Dr Jonathan Martin Consultant in Palliative Medicine, St Joseph's Hospice

1. Palliative care approaches to symptom management in advanced respiratory disease: anxiety and breathlessness Dr Jonathan Martin Consultant in Palliative Medicine, St Joseph's Hospice Visiting Fellow, Harris Manchester College, University of Oxford 28th June 2013 Thanks to: Rebecca Jennings, St Joseph’s Hospice Dr Sara Booth, Cambridge Breathlessness Intervention Service

2. Balance of Management Approaches Non-pharmacological NonPh NonPh NonPh Non-pharmacological interventions are the most effective interventions currently available to palliate breathlessness in the mobile patient Booth et al 2011 Pharm Pharm Pharmacological Pharm Dyspnoea on exercise Dyspnoea at rest Terminal dyspnoea Wilcock, 1998

3. Focus of non-pharmacological management in advanced disease is not on decreasing breathlessness but helping individuals to feel more in control of their breathing and be as independent as possible

4. Anxiety

5. Anxiety and breathlessness are probably linked Hopelessness Depression Non-cancer Cancer Psychological Physical Total dyspnoea Fear Therapy Why me? Isolation Spiritual Social Fatigue Loss of job Faith questioned

6. CBT Thoughts I might die How will my wife cope? Physical Breathless Deconditioned Weight loss Feelings Fear/anxiety Behaviours Staying in the house Not talking to wife Not eating well

7. Vicious daisy I might die Breathless How will my wife cope? Weight loss Fear / anxiety Not talking to wife Not eating well Staying at home Breathless Deconditioned

8. Anxiety (and depression) Non-drug treatments: good evidence for effect: Pulmonary rehabilitation. (Withers 1999, Paz 2007, Coventry 2009) Cognitive behavioural therapy (CBT). (Coventry 2008, Heslop 2009, Kunik 2008, Livermore 2010) [N.B. No RCT evidence] Drug treatments: limited contradictory evidence in COPD: TCAs, SSRIs (Lacasse 2004, Yohannes 2001)

9. Breathlessness

10. Non-pharmacological and Pharmacological ApproachesBreathlessness Non-pharmacological Pharmacological • • Personalised goals of care • • Symptom orientated • Multidisciplinary Approach • Maximise quality of life for • patients and their families • Involve patient and family in • care planning • Maximise physical function • and emotional wellbeing • • Holistic • Maximise usual treatments as appropriate eg: inhalers • Manage exacerbations actively as appropriate • Consider oxygen for hypoxia* • Cautious use of opioids* and benzodiazepines* • Education: Physiology and Anatomy • Positioning • Hand Held Fan • Breathing Control Techniques • Functional Exercise • Walking Aid (4 wheel rollator) * Beware the hypercapnic patient

11. Non-pharmacological Management

13. Recovery breathing “Rescue breathing” A three-part behaviour for use in distressing dyspnoeic episodes Positioning: to allow use of accessory muscles Focus on breathing out Use of a fan Cambridge Breathlessness Intervention Service

14. Pharmacological Management Opioids Oxygen Benzodiazepines e.g. lorazepam Antidepressants (direct & indirect) Major tranquillizers e.g. levomepromazine Others: furosemide, heliox, cannabinoids Booth et al, Expert Review of Respiratory Medicine, 2009

15. Opioids Consistent evidence of benefit(Jennings 2002, Abernethy 2003, Currow 2011) Safety: Entrenched societal and professional misconceptions No evidence for respiratory depression from low dose oral opioids Some evidence for safety (Clemens 2008, Estfan 2007, Chan 2004) Some evidence against Benefit may be limited to a few sensitive subjects (Pauwels 2001/2005) Longer term adverse effects on endocrine system, falls and cognitive function (Freynhagen 2013) Need adequately powered safety studies Particular caution with: Type 2 respiratory failure – no data specifically relating to this group Transdermal fentanyl

16. Opioids in Breathlessness When should they be considered? Use them for breathlessness at rest Use them at the end of life Consider them in anyone with severe SOB Consider in moderate breathlessness after other interventions

17. Breathlessness: opioid palliation Two approaches: Currow and colleagues start on 10mgs modified release (Currow et al , 2010) Booth, Rocker and colleagues start on 1mg NR o.d. (Rocker et al, 2010)

18. Oxygen Individual assessment essential for use for dyspnoea Some evidence in non-malignant disease – related to desaturation on exercise and hypoxia at rest Very little evidence in cancer that better than air – use according to clinical benefit in an individual Use the fan first Booth et al, Respiratory Med, 2004 Cranston et al, Cochrane Systematic Reviews, 2008

19. Benzodiazepines, buspirone Benzodiazepines: Recent Cochrane review. (Simon 2010) Non-significant trend for benefit. Buspirone: Anxiolytic and respiratory stimulant with theoretical benefits (Smoller 1996) Two RCTs with conflicting results (Singh 1993, Argyropoulou 1993)

20. Could antidepressants work? Possibly by: By treating depression By treating anxiety/panic disorder By an effect on serotonin-mediated pathways in the brainstem Detecting and treating depression essential Brenes, Psychosom Med, 2003

21. Summary of the evidence Good evidence for: Pulmonary rehabilitation Breathing training Walking aids Exercise CBT Fan Opioids Limited evidence for: Benzodiazepines Oxygen Antidepressants