Objectives

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Objectives
By the end of this module you will

• Have a better understanding of how physical and
  mental factors affect symptomatology
• Be able to use this understanding in the
  treatment of patients suffering from
  nausea/vomiting and dyspnea
• Incorporate skills and knowledge gained into your
  practice and teaching
•  

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Non-Pain Symptom Management

• James Hallenbeck, MD
• Assistant Professor of Medicine,
• Stanford School of Medicine
• Director, Palliative Care Services, VA Palo Alto
  HCS

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Definition of a Symptom
A physical or mental phenomenon, circumstance or
change of condition arising from accompanying a
disorder and constituting evidence for it
specifically a subjective indicator perceptible
to the patient and as opposed to an objective one
(compare with sign).
The New Shorter Oxford English Dictionary, cited
by The Oxford Textbook of Palliative Medicine
Symptoms as clues, not experiences, not suffering
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From the Patients Perspective- a Symptom Is What
Is Bothersome
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Disease As a Clue for the Symptom
Disease process
Symptom
Questions to ask How does the disease give rise
to the symptom through local, central
effects? What are emotional, cognitive and
spiritual components of the patients illness?
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What Symptoms?
Constipation Diarrhea Peripheral Edema Nausea,
vomiting Pruritus/itching Dyspnea Anxiety
Anorexia Sleep disorders Cough Akathisia
Dysphagia Anhedonia Death rattle/secretions
Drooling Urinary Incontinence Rectal Incontinence
Hiccups Flatulence Muscle spasms Confusion Memory
Loss Visual problems Hearing loss Dysgeusia Colic
Sexual dysfunction Polyuria Polydipsia Dizziness
Dyspepsia Xerostomia Dry skin Dysarthria
Dysphoria Dysuria Failure to thrive Fatigue Fear
Fever Crying Hallucinations Halitosis Impotence
Irritability Taste alterations Odor Mucositis
Panic attacks Photosensitivity Restlessness
Stomatitis Urinary frequency
N53, Oxford Textbook of Palliative Medicine
Index, 1998.
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Nausea and Vomiting
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So WHY do we have this disgusting problem?
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Consider our Hungry Ancestors
What protects this guy from eating something
poisonous?
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(No Transcript)
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Pearl for the Day
Rodents do not vomit!
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Receptor Affinity Common Antiemetics
Drug Dopamine 2 Musc. Chol.
Histamine Scopolamine gt10,000 .08
gt10,000 Promethazine 240
21 2.9 Prochlorperazine 15
2100 100 Chlorpromazine
25 130
28 Metoclopramide 270 gt10,000
1,000 Haloperidol 4.2
gt10,000 1,600
The lower the number,the stronger this agent is
at blocking this receptor
Adapted from Perourka, Snyder
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Causes of Nausea and Vomiting

• Vestibular
• Obstruction (Opioids)
• Mind (Dysmotility)
• Infection (irritation)
• Toxins (taste and other senses)

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VVestibular Apparatus

• Complaint of nausea with head movement
• Mediated by acetylcholine and histamine receptors
• DOC(s)
• Promethazine (supp)
• Scopolomine (patch, injection)
• Cyclizine (oral, injection)

Most anticholinergic, antihistminic drugs will
help!
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OObstruction

• Most common cause constipation
• May be caused by external or internal obstruction
• In advanced malignant bowel obstruction external
  compression most common
• May be mediated through both mechano and
  chemoreceptors
• Doc(s)
• True bowel obstruction
• Controversy as to best drugs
• Constipation- anti-constipation meds

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MMind

• Mediates emotional, cognitive aspects of nausea-
  anxiety, memory, meaning
• Can be very powerful
• Manipulating taste and other senses often helpful
• Doc(s)
• Lorazapam (poor solo agent)
• Appetite stimulants
• Megestrol, steroids, Cannibinoids

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MDysMotility

• Multiple causes
• Opioids
• Anticholinergic drugs
• Stomach/bowel compression, infiltration
• Upper intestinal dysmotility-very common, under
  appreciated
• Doc(s) Prokinetics
• Metoclopramide (upper only)
• Cisapride (upper and lower gut)
• Senna (lower only)

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IInfection/Irritation

• Mediated through chemoreceptors- acetylcholine,
  histamine, serotonin
• Gut and adjacent organ inflammation can trigger
• DOC(s) Anticholinergic/antihistaminic agents,
  such as promethazine

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TToxins

• Most important- drugs we give
• Various mechanisms of inducing nausea
• Local irritant
• NSAIDs
• Changing blood levels (via CTZ)
• opioids, ? SSRIs
• Toxic blood levels
• digoxin
• Doc(s) depends on mechanism of action

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Opioid Related Nausea
Via two mechanisms

• Gut effect Dysmotility of upper and lower gut
• Doc(s) prokinetics
• Effect on CTZ
• Mediated through D2 receptor
• Related to changing blood levels
• Improves with steady state blood level
• Doc(s) Haloperidol (po, inj.), Prochlorperizine
  (supp, po)

No good evidence, rationale for using promethazine
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5HT3 Antagonists

• Useful for certain forms of chemotherapy related
  nausea
• May have other special uses
• In CTZ related nausea, where dopamine blockade
  contraindicated
• ? Other refractory CTZ related causes
• ? In certain GI cases
• Very expensive currently

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Dyspnea
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Dyspnea

• Common- 70 of dying patients in last six weeks
  of life
• Traditional care for dyspnea largely palliative,
  as not curative
• Focuses on lung physiology
• Less attention to central processes
• Pathophysiology of dyspnea poorly understood

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Treating Dyspnea
In addition to what you already know

• Local
• Low-dose opioids
• Fan, cool breeze
• Central
• Low-dose opioids
• Benzodiazepines for anxiety
• Address emotional, cognitive, spiritual factors

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SUMMARY

• Symptoms matter in their own right as expressions
  of patient suffering
• Symptoms have their own pathophysiology,
• As is true for treatment of disease, treatment of
  symptoms is tailored to this underlying physiology