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

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Please use the Q&A function to submit questions.

Housekeeping

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• 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.

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

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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

Learning objectives

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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.

Outline

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• Part 1: Background information

• Part 2: Unique aspects of caring for patients with COVID-19 disease

• Part 3: Management of dyspnea (breathlessness)

Part 1:

Background information

COVID-19

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• 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

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

Part 2:

Unique aspects of

caring for patients with

COVID-19 disease

Fluid management

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• 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

Use of steroids: Specific disease states

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• 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

Aerosol generating procedures: Treating Hypoxemia

16ht tps : / /emergencymedic inecases.com/faq-items/covid-update-apri l -5th-2020/

Fraser Health policy RE: CPAP and BiPAP

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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.

Part 3:

Management of

dyspnea

(breathlessness)

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

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

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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

Dyspnea

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“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

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

Palliative sedation

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“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.

Emergency kits

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“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

Opioids and dyspnea

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• 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.

Opioids and dyspnea

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• 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.

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

Dyspnea in COVID-19

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See next slide for next treatment arm and more information

Dyspnea in COVID-19

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See next slide for next treatment arm and more information

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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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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.

Useful resources

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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)

Conclusions

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• 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.

Wrap up

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• 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

THANK YOU