“Palliative Care in End Stage Lung Disease: Lessons from Experience”

1. “Palliative Care in End Stage Lung Disease: Lessons from Experience” Laura A. Hogan, RN, MS, NP, ACHPN Sr. Nurse Practitioner Palliative Care Service Associate Professor of Clinical Nursing University of Rochester School of Nursing

2. University of RochesterStrong Memorial Hospital

3. Sussman Palliative Care Unit

4. Outline Pathophysiology of End Stage Lung Disease Common Symptoms Treatment Strategies Common health care provider concerns

5. Patient X Meningitis 1967 Hodgkin’s Disease 1975 s/p splenectomy & XRT Shingles 1976 CABG x 2 1983 CHF & PVD CAD s/p angioplasty 1987, 1990, 1991 CABG x3 1996

6. Patient X Restrictive Lung disease / COPD 1999 Pleurectomy secondary to restrictive lung disease /sleep apnea 2000 MI 2002 Non Hodgkin’s Lymphoma 2003 s/p Chemo, freq. relapses Compression fractures spine A Fib s/p cardioversion & RFA 2005

7. Patient X Consulted Palliative Care 2005 Dyspnea Fatigue Pain related to compression fractures Anorexia Anxiety

8. Dyspnea • Subjective experience of breathing discomfort • Multidimensional in nature • Physical & affective components

9. Prevalence of Dyspnea • 50 % of cancer patients • 70% in advanced cancer • 90 % advanced lung cancer • 95% of patients with COPD • 61% of patients with CHF • 72% CHF pts had dyspnea > 6 mths • Neurological conditions: CVA, ALS, dementia

10. Dyspnea • Chronic sensation of breathlessness • Can also have acute exacerbations • Accompanied by sensations of -anxiety, panic, -sense of doom -feeling of impending death

11. Pathophysiology of dyspnea in cardiopulmonary disease • Increased ventilatory demand • Impaired mechanical responses • Or both

12. Increased ventilatory demand • Increased dead space • Reduced vascular bed; vascular obstruction • Pulmonary emboli • Toxicity from chemo/radiation • Hypoxemia • Metabolic acidosis • Non-metabolic sources • Psychological sources

13. Impaired mechanical responseRestrictive deficits due to: • Muscle weakness • Pleural or parenchymal disease • Airway obstruction • Asthma • COPD • Tumor obstruction

14. Assessment of Dyspnea • Subjective symptom • Onset • Duration • Intensity • Aggravating/ alleviating factors • Associated symptoms

15. Physical Assessment • Abnormal breath sounds • Distended neck vessels • Use of accessory muscles • Quality of respirations • Respiratory rate • Oxygen Saturation

16. Remember: the patient’s expression/subjective experience of dyspnea does not necessarily correlate with objective signs such as respiratory rate and/or oxygen saturation

17. Management of Dyspnea Oxygen Pharmacologic agents Non pharmacologic Therapies

18. Oxygen May help in hypoxic vs non hypoxic distress Families often ask about use of oxygen Again: oxygen saturation levels do not necessarily correlate to patient’s subjective reports of dyspnea/comfort

19. Pharmacologic Management

20. Management of DyspneaOpioids Early use may improved QOL by reducing physical and psychological distress, rather than hastening death.

21. Mechanism of Opioid Action in treatment of dyspnea • Opioids work at the level of the respiratory centers of the brain • CO2 levels build up in the blood as pts have increasing difficulty with breathing. • The function of the brain’s hypercapnic drive to maintain the excretion of CO2 • Opioids reduce the sensitivity of the brain to CO2 levels, thereby decreasing the sensation of breathlessness.

