fans and rectangles - ministry of health · other strategies nebulised furosemide1,2,3 nebulised...
TRANSCRIPT
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Fans and RectanglesDR TRACY SMITH AND MS MARY ROBERTS
WESTMEAD HOSPITAL
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Pathophysiology of breathlessness
Booth et al, 2014
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Air hunger/unsatisfied inspiration
Occurs with increased respiratory drive
Occurs when demand exceeds capacity
Right anterior insular cortex lights up when air hunger is induced in healthy subjects
Parshall et al. AJRCCM 2011
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TightnessCommonly experienced during bronchoconstriction
Mechanical ventilation relieves effort ◦ But not tightness
Bronchodilators relieve tightness faster than effort
Blocking pulmonary afferents can diminish tightness
Parshall et al. AJRCCM 2011
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Work/effortPhysiology is less well understood than tightness
◦ Involves respiratory motor area
◦Respiratory muscle afferents
Occurs in exercise
◦Not unpleasant until capacity reached
◦Discomfort occurs earlier in cardiopulmonary disease
In respiratory muscle weakness, the perception of respiratory effort is magnified
Parshall et al. AJRCCM 2011
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Assessment of breathlessnessSeverity
Unpleasantness
Descriptions – tightness; work/effort; air hunger
Functional impact/ quality of life
Affective distress associated with breathlessness
◦ Association with past episodes
◦ Beliefs about breathlessness
◦ Prediction about possible consequences of what is perceived
Need to also assess associated symptoms e.g. cough, anxiety, painParshall et al. AJRCCM 2011
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Measurement toolsBorg scales
Visual analog scales
Numerical rating scales
Multi-item scales eg CRQ, MDP, Dysp 12
Ratings of disability or activity limitation, e.g. MRC scale
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Acknowledge breathlessnessPatients need to hear that you ‘get it’
Is their breathlessness proportional to pathophysiology?
◦ If no, what are you missing?
◦Cardiac co-morbidity
◦Musculoskeletal co-morbidity
◦Deconditioning
◦Psychological co-morbidity
◦Medication adherence
◦What do they mean by breathlessness?
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Principles of breathlessness management
Initiate & optimise opioid
therapy
Initiate & optimise non-phamacologic therapiesPulmonary rehab, energy conservation, hand held fan,
breathing techniques & positioning
Initiate & optimise disease specific therapiesSABA, SAMA, LABA, LAMA
Magnitude of breathlessness
Regular follow up and reassessmentEnd of life care
Exclude contributing factors
Modified from Marciniuk et al, Canadian Respiratory Journal, 2011
Inc
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Non-Pharmacological ManagementM S M A R Y R O B E R T S
M A R Y . R O B E R T S @ H E A L T H . N S W . G O V . A U
R E S P I R A T O R Y C L I N I C A L N U R S E C O N S U L T A N T
W E S T M E A D H O S P I T A L
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Non-pharmacological Mx of breathlessness2 Cochrane reviews ◦Rueda et al, 2011- Lung /thoracic ca◦Bausewein et al, 2008 - COPD, IPF, lung ca, CCF, MND
5 systematic reviews◦Kamal et al, 2012 - COPD◦Booth et al, 2011 - Malignant & non malignant diseases
◦ Thomas et al, 2011 - Advanced ca◦ Simon & Bausewein, 2009 - COPD◦ Zhao & Yates, 2008 - Lung ca
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Non Pharmacological strategies
FansPulmonary
rehab
Breathing retraining
Relaxation
Medication technique
Energy conservation
Walking framesNutritional
supplementation
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Inefficient breathingIncreased work ofbreathing
Thoughts about dyingMisconceptionsAttention to the sensationMemories, past experiences
Increased respiratory rateUse of accessory musclesDynamic hyperinflation Anxiety, distress
Feelings of panic
De-conditioning of limbs,chest wall and accessory muscles
Reduced activityTendency to self-isolateMore help from others
Breathing Thinking
Causes of breathlessness multifaceted
Treatment needs to be multifaceted
Booth et al, 2014
Functioning
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Breathing
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Check medication adherence -BreathingEven the nicest patients don’t always do what they are advised!!
Sometimes they don’t know what they don’t know!
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Breathing techniques & positioning –BreathingLean forward position (over railing, walking stick, table)
Pulse lipped breathing
Paced breathing
Recovery breathing
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Breathing techniques & positioningReported in all reviews to be of benefit however difficult to rate evidence due to differing definitions of techniques◦ Breathing control ◦ Promotes efficient breathing pattern deters hyperventilation (BTS/ACPRC, 2009)
◦ Pursed lip breathing ◦ Creates PEEP to maintain patency of unstable airways (BTS/ACPRC, 2009)
◦ Recovery breathing◦ Focuses on ‘breathing out’ to deter dynamic hyperinflation (Booth et al, 2011)
◦ Paced breathing (blow as you go)◦ Helps maintain control of breathing and deter dynamic hyperinflation (BTS/ACPRC, 2009)
◦ Lean forward position◦ Enhances respiratory muscle function by loading the diaphragm
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Breathing around the rectangleLong slow breath out
Long slow breath out
Sh
ort b
rea
th in
Sh
ort
bre
ath
in
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Hand Held Fan - BreathingCool air blowing across the face and nasal mucosa reduces the sensation of breathlessness
◦ Stimulation of 2nd and 3rd branches of trigeminal nerve
◦ Simple
◦Portable
◦Cheap
◦Gives the patients a sense of control
◦Gives carer something to do
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Hand held fan - Evidence3 studies involving 116 participants (Schwartzstein et al, 1987; Simon et al, 1991; Galbraith et al, 2010)
More recently, a secondary study was carried out reviewing qualitative data from 3 RCTs, 133 patients, Luckett et al, 2017)
Emerging evidence
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Thinking
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Dispel myths - Thinking
Breathlessness
is dangerous
I need to
STOP doing
everything
If only I
had
oxygen….
