The Basics of Symptom Management: Understanding, Assessment and Principles

1. The Basics of Symptom Management: Understanding, Assessment and Principles Dr. Leah Steinberg

2. Learning Objectives: • List several good on-line resources; • Review the model of pain and symptom management; • Describe basic management of • Constipation, Delirium, Dyspnea • Appreciate the principles of symptom management.

4. Cancer Care Ontario Guidelines • www.cancercare.on.ca • Palliative care tools • Symptom management tools

5. Objective 2: Review from yesterday • Assess – rectal exam • Treat underlying causes • Treat symptoms • pharmacological and non-pharmacological • Monitor • Educate

6. Objective 3: Constipation • Huge burden to patients • Uncomfortable, AND • Makes them stop using opioids

7. Constipation: Definition • Infrequent, hard stools, difficult to pass • Feeling of incomplete evacuation • Not just infrequency

8. Multiple causes: we know these! • Immobility • Disease • Neurologic abnormalities • Metabolic abnormalities (hypercalcemia) • Decreased intake • Medications (OPIOIDS, anticholinergics) • Weakness • Physical surroundings

9. Again, to manage – follow the steps • Assess – rectal exam • Treat underlying causes • Treat symptoms • pharmacological and non-pharmacological • Monitor • Educate

10. Management: Many products • Know the classes of laxatives to use • Stimulant (senna) • Lubricant (mineral oil) • Osmotic (lactulose) • Opioid antagonist (methylnaltraxone) • Usually don’t recommend: • Fibreor docusate • Create a protocol for your practice

11. Set up regular dosing of laxatives: • Sennosidesor bisacodyl: 2–4 tablets at bedtime to begin plus • Lactulose 30 mL at bedtime or • PEG 3350 powder 17 g once or twice daily • Monitor daily. • If no bowel movement by day 2: • Increase sennosides by 2 tablets (can be given in two doses) and increase lactulose or PEG 3350 to 30 mL twice daily • If no bowel movement by day 3: • Perform rectal examination • If stool in rectum: • Use phosphate enema or bisacodyl suppository • If no stool in rectum and no contraindication: • Give oil enema followed by saline or tap water enema to clear • Increase regular laxatives • If problems continue: • Do flat-plate radiograph of abdomen • Switch stimulant laxative • Use regular enemas

12. Set up regular dosing of laxatives: • Sennosidesor bisacodyl: 2–4 tablets at bedtime to begin plus • Lactulose 30 mL at bedtime or • PEG 3350 powder 17 g once or twice daily • Monitor daily. • If no bowel movement by day 2: • Increase sennosides by 2 tablets (can be given in two doses) and increase lactulose or PEG 3350 to 30 mL twice daily • If no bowel movement by day 3: • Perform rectal examination • If stool in rectum: • Use phosphate enema or bisacodyl suppository • If no stool in rectum and no contraindication: • Give oil enema followed by saline or tap water enema to clear • Increase regular laxatives • If problems continue: • Do flat-plate radiograph of abdomen – Rule out Bowel obstruction • Switch stimulant laxative • Use regular enemas

13. Constipation Pearls! • Prevent!!! • If not, treat aggressively • Myth: he’s not eating… • Regular laxatives if regular opioids • Easier to decrease laxatives

14. Dyspnea: • Frightening symptom • Often linked with anxiety, fear • Need lots of education and support for patient with severe dyspnea

15. Prevalence of dyspnea • 50% - 70% of all cancer patients • 60% of patients with NSCLC • Worsens as disease progresses • Prognostic indicator • When patients are dysnpeic at rest, prognosis is often in the range of weeks

16. Etiology • Multifactorial: • Dudgeon, Lertzman Dyspnea in the advanced cancer patient, JPSM 1998 Oct;16(4) • Reviewed 100 pts to determine etiology of dyspnea; • Average number of potential causes = 5

17. Etiology: many many causes From the Tumour itself; • Compression • Obstruction • Carcinomatosis Other Card/RespDx • COPD • CHF Indirectly from tumour: • Muscle weakness • Anemia • Thromboembolic disease • Effusions: pleural, pericardial, peritoneal • Infection

18. Again, to manage – follow the steps • Assess: to diagnose • Tachypnea is not dyspnea • Reverse when you can • Treat the symptoms • Monitor • Educate

19. Treat underlying cause if possible: • Antibiotics • Drain effusion: +/- Tenchkoff catheter • Radiotherapy • Stents • Transfusions

20. Non-pharmacological • Education ++ • Energy Conservation • Breathing techniques • Muscle strengthening • Cool air/fan • Positioning • Relaxation exercises

21. Pharmacological • Opioids are mainstay • Methyltrimeprazine • Anxiolytics • Steroids • Inhalers/diuretics • Secretion management at EOL • Trial of oxygen

22. What about respiration compromise? • 11 studies looked for evidence of respiratory compromise – no clinically relevant compromise found • Again, related to opioid naive

23. Opioid dosages • Opioid-naïve patients, mild dyspnea • codeine 30 mg q 4 hr • morphine 2.5 mg q 4 hr • Opioid-naïve patients, moderate - severe • morphine 2.5 - 5.0 mg q 4 hr (or equivalent) • titrate 25 - 50% every 24 hrs • in COPD, start low and go slower

24. Opioid dosages • Opioid tolerant patients • titrate baseline dose by 25 - 50 %

25. Anxiolytics: if anxiety a component • Lorazepam 1 – 2 mg sl q 8 hrsprn • Clonazpam0.25 - 2.0 mg q 12 hr • Midazolam 0.5 - 1.0 mg s/c or iv q 20 minsprn

26. Steroids • Dexamethasone 4 – 16 mg daily • Can give in one dose in the morning, rather than qid

27. Dyspnea summary: • Tachypnea is not dyspnea • Reverse when you can • Opioids are mainstay of medical therapy • Use non-pharmacological measures when you can

28. Delirium • Palliative care emergency! • A delirious patient cannot express their symptoms; • Distressing for patient and family • Remember: • Hyperactive • Hypoactive

29. Patient’s remember their delirium 50% of patients remember the experience – It is frightening for them

30. To manage – follow the steps • Assess: to diagnose • Don’t forget to do physical exam • Reverse when you can • Treat the symptoms • Monitor • Educate

31. Reverse when that is the goal • Hydration • Opioid rotation • Bisphosponates • Stop medications if possible

32. Non-pharmacologic measures: • Quiet room • Decrease stimulation • Light • Visible reminders of time and date • Verbal orientation of patient

33. But most importantly: TREAT IT • Don’t leave patient untreated while attempting to reverse: • First line: • Haloperidol 0.5 mg bid plus breakthrough • Risperidone0.5 mg bid plus breakthrough • Olanzipine 2.5 mg bid plus breakthrough • If severely agitated, we use Methyltrimeprazine

34. Delirium summary: • Prevent it when possible • PCUs may use daily screening tool (CAM) • Reverse when possible • Treat always • Counsel patient after, if needed

35. SUMMARY • Many symptoms • Don’t be overwhelmed • Use the model • Use the resources out there!

36. Opioids treat symptom of dyspnea • Cochrane review • Mechanism unclear • Systemic naloxone increases dyspnea • Opioid receptors in tracheobronchial tree and alveolar walls • But, no clear role for nebulized though