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8/2/2019 Power Point Report Hospice1

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Palliative medicine andnon-malignant, end-stagerespiratory disease

MADONNA R. BACORRO. M.D.SHPM fellow 2012UP-PGH


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HIV-related respiratory diseases

post-tuberculous

bronchiectasis


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USA and Europe

COPD

cystic fibrosis

restrictive chest wall diseases (e.g. scoliosis,thoracoplasty)

neuro-muscular disorders (e.g. muscular

dystrophies, old poliomyelitis)


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pathophysiological causes of dyspnoeaPathophysiological mechanism Typical causes

Increased respiratory drive

Hypoxaemia Many respiratory and cardiac diseases

Metabolic acidosis Renal failure, cardiac failure

Intrapulmonary receptor stimulation Infiltrative disease, pulmonary oedema

Mechanical impedence

Airflow obstruction Asthma, COPD, tumour, stenosis

Mechanical chest wall restriction Kyphoscoliosis, obesity, pregnancy

Reduced compliance (stiff lungs) Interstitial fibrosis, lymphangitiscarcinomatosis


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pathophysiological causes of dyspnoeaPathophysiological mechanism Typical causes

Respiratory muscle failure

Muscle disease/paralysis Poliomyelitis, muscular dystrophy

Mechanical disadvantage Hyperinflation, pneumothorax, pleuraleffusion

Intrapulmonary receptor stimulation Hyperinflation, pneumothorax, pleuraleffusionInfiltrative disease, pulmonaryoedemaWasted ventilation

Large vessel obstruction Pulmonary emboli, pulmonary vasculitis

Capillary damage Interstitial lung disease, emphysema

Psychological

Anxiety, depression Hyperventilation syndrome


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Assessment of dyspnoea

good history and examination

Diagnostic testing

measurement of the severity of dyspnoea aidsdecision making and may indicate the success

of a particular therapy


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Table 7 Modified Borg Dyspnoea Scale(72)

Intensity of sensation Rating

Nothing at all 0Very, very slight 0.5

Very slight 1

Slight 2

Moderate 3Somewhat severe 4

Severe 5

6

Very severe 7

8

Very, very severe 9

Maximal 10

The visual analogue scale

uses a 10 cm line, with nobreathlessness andmaximum breathlessnessat the two ends.

Verbally reported

intensity: reproducibleratings of dyspnoeaintensity can be made onlinear or numerical scales.

Simple verbal numerical

scales rate dyspnoea from0 to 10.


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Clinical implications of

cough

preventing sleep interrupting communication causing social embarrassment

Others:

haemodynamic changes (e.g.arrhythmias, hypotension)

ruptured vessels (e.g. eyes, nasal,bronchial)

urinary incontinence hernia neurological problems (e.g. syncope,

headache)

lung barotrauma (e.g. pneumothorax), rib fractures

Excessivecough


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Treatment of the causeProtussive therapy:

makes cough more

effective

Adequate hydration,steam inhalations, andnebulized saline.

Physiotherapy

Pharyngeal suctioning

Mini-tracheostomy

Pharmacological

Antitussive therapy:prevents or eliminates

cough

Opioids

Oral local anaesthetics Nebulized local

anaesthetics

Other antitussive agents

Antimuscarinics


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Oral local anaesthetics

benzonate (200 mg 8 hourly) is related toprocaine and inhibits stretch receptors.

Levodroproizine modulates C-fibre activity

and suppresses cough as well asdihydrocodeine but with less sedation.

Benzocaine and lignocaine lozenges may be

useful for laryngeal, pharyngeal, or trachealirritation but the risk of aspiration must beconsidered.


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Nebulized local anaesthetics

lignocaine (5 mL of 2 per cent solution 6hourly) and bupivacaine (5 mL 0.25 per centsolution 6 hourly) have been used for

intractable cough but they can causebronchospasm requiring bronchodilators.

Efficacy has not been established


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Other antitussive agents

theophyllines and 2-agonists Sodium cromoglycate

Steroids

antihistamine-decongestant (e.g.pseudoephedrine, dexbrompheniramine) andexpectorant (e.g. guaifenesin) preparations


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Antimuscarinic

Antimuscarinic bronchodilators

Hyoscine hydrobromide (0.4 mg sc prn) orglycopyrronium bromide (0.4 mg im prn) may be

essential for the control of the distressing chestrattle due to loose secretions in the terminalphase of chronic lung disease.

Both cause sedation and dysphoria and

occasionally, in the elderly, central anticholinergicsyndrome with excitement, ataxia, andhallucinations.


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chest radiography


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Chest pain

Musculoskeletal

disorders

Pleuropulmonary

disorders

Visceral and other

disorders


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Relatives should be warned and drugsimmediately available.

