Dyspnea in palliative home care¸ารประชุม... · Oxford textbook of palliative med,4...
Transcript of Dyspnea in palliative home care¸ารประชุม... · Oxford textbook of palliative med,4...
Dyspnea in palliative home care
Dr Rojanasak Thongkhamcharoen M D RCFPTDr. Rojanasak Thongkhamcharoen M.D., RCFPT
Overview
• Review of dyspnea pathophysiology
E id i d t• Evidence in dyspnea management
Assessment
Pharmacologic management
Non‐pharmacologic managementp g g• Case ตวอยาง
การบาบดอาการทกขทรมาน (why framework)การบาบดอาการทกขทรมาน (why framework)
WHY? ( )• WHY? (สาเหตของอาการ)• Is it reversible or irreversible?
• Where is the patient in disease trajectory?
• Can we do something about this symptom?Can we do something about this symptom?
Adapt from “Why framework” David Currow, Flinder university,2010
Lynn J, Adamson DM. White Paper: Living Well at the End of Life. RAND Health, 2003: 1‐19
Symptom management by Buddhist principle
• ทกข คอ อะไร?-คนไขและครอบครว ทกขแบบองครวม (suffering)
• ไ • สมทย คอ อะไรคอเหตแหงทกข • นโรธ คอ ความพนทกข (goal of care) • นโรธ คอ ความพนทกข (goal of care) • มรรค คอ หนทางดบทกขมรรค คอ หนทางดบทกข
“The gold standard for diagnosis of dyspnoea is the patient’s self‐report.”
Thomas JR von Gunten CF Clinical management in dyspnea The Lancet 2002 april;3: 223‐228Thomas JR, von Gunten CF. Clinical management in dyspnea. The Lancet 2002,april;3: 223 228
DyspneaDyspnea
Definition “a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity
The experience derives from interactions among multiple physiological, social, and environmental factors, and may induce secondary physiological and behavioral responses ”
ATS ad hoc Committee,1999.,
Dyspnea
10 70%• cancer 10‐70%
• AIDS 11‐62%
• Heart disease 60‐88%
COPD 90 95%• COPD 90‐95% • Renal disease 11‐62%
Solano JP Gomes B Higginson IJ A Comparison of Symptom PrevalenceSolano JP, Gomes B, Higginson IJ. A Comparison of Symptom PrevalenceIn Far Advanced Cancer, AIDS, Heart Disease,Chronic Obstructive Pulmonary DiseaseAnd Renal Disease. JPSM 2006;31(1) : 58-69
ป ใ โ อาการทกขทรมานของผปวยในโครงการกลยาณมตร
อาการป (รอยละ)
อาการ
2550 2551 2552 25532554
(2 ไตรมาตร)
pain 60.7 38.6 32.7 49.2 30 ราย
dyspnea 39.3 15.8 20 58.5 21 ราย
fatigue 46.4 8.8 12.7 63 28 ราย
readmissionreadmissionสาเหตการนอน รพ. Frequency Percent
dyspnea 42 33%pain 38 30%p %
confusion 7 5.5%fatigue 14 11%fatigue 14 11%
bleeding 13 10.2%infection 7 5.5%
other cause 6 4.8%Total 127 100
Intubation และการเสยชวตทบานป
ผปวยในโครงการ
ป
2550 2551 2552 2553ราย(รอยละ) ราย(รอยละ) ราย(รอยละ) ราย(รอยละ)
ใ การใสทอชวยหายใจ 6(10) 4(7) 5(9) 3(4)
เสยชวตทบาน 34(61%) 35(61%) 28(50%) 32(49%)
Ripamonti C, Bruera E. Dyspnea : Pathophysiology and assessment. JPSM1997;13(4):220‐232
3 possible mechanisms3 possible mechanisms
• increase afferent input from chemoreceptors and mechanoreceptors from upper airway, p pp ychest wall, and lung
• increase sense of respiratory effort • increase sense of respiratory effort • afferent mismatch
Oxford textbook of palliative med,4th 2010Booth S and Dudgoen D. Dyspnoea in advanced disease: a guide to clinical managementOxford university press, New York,2006
‘corollary discharge’ Efferent -afferent mismatch
voluntary
Involuntary or reflexy
Manning H, Schwartzstein R: Pathophysiology of Dyspnea. N Engl J Med 1995 ;333 :1547–1553
Management of dyspneaManagement of dyspneaManagement of dyspnea in cancer patients involves theManagement of dyspnea in cancer patients involves the
following stepwise approach:1 assessment of dyspnea1. assessment of dyspnea2. management of specific dyspnea syndrome3 non pharmacologic management3. non‐pharmacologic management4. oxygen
h l i5. pharmacologic treatment6. other potential drugs 7. palliative sedation
Oxford textbook of palliative med,4th 2010
