Todd Gale; February 24,2009

1. Approaches to Palliative Dyspnea Management in COPD Todd Gale; February 24,2009

2. My Discussion • Issues affecting our management • What is dyspnea? • The evidence/lack of evidence • A simplified treatment algorithm • COPD Pearls

3. Topic #1 • Issues affecting our management • What is dyspnea? • The evidence/lack of evidence • A simplified treatment algorithm • COPD Pearls

4. Issues of Dyspnea Management • Differences between malignant and non-malignant illnesses • When do you begin Advance Care Planning? • When have clients reached the terminal stage - prognostication? • Lack of awareness of this global killers burden of symptoms

6. Two Streams

7. Prognostication

8. COPD Death Trajectory There is a gradual decline in health status punctuated by acute or crisis events which cause progressive deterioration and ultimately, but often unpredictably, death.

9. Global Killer • Teaching all patients at any stage of severity that COPD is a progressive, disabling and irreversible disease causing premature death in men and women; a global killer! • The main reason is to inform clients is so that they will seriously undertake advance care planning when it is appropriate to do so.

10. What is palliative care • As defined by Cairns, • "Palliative care is an area of health care that specifically addresses the needs of patients who have illnesses that are causing their health to deteriorate progressively, and often rapidly, towards death.” • Cairns W. The problem of definitions. Progress in Palliative Care. 2001;9:187-189 [editorial].

11. Topic #2 • Issues affecting our management • What is dyspnea? • The evidence/lack of evidence • A simplified treatment algorithm • COPD Pearls

12. 1. What is Dyspnea? • A clinical term for shortness of breath or uncomfortable breathing • A subjective experience: Ask! • Associated with panic and anxiety; panic may present as dyspnea, and dyspnea may cause panic. • Worsens with activities “exertional & incidental dyspnea”

13. “…A term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity • Result of multiple interactions: • Physiological • psychological • social • environmental factors • May induce secondary physiological and behavioral responses…“

14. Pathophysiology Dyspnea = imbalance between the perceived need to breathe and the perceived ability to breathe.

15. At the Bedside • Research has demonstrated we should likely distinguish between the sensation of and reaction to dyspnea • The sensory component describes the intensity or degree of dyspnea [sensation] • The affective component describes the unpleasantness, or aversion the patient has to their dyspnea [reaction] • Using simple,1 dimensional scales such as the Borg Dyspnea Scale to score dyspnea may be controversial

16. Sensations • "My breathing requires effort“** COPD ** • "I feel out of breath" • "I can not get enough air in" • “Chest tightness" • “Increased effort"

17. Reactions • Negative emotions (acute versus chronic) • Depression • Catastrophic thinking • Panic

18. Assess to Intervene

19. Clinical Assessment • Dyspnea history - circumstances, frequency, alleviating/exacerbating factors • Physical exam (cardiopulmonary problems + muscles and fitness) • May use a scoring system such as the Borg Scale • Tests: CBC, O2 sat, CXR, V/Q scan as appropriate

20. Topic #3 • Issues affecting our management • What is dyspnea? • The evidence/lack of evidence • A simplified treatment algorithm • COPD Pearls

21. 2 Golden Rules: (1)Treat the underlying cause of dyspnea as appropriate both pharmacologically and non- pharmacologically (2) Treat the distress associated with the dyspnea

22. Evidence Bullets #1 • Bronchodilators per CTS guidelines • Opioids give significant relief in all causes of dyspnea in advanced disease given PO/SC/IM/IV - Principles same as for pain management Lack of awareness of opioid use for palliative dyspnea • Nebulized opioids do not show consistent significant benefit but may be useful in intermittent dyspnea • Although benzodiazepines are commonly used in the treatment of dyspnea, results of clinical trials are varied - no evidence other than for anxiety/panic

23. Evidence Bullets #2 • Limited evidence supporting phenothiazines as an effective treatment of dyspnea/anxiety – “Big Gun” Analgesic, anti-emetic and sedative properties. Adjuvant for pain, nausea, delirium, hiccups, dyspnea • Corticosteroids are effective for carcinomatouslymphangitis, superior vena cava syndrome, tracheal obstruction and bronchospasm (asthma and COPD) • Diuretics may be useful for dyspnea related to CHF & edema associated with superior vena cava syndrome

24. Evidence Bullets #3 • Anxiety disorders are higher in HF and COPD patients compared with the normal population • There are no data to suggest that the proper use of opioids for management of breathlessness is associated with a reduction in a patient's life expectancy • Oxygen therapy is controversial (SpO2 <= 88%) is probably helpful Air flow vs oxygen flow?