I’m going
to stop
breathing
I’m never
going to
catch my
breath
I’m going
to have a
heart
attack
I’m going
to die
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Psychological interventions -ThinkingRelaxation
◦ Progressive muscle relaxation and guided imagery
◦ 4 studies involving 238 participants
Counseling and support
◦ Nurse clinics and home visits
◦ 6 studies involving 1127 participants
Psychotherapy
◦ Emerging evidence that Cognitive Behavioural Therapy and Mindfulness may have a role in the management of breathlessness (often included in multimodality interventions)
◦ RCT at Westmead Hospital
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Functioning
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Physical activity - FunctioningSitting is the new smoking!
Promote physical activity◦ Give a pedometer◦ Give simple hints on increasing step counts
Pulmonary rehabilitation
Suggest walking aids◦ 4 wheeled walkers◦ Walking stick◦ Shopping trolley◦ Bunnings trolley
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Exercise & physical activity - FunctioningExercise, physical activity and pulmonary rehabilitation (Cochrane review - McCarthy, 2015)
◦ Improves the efficiency of muscle function
◦ Stops / reverses deconditioning
◦ Desensitises the patient to breathlessness
◦ 65 RCTs involving 3822 participants
◦ Strong evidence (essential component of COPD management)
Energy conservation◦ Maintains independence, encourages pacing however lack of robust
evidence
◦ Most studies focusing on the use of walking aids decreasing work of breathing (Criafulli et al, 2007; Gupta et al, 2006; Probst et al, 2004)
◦ 7 studies involving 202 participants
◦ Strong evidence
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Plan for breathlessnessWhen breathless,
remember the 3 Ps
Pause(stop what you are doing)
Position(get into a position that relieves your breathlessness, lean
forward, drop your shoulders)
Purse lips(smell the roses, flicker the candle)
And use your fan!Booth et al, 2014
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Plan for breathlessness
The 3 FsI have had this feeling before – I know it
will go away soon!
1. I am going to lean forward
2. I am going to use my fan (and Ventolin)
3. I am going to focus on gently breathing
out
Booth et al, 2014
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Pharmacological ManagementDR TRACY SMITH, STAFF SPECIALIST
RESPIRATORY AND SLEEP MEDICINE
WESTMEAD HOSPITAL
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Off-label prescribingNone of the following drugs have breathlessness as an approved indication anywhere in the world
Efforts currently to change this for opioids ONLY
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Opioids for dyspnoeaExtensive evidence base
No evidence of clinically significant worsening in respiratory failure with opioids
Morphine >> other opioids
Usual effective dose 10-30mg morphine/ day(Currow2011 JPSM)
Watch for constipation and other side effects
Most effective for dyspnoea at rest
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Systemic opioids for dyspnoeaRecent systematic review in COPD (Ekstrom 2015 AJRCCM)
◦ 8 studies of oral opioids; 118 participants. Longest trial 6 weeks.
◦ No serious adverse events
◦ Reduced breathlessness
Recent systematic review in adv. cancer (Vargas-Bermúdez, 2015 J Pain PC pharm)
◦ No serious adverse events episodes of respiratory failure (or worsening of blood gas parameters)
◦ 14 trials (different routes and opioids)
◦ Improved dyspnoea
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Benzodiazepines for dyspnoeaConflicted evidence base
Variety of agents tried
Cochrane review (2000 and 2016)
◦ Ineffective
◦High rate of side effects
Despite this, I know they are commonly prescribed
Please don’t!
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Other strategies
Nebulised furosemide1,2,3
Nebulised opioids1,4
Antidepressants 5
1. Boyden J Aerosol med 2014; 2. Vahedi 2013 Respiratory Care (AECOPD) 3. Jensen D
2008 Thorax 4. Ekstrom AJRCCM 2015; 5. Marciniuk Can Resp J 2011
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Oxygen for dyspnoea?
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Forest plot summarising randomised trials of the symptomatic effect
of oxygen on breathlessness in people with COPD who do not
qualify for long-term oxygen therapy; all trials.
Hope E Uronis et al. Thorax 2015;70:492-494Copyright © BMJ Publishing Group Ltd & British Thoracic Society. All rights reserved.
Two large studies completed
after this review found oxygen
did not reduce breathlessness
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A few words about other things…
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Symptoms in “advanced” COPD
Janssen, 2008 Pall Med 22;8
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Other symptoms
Pain
Anxiety/ Depression
Cachexia
Mouth
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Will I
choke to
death?
Is the Dr
holding
out on
me?
Am I
dying?
What will
death be
like?
How long
have I
got?
Who’ll look
after the dog/
cat/ wife/ vege
patch/
Kingswood?
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Shall we dance?
Patients wait for us to raise advance care planning
We may wait for patients to raise advance care planning
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Putting it all together – Part 1Acknowledge the symptom!
Include the carer
Treat reversible factors/ Identify co-morbidities
Complete an accurate assessment◦ Physical
◦ Emotional
◦ Social and Spiritual aspects
◦ What has / hasn’t worked in the past
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Putting it all together – Part 2
Multicomponent non-pharm treatment first◦ Fans
◦ Rectangles
◦ Purse lip breathing
◦ Pulmonary Rehab
◦ Exploit your multidisciplinary team (nurses, physio, OT)
Opioids are good!
Beware the benzos!