainage Anemia – Transfusion Airway obstruction – Steroids, Clean out tracheostomy tube (if present)

9. Management of Shortness of Breath (2) After treating reversible causes (if any), then treat symptomatically ▫Pharmacologic  Opioids  Benzodiazepines  Anticholinergics ▫Non-pharmacologic

10. Opioids (1) Most effective for alleviating dyspnea ▫Exact mechanism unclear but thought to alter perception of dyspnea Common Routes: oral, parenteral Unlikely to hasten death or cause addiction if adhere to dosing guidelines

11. Opioids (2) Opioid naïve patients – Start with Morphine 10 -15mg po q1hr prn or morphine 5mg SC q 30min prn – Titrate to patient’s relief using standard opioid dosing guidelines Opioid non-naïve patients – Increase opioid dose by 25% – Titrate to patient’s relief using standard opioid dosing guidelines – Once chronic dyspnea controlled, provide extended release formulation and short acting formulation  Short acting formulation: 10% of total dose of same opioid in 24 hr period, offered at q1hr prn

12. Benzodiazepines (1) Can relieve dyspnea associated with anxiety Potential side effects, especially in elderly patients – Increased risk of confusion, falls Can use conjunction with opioids without causing respiratory depression when dosing guidelines followed

13. Benzodiazepines (2) Common routes: oral, sublingual, subcutaneous Example of dosing for dyspnea ▫Lorazepam 0.5 mg po / SL q 1 hr prn, titrate to patient’s relief ▫Once total dose in 24 hr period determined, then can give 1/3 of total dose q8hrs

14. Anticholinergics (1) Dries excessive secretions Effective for patients with weak cough reflex Examples: Atropine, Hyoscyamine (Levsin), Scopolamine, Glycopyrrolate (Robinul) Atropine, hyosyamine, scopolamine are equally effective in treatment of death rattle Effectiveness of medications better at lower initial rattle intensity

15. Anticholinergics (2) Atropine 1% ophthalmic drops – 1-2 drops SL every 1 hr prn Scopolamine – 1-3 transdermal patches q72hrs – 0.1-0.4 mg SC / IV q4hrs – 10­80mcg/hr by continuous IV or SC infusion Hyoscyamine 0.125 mg PO / SL q8hrs prn Glycopyrrolate – 0.4-1.0 mg daily by SC infusion – 0.2 mg SC / IV q4-6hrs PRN

16. Non-pharmacologic Interventions Educate patients, families/caregivers Repositioning – Turning patient on side, Elevate head of bed Suctioning – Gentle, anterior (not deep) suctioning Increase airflow – Fans, open windows, oxygen nasal cannula – Stimulates V2 branch of trigeminal nerve, which has central inhibitory effect on dyspnea Reduce room temperature without making patient too cold Behavioral techniques – Relaxation, Distraction

17. References & Suggested Readings EPEC (Education for Physicians on End-of-Life Care) : http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/module-3 Mercandante S, Villari P, Ferrera P. Refractory death rattle: deep aspiration facilitates the effects of antisecretory agents. J Pain Symptom Manage. 2011 Mar;41(3):637-9. Pantilat SZ and Isaac M. End-of-life care for the hospitalized patient. Med Clin North Am. 2008; 92(2): 349-70. Quaseem A et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Jan 15;148(2):141-6. Shinjo T, Okada M. Atropine eyedrops for death rattle in a terminal cancer patient. J Palliat Med. 2013 Feb;16(2):212-3. Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005177 Wildiers H et al. Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manage. 2009 Jul;38(1):124-33