Dyspnea: The top things you need to you know!

Dr. Megan Sellick & Dr. Lawrence Lee Edmonton Zone Program Faculty / Presenter Disclosure

• Faculty: Dr. Lawrence Lee

• Relationships with commercial interests: • Grants/Research Support: none • Speakers Bureau/Honoraria: none • Consulting Fees: none • Other: none Faculty / Presenter Disclosure

• Faculty: Dr. Megan Sellick

• Relationships with commercial interests: • Grants/Research Support: none • Speakers Bureau/Honoraria: none • Consulting Fees: none • Other: none Disclosure of Commercial Support

• This program has received financial support from: none • This program has received in-kind support from: none Objectives

By the end of our time together, you will be able to : • Recognize the subjective nature of dyspnea • Provide an initial management plan for dyspnea (non-pharmacological and pharmacological) • Briefly describe “palliative sedation” and describe the medication used Dyspnea

This man has metastatic lung cancer. Which of the following is the best measure of his dyspnea? A- respiratory rate B- use of accessory breathing muscles C- oxygen requirements D- oxygen saturations E- all of the above F- none of the above (patient’s report is best) Dyspnea

Definition: “feeling like one cannot breathe well enough”

American Thoracic Society: “a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.” Dyspnea

Overall Management Approach: Screen+Assess Identify Cause(s) Management Underlying Cause Symptoms Dyspnea

Screen for it

ESAS-R ECG of symptoms (here and now) Patient completes if possible Dyspnea/ is included

Dyspnea

Assessment: History Duration Onset Pattern Severity: Rest vs Exertion Triggers/Alleviating Factors Physical Examination

Dyspnea

Cause Investigations* Treatments* Identify + Pleural Effusion CXR Thoracentesis Manage Pneumonia CXR + Bloodwork Antibiotics Underlying Airway Imaging +/- Radiation Causes Obstruction Bronchoscopy Stenting/Steroids Lymphangitic Imaging: CXR/CT Steroids Carcinomatosis in accordance Anemia Bloodwork Blood Transfusion with Goals of COPD Bronchodilators, Steroids CHF Cardiac meds, Lasix Care* ALS BiPAP

Dyspnea

Symptomatic Management: Non-Pharmacological Fan Position: leaning forward, head up Avoid irritants Avoid exacerbating activities: mobilization, transfers, constipation Dyspnea

*Symptomatic Management: Pharmacological Oxygen Other Therapies Dyspnea

Symptomatic Management: Oxygen Useful for patients with hypoxia Use cautiously in patients with severe COPD (ie. CO2 retainers) Role in non-hypoxic patients less clear: some may still benefit Not clear whether it is the oxygen or the airflow that is helpful

Dyspnea

Symptomatic Management: Oxygen

When used for comfort, oxygen should be titrated to: A-Improved Oxygen Saturations (ie. O2>95%) B-Reduce Tachypnea (ie. Decrease respiratory rate) C-Decrease Work of Breathing D-All of the Above E-None of the above (titrate to decrease pt’s sensation of dyspnea)

Dyspnea

Symptomatic Management: Oxygen

When using O2 for comfort: No need to start if the patient is not complaining of dyspnea No need to continue measuring oxygen saturations at end of life Increase O2 around periods when patient has more dyspnea (ie. Could increase on exertion) Dyspnea

Symptomatic Management: Opioids

Which is the following is true regarding the use of opioids for dyspnea:

A- They block lung receptors to decrease the sensation of dyspnea B- Opioids diminish the sensation of being short of breath in the brain C- They reduce the respiratory rate and allow the patient to rest D- All of the above E- None of the above Dyspnea

Symptomatic Management: Opioids

Opioids are safe and effective for dyspnea When you “start low and go slow”, low risk of respiratory depression Similar to cancer pain, they can be provided ATC + PRN (ie. Morphine 2.5 mg PO q6h + q1h PRN for shortness of breath)

Diminish the sensation of dyspnea in the brain Nebulized opioids do not show significant benefit Dyspnea

Symptomatic Management: Anxiolytics

Anti-psychotics: helpful in managing dyspnea-related anxiety Haldol 1 mg PO/SC q12h-q4h ATC + q1h PRN Olanzapine 2.5-5 mg PO/Zydis q12h-q4h ATC + q1h PRN Nozinan 6.25-25 mg PO/SC q12h-q4h ATC + q1h PRN Dyspnea

Palliative Sedation • Process of inducing/maintaining deep and permanent sleep in order to relieve refractory symptoms in palliative pts who are close to death.

NOT

• Most common indications: , dyspnea • ?Risk of hastening death → No evidence! • : with short t1/2  easily titratable by SC infusion

Dyspnea

Palliative Sedation: Communicating with Family • Discuss proactively • Review understanding of illness/prognosis, goals of care • Sedation used only if symptoms refractory to all other measures • Patient will lose ability to communicate • Usually irreversible, with death from underlying illness occurring within days

Dyspnea

Take Home Messages • Dyspnea is what the patient self-reports • Screen for dyspnea • Determine and treat underlying causes when possible/appropriate • Use oxygen if it helps and titrate it to comfort, not oxygen saturations • Opioids are safe and effective for symptomatic management of dyspnea • Treat the anxiety component of dyspnea if it is present • Palliative sedation is available for intractable dyspnea