Palliative Management of Dyspnea Katherine Clark Clinical Associate Professor Calvary Mater Newcastle Hunter New England

1. Palliative Management of Dyspnea Katherine Clark Clinical Associate Professor Calvary Mater Newcastle Hunter New England Health

2. Contents • Dyspnea defined • Epidemiology of dyspnea in palliative care? • The experience of dyspnea • Anxiety and dyspnea • Causes of dyspnea • Palliation of dyspnea

3. Dyspnea defined • Dyspnea is an uncomfortable sensation or awareness of breathing. • A complex experience of mind and body that is likely to progress with disease severity. • Significant correlation with impaired QoL and poor survival.

4. Prevalence of dyspnea in cancer • Dyspnea is a common and distressing symptom experienced by patients with advanced cancer, occurring in 19–51% of patients. • Higher incidences are reported towards the end of life with dyspnea defined as a poor prognostic indicator.

5. Prevalence of dyspnea? • The prevalence of dyspnea varies with the primary tumor site; • It occurs in 46% of patients with advanced lung cancer, but in only 7% of those with advanced gastric cancer. • Of those with the symptom, 60–80% rate it as clinically important.

6. Dyspnea in non-malignant disease • For patients with COPD, intractable breathlessness develops late in the course of the disease, gradually increasing in severity over a period of years in the majority of people. • There is a long pre-clinical phase when patients may not have any respiratory symptoms at all, although lung damage exists.

7. Dyspnea in non-malignant disease • There is then a protracted period of gradual decline punctuated by severe exacerbations, which may be life-threatening and require inpatient management. • Breathlessness tends to be associated predictably with exertion, until the end of life when it may be present at rest.

8. The personal experience of dyspnea • Many studies have confirmed that breathlessness is a particularly distressing symptom for patients and their families. • A qualitative study that investigated the experience of patients with cancer or COPD and carers, found high levels of anxiety, particularly at night.

9. Personal experience’s of dyspnea • This anxiety was reported in both relatives and patients. • Patients reported thinking "Will I get much shorter of breath? Can I manage it? Is something terrible going to happen? Will I suffocate to death?" • Carers report a sense of helplessness and fear.

10. Anxiety and dyspnea • There is uncertainty about the contribution of anxiety in breathlessness; • The incidence of anxiety in patients with the diagnosis of any cancer greatly exceeds that in the normal population. • Neuroimaging and psychophysical studies are now helping to assess the contribution of distress and anxiety to the genesis of breathlessness;

11. Pathophysiology of dyspnea • The neurophysiology of dyspnea is complex and poorly understood, but it is clear that there is some similarity with the genesis of intractable pain. • Both pain and dyspnea are somatopsychic experiences arising from multiple receptors integrated at various levels in the central nervous system and therefore susceptible to modulation by both physiological and psychological influences.

12. Pathophysiology of dyspnea

13. Some causes of dyspnea in palliative care • Direct • Tumour mass, pleural and pericardial effusion, phrenic nerve paralysis, vena caval obstruction, carcinomatosis, airway obstruction. • Indirect • Anaemia, radiotherapy, infection, cachexia, pulmonary embolus. • Co-morbidity • Airways, cardiac and renal diseases, depression, anxiety.

14. Causes of dyspnea • Dyspnea in advanced cancer is usually multifactorial: • Although reversible causes should be sought, a significant proportion of the underlying causes are irreversible. • The burden/benefit of the intervention for the patient needs to be evaluated by them. • If extra visits to hospital are required, will the relief provided exceed the exhaustion incurred?

15. Palliating Dyspnea

16. Non-pharmacological approaches • Good evidence to support behavioural and nursing interventions to manage dyspnoea. • Emotional and cognitive aspects which respond well to: • Relaxation, • Breathing exercises, • Psychological support, • Positioning, • Moving air over the face.

17. Pharmacological approaches • Opioids, • Oxygen, • Antidepressants, • Anxiolytics, • (Corticosteroids), • (Bronchodilators).

18. Opioids • Opioids are the most effective pharmacological agents for the relief of dyspnoea. • High level evidence supports: • Low dose of oral morphine for opioid naïve (10-20mg/24hours), • Increase dose by 25% patients taking morphine for other reasons. • No role yet confirmed for nebulised morphine.

19. Oxygen • Regardless of whether people are hypoxic or non-hypoxic, O2 has little role to play in the management of the symptom of dyspnea; • In hypoxic people, O2 confers a survival benefit. • In non-hypoxic people, recent RCT supports the null hypothesis that very few people will gain any benefit from supplemental O2.

20. Antidepressants and Anxiolytics • There is some evidence which supports the use of antidepressants in the palliation of dyspnea; • But less evidence for the use of benzodiazepines; • However, best clinical guidelines continue to recommend agents such as lorazepam or clonazepam be readily available.

21. An evidence based algorithm to palliate dyspnea?

22. Increasing shortness of breath in a person with life-limiting illness and estimated prognosis of less then 3 months Reversible causes of dyspnoea sought? Sa02 >90% on room air Sa02 <90% on room air • Multidisciplinary referrals: • Physio • Breathing control exercises • Relaxation exercises • Walking frame • Chest physio • OT • Physical aids • Activity pacing • Social work • Social support/finances • Meditation/relaxation • Pastoral Care • Medical Officer • Low dose morphine • Screen for depression and • anxiety • Nursing • Advice re positioning • Moving air Request for O2 Ongoing dyspnoea? Referral to palliative care Trial of O2

23. Questions?