22. Opioids in dyspnea • No evidence that nebulized opioids work better than oral, SQ or IV • Stigma to using opioids: might hasten death, or cause intolerable adverse effects

23. Corticosteroids:Useful in patients with: Radiation pneumonitis Superior vena Cava syndrome Lymphangitic spread of cancer in lung parenchyma Restrictive lung disease

24. Anxiolytics • Studies are variable in outcomes • High anxiety component, may benefit from combination of opioid and anxiolytic medication

25. Odds and Ends CHF: Diuretics, Ace inhibitors, Digoxin, Bronchodilators Antibiotics

26. Non pharmacological management of dyspnea • Thoracentesis • Paracentesis • Pericardial drainage • Radiation Therapy • Palliative Bronchial Stenting

27. Non pharmacological management of dyspnea • Positioning • Pursed lip breathing • Open window and/or fan • Acupuncture/acupressure • Cognitive behavioral techniques

28. Secretioncontrol • Excessive secretions in throat and lungs • Inability of patient to clear airway • Results in movement of secretions in upper airway during inspiration and exhalation

29. Secretion Control at end of life • Scopolamine patch • Atropine gtts sublinguinal • Glyopyrrolate (Robinul)

30. Secretion Control at end of life • Change position • Re-evaluation hydration / fluids • Patient and family teaching

31. Cough • Natural protective mechanism to keep foreign materials from entering respiratory tract • Forceful expiration of air; conscious or reflexive • Acute or chronic • Productive or non productive

32. Cough • Prevalent in patients with: -advanced diseases CHF, COPD, asthma, HIV, malignancy • Interferes with sleep, eating/nutrition social interactions

33. Pathophysiology of cough • Stimulated by irritant receptors in larynx and pharynx, c-fiber stimulation in tracheobronchial tree • Inflammation, infections, mechanical or chemical irritants, GERD, medications

34. Management of cough • Identify underlying cause • Antitussive medicationscentrally acting: suppress cough center in medullaperipherally acting: alleviate irritation

35. Management of cough • Chest physiotherapy • Humidity • Suctioning • Oxygen • Smoking cessation • Avoid irritants

36. Health care providersconcerns re: End of life care “Opioid phobia” Rule of Double Effect: the intention is to alleviate the symptom causing the suffering, even though it may cause other effect such as somulence or hasten death.

37. Patient X Meningitis 1967 Hodgkin’s Disease 1975 s/p splenectomy & XRT Shingles 1976 CABG x 2 1983 CHF & PVD CAD s/p angioplasty 1987, 1990, 1991 CABG x3 1996

38. Patient X Restrictive Lung disease / COPD 1999 Pleurectomy secondary to restrictive lung disease /sleep apnea 2000 MI 2002 Non Hodgkin’s Lymphoma 2003 s/p Chemo, freq. relapses Compression fractures spine A Fib s/p cardioversion & RFA 2005

39. Patient X Consulted Palliative Care 2005 Dyspnea Fatigue Pain related to compression fractures Anorexia Anxiety

40. Patient XInitial outpatient treatment to address symptoms: PRN Morphine IR for pain & dyspnea Eventually transitioned to Morphine SR BID with short acting for breakthrough Ativan Q 4 hours prn Prednisone daily Albuterol nebulizer prn

41. Patient XCounseling • Depression & Anxiety • Energy conservation techniques • Non pharmacologic management • Health care proxy & advanced directives

42. Patient X Emergency Room with 1 week hx of: increased weakness frequent falls confusion increased Work of breathing Radiology: upon return to ED unresponsive, agonal respirations PEA arrest, and intubated

43. Patient X Prolonged mechanical ventilation pulmonary fibrosis with pneumonia Multiple complications -Afibrillation -Bilateral pleural effusions -Moderate aortic, mitral and tricuspid regurgitation -RV dysfunction/Fluid overload -adrenal insufficiency -C diff

44. Patient X Symptom Management Hydromorphone continuous infusion with PCA Ativan ATC and prn Positioning/Suctioning/Fan Discussions re: quality of life, end of life wishes DNR, continued trial to wean from ventilator

45. Patient X Unable to wean Sepsis / Pressors Pt had capacity and requested ventilator withdrawal Ventilator withdrawal protocol Died peacefully, surrounded by family, friends, care providers.

46. Summary Patients with End stage Pulmonary Disease have significant symptoms that greatly impact QOL. Patients and families can benefit from education regarding the illness and management, as well as discussions regarding advanced directives

47. Summary As health care providers, we have many tools to promote comfort, alleviate suffering, and support patients and families through our care. Effective Palliative Care treatment can improve symptoms, promote quality of life-from early on in the disease process through the illness trajectory.