25. The Problems with O2 • The potent symbol of medical care in the dyspneic patient [on TV, in ER and in care areas] • Diverts attention away from the more effective interventions • May contribute to mucosal dehydration • May prolong death inappropriately

26. We’re half-way done!

27. Oxygen and Dyspnea Dyspnea Quantified? • Do not use oxygen saturation as a measure of dyspnea–often there is poor correlation • In terminal stages, stop measuring oxygen saturation ! • The patient’s assessment of their dyspnea is the most reliable one

28. Evidence Bullets #4 There is some limited support for the following: • Acupuncture and acupressure • Breathing retraining • Muscle relaxation • Coping strategies • Function enhancing activities such as walking * • Fans or cold air

29. Fans • Dyspneic patients commonly describe subjective relief when seated near an open window or in front of a fan • Studies suggest that a flow of air or application of cold solutions to the face, nasal mucosa, or pharynx may alter ventilation. • Cold air may reduce breathlessness in COPD, probably by dropping rate • A fan often provides as much relief as nasal oxygen and does not impede bedside companionship

30. Trigeminal Nerve

31. Topic #4 • Issues affecting our management • What is dyspnea? • The evidence/lack of evidence • A simplified treatment algorithm • COPD Pearls

32. Know Your 1..2..3s • Try to find the cause(s) + contributing factors (most likely cardiopulmonary disease +/- affective factors + / - muscle weakness) 2. Treat and optimize using established therapies (drugs, non-pharmacologic, medical, and surgical as appropriate) All the interventions used for COPD/HF in those who aren’t dying may also work in palliative care. i.e. rate control for afib, digitalis, treat infections etc 3. Treat in the moment using your A..B..C..s

33. Know Your ABC’s A – Anxiety (also stand for Ativan) B – Bronchodilators (COPD) C – Contin : Short and long-acting opioids D – Decadron / Diuretics (for COPD/CHF respectively) E – Empathy and Explanation F – Fan or fresh air

34. The ABCs are a distillation of the dyspnea mgt algorithm in this guide

35. Last Section - can skip slides

36. Topic #5 (if time) • Issues affecting our management • What is dyspnea? • The evidence/lack of evidence • A simplified treatment algorithm • COPD Pearls

37. Morphine • Hydromorphone • Oxycodone • Fentanyl • Methadone

38. Open airways + remove mucus if possible • Adequate hydration to maintain reasonable mucus viscosity but not push into HF • Cough and chest physio techniques, mucolytics, nebulized saline • Bronchodilators – long and short-acting; nebulizers • Decadron - corticosteroids • Use your team - PT, RT, OT dietitian etc • At terminal phase – Atropine for death rattle

39. Dynamic Air Trapping

40. Hyperinflation on CXR

41. Slowing breathing rate Assuming 1 second for inspiration… • At 10 bpm-> leaves 5 seconds for exhalation (60 sec / 10 bpm) • At 20 bpm -> leaves 2 secs • At 30 bpm -> leaves 1 secs • The faster clients breathe, the more air they trap! Anxiety-affective interventions bronchodilators, +/-pursed-lip breathing,positioning-postural therapies….

42. How does postural therapy work?

43. Factoids • Qualitative studies suggest that communication about end-of-life care and concerns about death are important to patients but are not always discussed • People with COPD are more likely to die in a hospital, not hospice or home • Many patients with heart failure may not be aware that the disease commonly leads to death. The course of their illness is unpredictable.

44. Things To Say and Do • “As you think about what lies ahead, what is most important to you?” • “What is the most difficult part of this journey for you”? • Emphasize a desire to respect patient’s wishes and follow through • Avoid promises you can’t keep • So what made you so famous? • Are you sure you have the PRT number/call bell etc.

45. Problem Solving • Help the patient and family identify the barriers that are preventing them from successfully reaching their goals • Work with the patients/families to develop strategies to overcome these obstacles: • What are somewaysyoumightbe able to feellessanxious • How do you think you can overcome this barrier? • Skills plus confidence

46. Teaching Problem Solving 1. Define the problem 2. Think of solutions and make a list 3. Try to find one that works. If it doesn’t work, try another 4. If none of your proposed solutions works after a reasonable effort, then consult an expert or try later Things change. We learn from the past Stay solution focused!

47. Cannabinoids – no good studies

48. Key Messages • Most traditional COPD therapies + opioids & adjuvants + fan…A..B..C..s • When to treat is important as deciding how to treat • There is no good predictor of when a nonmalignant client is going to die, however, these clients deserve appropriate palliative care at end of life

49. Key Messages • Crisis states in health status representopportunities to provide palliative care in terminal patients as we do not know if any given crisis will end in death • Maximize management of their underlying disease processes as appropriate

50. Falling asleep? We’re almost done!