Dyspnoea in Palliative Care

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Dyspnoea in Palliative Care
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Case study

• You are asked to see Mr Smith as he seems to be
  getting very short of breath
• What would you like to know?

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History

• Onset?
• Timing?
• Associated symptoms?
• Association with exercise?
• Association with social situations?
• Specific concerns?
• PMHx / DHx / SHx

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Examination

• Observe walking a set distance
• Airways
• Any stridor?
• Chest
• Any signs of LVF / infection / effusion?
• Peak flow

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Investigations

• Weigh up benefits / drawbacks
• FBC
• CXR / USS chest
• Oxygen saturations
• Spirometry

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Why is the patient breathless?

• Is it caused by the cancer?
• Is it a reversible cause?

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Is it caused by the cancer?

• If not, consider
• Antibiotics for chest infection
• Bronchodilators for COPD
• Diuretics for LVF
• Anticoagulation for PE
• Medications
• Psychological factors

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Can the cancer be modified?

• Chemotherapy
• Radiotherapy
• Surgery
• Hormone therapy
• Discuss with oncologist or appropriate specialist

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Can the effects of the cancer be modified?

• Effusion drainage
• Bronchial / SVC stents
• Corticosteroids for SVC obstruction, tracheal
  compression or lymphangitis carcinomatosis

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SVC obstruction

• Swelling / oedema face arms
• Prominent veins
• Dyspnoea sense of fullness in head, worse on
  leaning forwards
• In 50 cases first manifestation of disease
• Active treatment consider steroids, consider
  radiotherapy

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General principles of treating dyspnoea

• Most common causes fatigue, muscle weakness and
  anxiety
• Consider treatment in 3 main groups

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1. Breathlessness on exertion

• Prognosis may be months or years
• Consider underlying cause
• Pharmacological therapy of minimal benefit
• Basis of treatment non-pharmacological

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Perceptions

• Patient / carer anxieties e.g. fear of sudden
  death when breathless
• Explanation of symptoms
• Reassurance / challenging abnormal beliefs
• Help to come to term with losses

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Maximise feelings of control

• Relaxation techniques advice for control over
  breathing
• Written instructions?
• Electric fan
• Complementary therapies
• Acupuncture, aromatherapy, massage, homeopathy,
  spiritual healing

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Maximise functional ability

• Encourage exertion to point of dyspnoea
• MDT input
• Reduce feelings social isolation
• Consider Day Centre
• Respite

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2. Breathlessness at rest

• Prognosis weeks to months
• Consider opioids
• Start with low dose in opiate-naive e.g. 2.5mg
  oral morphine qds
• Consider oxygen
• Of proven benefit in those with PaO2 lt9kPa
• In less hypoxic patients ?placebo effect /
  cooling effect of air against face
• Consider benzodiazepines
• Work via anxiolytic effect

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3. Terminal breathlessness

• Prognosis last few days of life
• No patient should die with distressing
  breathlessness
• Need to explain aims of treatment and seriousness
  of situation
• Syringe driver combine morphine and sedative
  anxiolytic
• Can add in haloperidol or methotrimeprazine if
  becoming agitated or confused
• Consider retained secrettions add in hyoscine

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Summary

• History examination is there a specific
  cause?
• Treat specific cause if appropriate
• If more general causes, consider 3 treatment
  groups
• Reassurance and advice may be all that is
  required