E L N E C Geriatric Curriculum End-of-Life Nursing Education Consortium “Respiratory Issues at End-of-Life” Module 3: Jerry Boltz, FNP Nonpain Symptoms at the January 27, 2012 End of Life Part I E L N E C Geriatric Curriculum Common Respiratory Issues Dyspnea: Definition Near the End of Life • Distressing shortness of breath, air • Dyspnea hunger, or difficulty breathing • • Associated with anxiety, depression, Cough and decreased quality of life • Changes in respiratory rate & rhythm • Can be acute or chronic • Increased Respiratory secretions • Sometimes occurs or worsens only with activity E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Dyspnea: A subjective Feeling • Dyspnea refers to the sensation of difficult or uncomfortable breathing. It is a subjective experience perceived and reported by an affected patient. E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum 1 Dyspnea Dyspnea Major Pulmonary Causes • Major Cardiac causes Tumor Infiltration Pleural Effusion Aspiration COPD – Congestive Heart Failure Pneumonia Bronchospasm – Pulmonary edema Pulmonary Embolism Pulmonary Fibrosis – Superior Vena Cava Syndrome Pulmonary Hypertension Thick Secretions caused by infectious diseases or – Pericardial Effusion dehydration… – Cardiac disease - arrhythmias Thick secretions caused by Us? Later E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Dyspnea Dyspnea • Cancer Related Causes • Major Neuromuscular Causes – – Metastatic disease from any primary site Amyotrophic Lateral Sclerosis (ALS) – – Obstruction of Bronchus Muscular dystrophy – – Malignant Ascites Myasthenia Gravis – – Anemia (Anemia of chronic disease) Cerebrovascular Disease – – Superior Vena cava Syndrome Trauma as a result of physical injury – Pneumonectomy E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Dyspnea Assessment of Dyspnea Other causes • Subjective report • Generalized weakness Clinical assessment – Anorexia Cachexia Physical exam – Hyperventilation Anxiety Diagnostic tests Uncontrolled Pain Hyperthyroid Derby et al., 2010; Dudgeon, 2010 Obesity Spiritual issues E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum 2 Dyspnea Assessment Subjective Report Subjective • Impact on Function & Quality of Life • Dyspnea Assessment Is like a Pain – Ability to sleep Assessment. The subjective report of the – Ability to perform ADL’s (get dressed, patient is the only reliable indicator of this talk, eat, sleep, etc.) symptom. • The patient may report breathlessness • The patient’s respiratory rate & in spite of good oxygenation status or Oxygenation status Do Not always correlate limited disease state. with the symptom of breathlessness. E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Clinical Assessment of Dyspnea Clinical Assessment of Dyspnea • Determine history of: • Physical Examination – Acute or chronic dyspnea – Elevated Jugular Pressure – Smoking – Lung Sounds – Heart Disease or Lung Disease – Respiratory Rate, Depth – Concurrent Medical Conditions – Use of Accessory Muscles – Peripheral Edema E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Non-Pharmacologic Treatments Other Non-Pharmacologic for Dyspnea Treatments for Dyspnea –Education, Education, Education • Transfusion of PRBC’s –Pursed lip breathing • Thoracentesis –Energy conservation • Paracentesis –Fans, elevating head of the bed • Radiation therapy to shrink tumor –Prayer, Music, • –Calm environment Stent tube placement to open an Dudgeon, 2010 occluded airway E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum 3 Oxygen Therapy for Dyspnea Pharmacologic Treatment of Dyspnea • Effectiveness has not been established by research – Opioids • Worth trying especially if oxygen – Bronchodilators saturation is low – Diuretics • Trial O 2 2-6 L per nasal prongs; – Other reassess 2 hours after each change in Clemens & Klaschik, 2007; Derby et al., 2010; liter flow Dudgeon, 2010; Jacobs, 2003 Derby et al., 2010; Dudgeon, 2010; Gallagher & Roberts, 2004; Pan, 2003 E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Opioids for Dyspnea How do Opioids work for Dyspnea? • Can be administered by oral, subcutaneous, sublingual, or intravenous routes Possible Mechanisms • Studies show that Opioids have a small, but positive effect on reducing dyspnea – They interrupt the neural pathways that • Significant respiratory depression is give rise to the sensation of dyspnea uncommon – They have a sedative & anxiolytic effect • Nebulized opioids are no more effective to relieve the discomfort of dyspnea than opioids given by other routes – Vasodilatation – Reduce Preload E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum What Opioids do not do Is there a role for Anxiolytics in Dyspnea? • Opioids do not relax the respiratory