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WELCOME
Managing Dyspnea in Patients with COVID-19
Host:
José Pereira, MBChB, CCFP(PC), MSc, FCFP
Presenters:
Doris Barwich, MD, CCFP(PC)
Shalini Nayar, MD, FRCPC
The webinar will begin soon (please note your microphone is muted).
Please use the Q&A function to submit questions.
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Housekeeping
2
• Your microphones are muted.
• Use the Q&A function at the bottom of your screen to submit questions.
Please do not use the chat function for questions.
• This session is being recorded and will be emailed to webinar registrants
tomorrow.
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Presenters
Host
Dr. José Pereira MBChB, CFPC(PC), MSc,
FCFP
Professor and Director, Division of Palliative
Care, Department of Family Medicine,
McMaster University, Hamilton, Canada
Scientific Officer, Pallium Canada
Panelists
Dr. Doris Barwich MD, CCFP(PC)
Medical Director Fraser Health Palliative
Care Network & BC Centre for Palliative
Care
Dr. Shalini Nayar MD, FRCPC
Palliative Care & Respirology Fraser Health
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Declaration of conflicts
4
Pallium Canada• Non-profit
• Funded mainly by Health Canada over the years in the form of a contribution program
• Recently received funding from CMA, which it is using to address COVID response
(e.g. making LEAP modules available online and webinars)
• Generates funds to support operations and R&D from course registration fees and
sales of the Pallium Palliative Pocketbook
Presenters• Dr. Jose Pereira – Paid by Pallium Canada as Scientific Officer
• Dr. Doris Barwich
• Dr. Shalini Nayar
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Learning objectives
5
Upon completing this webinar, you should be able to:• Describe the prevalence of dyspnea (breathlessness) in patients with COVID-19
disease, and its frequency relative to other symptoms;
• Describe some pathophysiological processes of the virus that relate to
breathlessness, including ARDS;
• Describe the role of some treatments like fluid therapy and steroids relative to COVID-
19 disease;
• Apply a protocol to manage dyspnea in these patients, highlighting the central role of
opioids; and,
• Compare usual palliative care approaches versus COVID-specific palliative care
approaches.
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Outline
6
• Part 1: Background information
• Part 2: Unique aspects of caring for patients with COVID-19 disease
• Part 3: Management of dyspnea (breathlessness)
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Part 1:
Background information
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COVID-19
8
• Incubation period 1 – 14 days
• Highly contagious – symptoms do NOT need to be present
• Transmissiono Between people who are in close contact with one another (within about 6 feet).
o Respiratory droplets produced when infected person coughs, sneezes or talks.
o Droplets can land in the mouths or noses of people who are nearby or possibly be inhaled into
the lungs.
o Aerosol-generating procedures are a caution
• COVID-19 may have unique ability to target lower airways
• From Wuhan data, infection appears most commonly after 5.2 days
• Onset of symptoms to death ranged from 6-41 days (median 14 days)o Older the patient, shorter the time
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Presentation, symptoms, and course of COVID-19
• Common presentations:o Fever, dry cough, fatigue, shortness of
breath
o Viral pneumonia
• If progresseso Initially mild can progress over a week
(+dyspnea)
o Cases of rapid progression have been
noted, going within hours from
mild/moderate symptoms to severe
respiratory problems
o Severe Complications: ARDS,
arrhythmias, acute cardiac injury, shock
• Recovery: ~2 wks if mild, 3-6 wks if
severe
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Pathophysiology COVID-19
Four broad categories
• Subclinicalo Asymptomatic; infectious
• Upper respiratory tracto Dry cough, headache, sinus symptoms
• Systemic flu-like symptomso Fever, myalgia, cough
• Lower respiratory tract/diffuseo Viral pneumonia
o Wuhan data: ~6% severe illness
o ARDS
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ARDS
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Part 2:
Unique aspects of
caring for patients with
COVID-19 disease
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Fluid management
14
• Aggressive fluid resuscitation should generally be avoided
o COVID-19 patients are seemingly sensitive to fluid overload
o Use of vasopressors is appropriate
o Patients that are volume deplete should get small volume bolus of IVF
o Excessive fluids to clear the lactate in patients who appear euvolemic should be
avoided
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Use of steroids: Specific disease states
15
• Corticosteroid useo Mixed results, but overall not convincing, RCT or fully peer reviewed evidence for tx
COVID alone
• COPDo Regular treatments, including steroids if needed for reactive airways
• Asthmao Treat with regular asthma tx, including steroids for reactive airways
• Septic shock/concomitant infectiono Follow antimicrobial guidelines
o May opt to use steroids for the indication of septic shock
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Aerosol generating procedures: Treating Hypoxemia
16ht tps : / /emergencymedic inecases.com/faq-items/covid-update-apri l -5th-2020/
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Fraser Health policy RE: CPAP and BiPAP
17
1. Any patient suspected or confirmed COVID-19 should not receive NIV
or CPAP without careful consideration.o Early endotracheal intubation may be advised with respiratory failure.
o Full PPE for staff.