Simple measures like the use of green towels

and bed linen to mask the evidence of blood,nursing the patient with the affected chestside down, and the calming influence of acontrolled situation are invaluable. Palliative

treatment should aim to reduce awarenessand fear. Both opioid and anxiolytic therapymay be required.

Management of massive haemoptysis


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Respiratory failure(COPD)

(a) pharmacological therapies: to reduceairways obstruction, correct hypoxaemia, andrelieve dyspnoea

(b) non-pharmacological therapies: toimprove respiratory musclefunction/ventilation and enhance gas

exchange.


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Palliative oxygen therapy In patients with refractory hypoxaemia despite

high flow rate oxygen, a nasal reservoir (e.g.oximizer), which stores oxygen during

expiration and delivers a larger bolus at theonset of inspiration, may be useful.

A blood gas should be measured or end tidalCO2 checked to confirm hypercapnea and theoxygen flow rate reduced whilst monitoringCO2 and mental function.

Drug treatment for the relief of


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Drug treatment for the relief ofdyspnoea

Anxiolytic agents and promethazine

Antidepressant drugs

Oral opioids Nebulized opioids

Mucolytics

Other drugs


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Non-pharmacological therapies

Vaccinations: Influenza and pneumococcal

General nursing

Nutrition

Physiotherapy

Controlled breathing techniques

Non-invasive mechanical ventilation

Lung reduction surgery and lungtransplantation


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Interstitial/fibrotic lung disease

Immunosuppressive therapy includingsteroids, cyclophosphamide, azothioprine, andpenicillamine

It is rare for CO2 retention to occur and it issafe to use high inspired concentrations ofoxygen.


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Neuromuscular, restrictive, and chestwall disease

ventilatory support iffar advanced andhypercapnic respiratory failure is developingor already established

Advances in respiratory care and theavailability of specialist respiratory facilitieshave made it possible for patients to live forlong periods with an acceptable quality of lifeon mechanical ventilation with or withouttracheostomy.


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Bronchiectasis and cystic fibrosis

Treatment involves management of infection,secretions, haemoptysis, and obstructiveairways disease and includes:

Antimicrobial drugs, bronchodilator therapy,chest physical therapy, nebulized recombinanthuman deoxyribonuclease, anti-inflammatory

therapy ,supplemental oxygen and mechanicalventilation, surgery

HIV associated chronic infection


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HIV-associated chronic infectionPulmonary complications Examples

Infection

Bacterial Streptococcus pneumoniae, Haemophilusspecies, Pseudomonas aeruginosa

Mycobacterial M. tuberculosis, M. avian complex, M. kanasii

Fungi Pneumocystis carinii, Cryptococcus neoformans,

Histoplasma capsulatum, Aspergillus species,Blastomyces dermatitidis, Penicillium marneffei

Viruses Cytomegalovirus

Parasites Toxoplasma gondii

Malignancies Kaposi's sarcoma, non-Hodgkin's lymphoma,bronchogenic carcinoma

Interstitial pneumonitides Lymphocytic and non-specific interstitialpneumonitis

Other COPD, PHT, diffuse alveolar damage, bronchiolitis

obliterans organizing pneumonia, alveolarproteinosis

T b l i


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Tuberculosis

Poorly treated tuberculosis with recurrentreactivation results in severe pulmonary scarring,cavitation, and secondary aspergillus infection.

In deprived populations, these patients maydevelop respiratory failure, recurrent bacterial and

tuberculosis-related infection, and massivehaemoptysis.


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Respiratory terminal care and

palliative sedation During the terminal phase of end-stage

respiratory disease, simple nursing measuresincluding a constant draught from an openwindow or fan, regular sips of water to moisten

the mouth (particularly when using oxygen), andsitting upright may be very beneficial.. In the terminal stages of end-stage respiratory

disease, including the neuromuscular diseases,

the emphasis of management changes fromactive interventions to purely supportive andsymptomatic measures.


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palliative sedation Non-invasive ventilatory support and active

physiotherapy may be withdrawn to facilitategreater comfort for the patient.

Drug treatments aimed at palliating symptoms ofpain, breathlessness, constipation, andhaemoptysis are often unavoidable.

If possible drugs should be given orally using

sustained release preparations but subcutaneousinfusions or intermittent, intramuscular injectionsmay be necessary.

R i t t i l d


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Respiratory terminal care andpalliative sedation

Use of nasal prongs facilitates communication withrelatives and carers. Similarly, nebulizers should becontinued as long as practically possible to provide

bronchodilators, local anaesthetic, and opioids toalleviate


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palliative sedation

The use of palliative sedation for the relief ofrefractory dyspnoea is particularly difficultbecause of the perceived risk of respiratory

depression Benzodiazepines, in particular midazolam and

opioids, are the sedatives most frequently

used and can be titrated to achieve thedesired level of sedation


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E N D

Thank You!!!!


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Reference:

Oxford Textbook of Palliative Medicine, 3rd

Edition

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