muscles, allowing the patient to • Sedation and reduction of anxiety are breathe easier. “side effects” of Opioids. Like all side • This explanation could be easily be effects, (except for constipation), These misconstrued by patients and families. side effects may disappear over time. • If an anxiety component is identified, anxiolytics may be helpful. E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum 4 Bronchodilators Diuretics • Albuterol (relaxes bronchial smooth • Reduce pre-load on the heart muscle by action on the Beta-2 • May reduce the sensation of dyspnea receptors). that may be caused by congestive heart • Atrovent (Anti-cholinergic agent that failure. causes bronchodilation) • Given by SVN is more effective than if given by metered dose inhalers. E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Other Pharmacologic treatments Cough • Chlorpromazine (Thorazine) – There is • Cough is: some evidence that low doses of • A Common Symptom in Chlorpromazine (25mg q 4 hours) may advanced disease relieve the symptoms of dyspnea. • Cough causes: • Antibiotics – Pneumonia • Pain, Fatigue, Insomnia • Steroids – Reduce inflammation Dudgeon, 2010 E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Some Causes of Cough Assess the Type of Cough • Post Nasal Drip Asthma • Acute Cough – Often caused by: •Bronchitis Obstruction • Allergens, Environmental irritants, Post- •Pleural effusion P.E. Nasal drip, GERD, Lung lesions, TB, •Pneumothorax Allergens Pneumonia, Foreign Body • Chronic Cough: Allergens, Chronic •Cigarette Smoking diseases (COPD, Bronchitis, Airway •Environmental irritants Inflammation) •Medications (ACE Inhibitors) • Nocturnal: GERD, Asthma, CHF E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum – 5 Treatment Decisions Pharmacologic Interventions for Cough • Patient’s condition – Where are they on the trajectory of their illness. • Suppressants/Anesthetics • Does the patient have a strong or a • Expectorants weak cough? • Antibiotics • Suppress by night – Expectorate by • day Steroids • • Do we really want to dry it up? Anticholinergics Lingerfelt et al., 2007 E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Cough Suppressants Cough Suppressants • Opiates • Non-Opioid – Morphine Sulfate – Dextromethorphan – Structurally related – Codeine – Metabolized to Morphine to Codeine, Depresses Medullary cough – Hydrocodone & Homatropine center. – – Opioids in general - Bind to opiate Benzonatate (Tessalon Perles) receptors & suppress cough in the Suppresses cough by topical anesthetic medullary center action on the respiratory stretch receptors E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Non-Pharmacologic Changes in Respiratory Interventions for Cough Rate and Rhythm • Education, Education, Education • Chest PT • Autonomic Nervous System - • Humidifier • “Normal” Respiratory rate 12 – 20 • Positioning breaths per minute. • The term “Normal” changes depending on where the patient is at on their “Journey” E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum 6 “They are Breathing So Fast!! Some Things to Think About When the Patient’s Respiratory Rate is Fast • Kussmaul Breathing – Deep Rapid and “labored” respirations – Acidosis – Blowing off Carbon Dioxide. Body is trying to Do we need to slow down the patient’s respiratory maintain acid / base balance… rate? How much Morphine (Opioid) does it take to slow down a person’s respiratory rate? Who are we treating when we try to slow down the respiratory rate? E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Other “End of Life” “Death Rattle” Breathing Patterns • “Death Rattle” – Now that is an • Apnea uncomfortable couple of words! • • Cheyne Stokes Breathing “Increased Respiratory Secretions” • Guppy Breathing – Why is the terminology problematic? – Who are treating? E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Non-Pharmacologic “Treatments” Pharmacologic Treatments • Education, Education, Education • Scopolamine Patch – Crosses the blood – Tell family members what to expect brain barrier - “Mad as a Hatter”. – Ask them not to feed their loved ones • Glycopyrrolate unless they are wide awake, and able to • Atropine drops swallow. • Hyoscyamine • Patient Positioning E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum 7 Just a Thought Key Nursing Roles • Asking for Refills on these medications • # 1 Patient Advocacy should be a rare event. • “We all believe in patient determined end of life care…As long as they agree with our plan” Charles von Gunten, M.D. • E L N E C Geriatric Curriculum E L N E C Geriatric Curriculum Key Nursing Roles • Patient/Family Teaching • Assessment • Pharmacologic treatments • Non-pharmacologic treatments • Presence E L N E C Geriatric Curriculum 8.