2. For other in-patients who are on BiPAP or CPAP at home: Consult
Respirology.o Patients on nocturnal CPAP for obstructive sleep apnea should be trialed off CPAP.
Clinical judgement in the case of patients at high risk of desaturation (e.g. post operative cases) may
lead to a decision to order the CPAP be continued.
o Patients on nocturnal BiPAP for obesity hypoventilation syndrome are at increased
risk of death compared to patients with OSA therefore continue with BiPAP.
o Caregivers should wear goggles and N95 masks when caring for patients on CPAP &
BiPAP.
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Part 3:
Management of
dyspnea
(breathlessness)
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BC Centre for Palliative Care & Fraser Health Guidelines 2020
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Dyspnea management guidelines
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• Appropriate Goals of Care conversations essential to clarify treatment
goals and realistic options for care.
o E.g. Adaptation of the Serious Illness Conversation Guide: www.fraserhealth.ca/-
/media/Project/FraserHealth/FraserHealth/Health-Professionals/Clinical-
resources/Advance-Care-Planning---Serious-Illness/Serious-Illness_Mini-
Reference_COVID19-Guide.pdf
o HPCO resources: www.speakupontario.ca
o Vital Talk resources: www.vitaltalk.org/guides/covid-19-communication-skills
o Speak Up resources: www.advancecareplanning.ca/covid19
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BC Centre for Palliative Care & Fraser Health Guidelines 2020
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BC Centre for Palliative Care & Fraser Health Guidelines 2020
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Dyspnea management guidelines: Fraser Health process
23
1. General guidelines: Fraser Health; McMaster etc.
2. Pre-printed orders (PPOs): o Crisis order set to complement Actively Dying PPO in Acute Care and Long-Term
Care
o Palliative Sedation Guideline
o Med kits and discharge checklist for COVID positive patients going home
3. Developing a “COVID code” and Emergency med kit for COVID units
4. Facilitating improved access to Palliative Care Physician expertise
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Dyspnea
24
“Usual” Palliative CarePalliative care for COVID-19 +ve
patients
Fans:
Fans are sometimes recommended Fans are not to be used as they
aerosolize the virus
High flow oxygen:
E.g. ≥ 60% O2, or as per
CAEP > 6 lpm
In some cases, high flow oxygen may
be required, titrated to clinical effect.
High flow O2 aerosolizes virus; use
PPE
Non-invasive ventilation:
BiPAP or CPAP is used in select cases;
e.g. end-stage ALS or COPD; OSA
Use PPE when NIV used
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Dyspnea
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“Usual” Palliative Care Palliative care for COVID-19 +ve patient
Airway secretion
management
Secretions are usually from the upper
airway.
In severe cases, scopolamine or
glycopyrrolate PRN
In severe COVID disease, ARDS and
pulmonary edema is more common. Need
furosemide and ARDS approaches for that
Opioids
Opioids are useful in the management of
severe dyspnea.
They are safe and effective
(see LEAP online module on Dyspnea for
guidelines on doses).
Opioids are very useful in the management
of severe dyspnea.
They are safe and effective
In COVID, they may need to be initiated
sooner for their physiological and symptom-
relief benefits
Morphine remains a useful first-line opioid.
Hydromorphone is preferred if a patient has moderate to severe renal impairment.
Fentanyl is preferred over morphine or hydromorphone in severe renal impairment
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Palliative sedation
26
“Usual” Palliative Care Palliative care for COVID-19 +ve patient
First-line options
• Methotrimeprazine or midazolam
continuous infusion first choice.
• Phenobarbital is second or third
line, added to midazolam if
midazolam alone is ineffective.
Potential drug shortages.
• If shortages of midazolam occur,
methotrimeprazine becomes a first choice.
• If infusion pumps are not available, may have
to use intermittent injections of midazolam (or
methotrimeprazine).
• If methotrimeprazine or midazolam are not
available, may use lorazepam or phenobarbital
as first choice.
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Emergency kits
27
“Usual” Palliative Care Palliative care for COVID-19 +ve patient
• Emergency kits in the home often promoted for EOL care at
home.
• Generic kits with medications such as opioid,
haloperidol, methotrimeprazine, scopolamine.
• But once dispensed, the medications cannot be reused
for anyone else and have to be disposed of, resulting in
wastage.
• Some recommend instead a just-in-time, tailored-to-specific-
patient approach;
• Requires a system in place with 24/7 access to
pharmacy services (difficult in rural regions or small
communities).
In the pandemic, there is a great risk of significant
wastage of precious medications such as
midazolam if generic kits are prescribed and
cannot be reused
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Opioids and dyspnea
28
• Multiple studies have shown that opioids are effective for treating dyspnea,
and are recommended even in patients with advanced lung disease.
• Opioids treat dyspnea through many mechanismso Reducing respiratory drive
o Reducing anxiety
o Altering central responses to exertion
o Cough suppression
Mahler and O’Donnell, CHEST 2015; 147(1):232 -241.Hayen et al. Neuroimage 2017;150:383-94.
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Opioids and dyspnea
29
• Symptom-titrated opioids do not hasten death
• In severe COPD, opioids… o Reduce dynamic hyperinflation and work of breathing
o Allow the patient to take slower, deeper breaths
o Have been used in large studies with no reports of clinically-important respiratory
depression
• In cancer, ALS and severe COPD, opioids… o Improve dyspnea and reduce respiratory rate without increasing CO2
Breathing is necessary for life. Shortness of breath is not.
Abdallah et al. Eur Resp J 2017;50:1701235.Currow et al. JPSM 2011;42:388-99.
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McMaster Dyspnea in COVID-19 Protocol
Adapted from BC Centre for Palliative Care and Fraser Health Protocol
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Dyspnea in COVID-19
31See next slide for each of these treatment arms
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Dyspnea in COVID-19
32
See next slide for next treatment arm and more information
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Dyspnea in COVID-19
33
See next slide for next treatment arm and more information
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34
Airway
Secretions
UPPER AIRWAY SECRETIONS
If mild, no drugs needed. No suctioning or meds.
If moderate to severe. No suctioning. Start pharmacological treatment:
Scopolamine: 0.4-0.6mg subcut q 4hrs PRN (more sedating than
glycopyrrolate, which may be useful if patient is also agitated)
OR
Glycopyrrolate: 0.4mg subcut q 4hrs PRN
Timely management is important.
Select according to availability of medications.
LOWER AIRWAY SECRETIONSLikely ARDS/pulmonary edema. Administer furosemide 20mg - 40 subcut/IV
q2hrs PRN and monitor
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35
Cough
If on opioid already, titrate (see Dyspnea protocol)
If not on opioid:
o If moderate, select one of the following:
Dextromethorphan 10mg-20mg PO q 4-6 hrs PRN
Hydrocodone 5mg q 4-6hrs PRN
Normethadone antitussive (Cophylac) 15 drops po QHS or BID
(Not covered by some provincial plans)
o If severe:
Start opioid
Morphine 2.5 - 5 mg PO q4hrs (SC dose is ½ of oral dose)
Or
Hydromorphone 0.5 - 1 mg PO Q4H (SC dose is ½ of oral dose)
For any opioid, reduce the dose by half and consider q6hrly
dosing if patient is frail, elderly or has advanced comorbid illness.
If moderate to severe renal impairment, use hydromorphone
instead of morphine.
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Useful resources
36
Several useful resources are available to help you manage symptoms:• BC Centre for Palliative Care bc-cpc.ca/cpc/all-resources/hcp-resources
• Fraser Health; Island Healtho “Actively Dying Protocol”, with new CRISIS orders for COVID-19 patients. Actively
Dying Protocol Part 1, Actively Dying Protocol Part 2, FH Actively Dying Protocol
COVID-19 Addendum 3-4-20.
o Island Health: PPOs for dyspnea management; Palliative Sedation
• Arya et al. Pandemic Palliative Care: Beyond Ventilators and Saving Lives. CMAJ
31 March 2020 https://www.cmaj.ca/content/early/2020/03/31/cmaj.200465
• Canadian Association of Emergency Physicians Protocol: End-of-life care in the
Emergency Department for the patient imminently dying of a highly transmissible
acute respiratory infection (such as COVID-19)
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Conclusions
37
• Breathlessness is a common presentation in moderate to severe COVID-
19 disease.
• It can take a fulminant course in some cases.
• Opioids offer a very useful and safe symptom management option.
• Become acquainted with protocols in your region, or where these are
absent, use protocols such as the ones from Fraser Health and McMaster.
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Wrap up
38
• We would appreciate your feedback. You will receive a link to evaluate
the webinar.
• This session is being recorded and will be emailed to webinar registrants
tomorrow or available here: www.pallium.ca/pallium-canadas-covid-19-
response-resources
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THANK YOU