Thomas JR, von Gunten CF. Clinical management in dyspnea. The Lancet 2002,april;3: 223-228
Del Fabbro et al. Symptom Control in Palliative Care—Part III: Dyspnea and Delirium. JOURNAL OF PALLIATIVE MEDICINE 2006;9(2): 422‐436
Dyspnea severity
Farncombe M, Support Care Cancer (1997) 5:94-99
Rating scaleg
100
80
60
40
20
symptom presence not
severe all time
disturb
not disturb
no symptom
Missing
Coun
t
0
dyspnea2
symptom presence,notdisturbno symptom
ประเมนอาการประเมนอาการ
จานวนผปวยทใช morphine ป 2551‐2553จานวนผปวยทใช morphine ป 2551‐2553
Pain level รวม(ราย)
Dyspnea mild moderate severe not assess
7 ราย 4 ราย 16 ราย 25 ราย 14 ราย 66 ราย
ตงแตป 2553‐2554ตงแตป 2553‐2554
dyspneaMO user Total
yes noyes nono symptom 17 10 27
t di t bnot disturb 24 6 30
disturb 5 9 14
severe all time 16 6 22
Total 62 31 93Total 62 31 93
คนไขททอาการเหนอยอยางเดยวและไมมอาการปวดคนไขททอาการเหนอยอยางเดยวและไมมอาการปวด
MO user * dyspnea2 Crosstabulation
Countdyspnea2
not disturb disturb severe all time
symptompresence,notassess severe
dyspnea2
Total1 0 6 0 79 6 8 1 24
10 6 14 1 31
yesno
MO user
Total
Cachia and Ahmedzai, EJC2008 ; 44:1116 – 1123
Strong OpioidsStrong Opioids
• Oral and subcut. route morphine significantly p g yimprove dyspnea*,**
N b li d i id i t h id * **• Nebulized opioids is not enough evidence*,**
• Oral or Parenteral Opioids**p
*Jennings et al. Cochrane Database of Systematic Reviews , 2001**DiSalvo et al. Putting Evidence Into Practice®: Evidence-Based Interventions for Cancer-Related Dyspnea.Clinical Journal of Oncology Nursing, 2007# Jennings et al. A systematic review of the use of opioids in the management of dyspnoea. Thorax 2002;57:939–944
Strong OpioidsStrong Opioids
Si ifi t i t i th i t it f d• Significant improvement in the intensity of dyspnea (P=0.003)
( ) d /• Decrease RR=41.8 to 35.5 (30 min) and to 25.7 /min (90 /min)
• No opioid-induced respiratory depression• SpO2 ,PCO2 and pH normalSpO2 ,PCO2 and pH normal
• using opioids for dyspnea was not associated with reduced survival2reduced survival
1.Clemente et al. J Pain Symptom Manage 2007; 33(4): 473- 4812 Bengoechea et al JPM 2010; 13(9): 1079-10832. Bengoechea et al. JPM 2010; 13(9): 1079 1083.
Benzodiazepine
• Inhibit GABA pathway –decreased anxiety*• In panic attack‐short acting lorazepam 0.5 mg SL*• Diazepam is not appropriate: long acting, delayed
*onset*• Subcut. Injections or a continuous sc infusion of midazolam are helpful*midazolam are helpful*
• Combine midazolam to morphine improved baseline dyspnea control**dyspnea control
• Cochrane review showed not enough evidence for benefit for dyspnea@y p
* Cachia and Ahmedzai, EJC 2008 ; 44:1116 – 1123**Navigante et al J Pain Symptom Manage 2006;31:38-47Navigante et al. J Pain Symptom Manage 2006;31:38 47.@ Simon et al. Cochrane Database of Systematic Reviews 2010,Issue1.
OxygenOxygen
O f il d i d i ildl• Oxygen failed to improve dyspnea in mildly-or non-hypoxaemic cancer patients two meta‐analyses*,**
D bl bli d lti t RCT i O2 i i• Double blind, multi‐center RCT comparing O2 vs room air in non‐hypoxic cancer patients showed that no additional benefit of O2 comparing to room air***benefit of O2 comparing to room air
• sensory stimulation rather than correction of hypoxaemia*****hypoxaemia
*Uronis et al. British Journal of Cancer 2008;98: 294–299**Cranston et al. Cochrane Database of Systematic Reviews 2008,Issue3.y***Abernethy et al. Lancet 2010; 376: 784–93**** Thomas and Gunten Lancet Oncol 2002; 3: 223–28
Galbraith S, Fagan P, Perkins P, Lynch A, Booth S. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Management 2010; 39: 831‐838.
Stephenson D and McHugh A. The non‐pharmacological nursing management of dyspnoea in end‐stage respiratory disease and palliative care populations. Collegian 2004 ;11(2 ) : 37‐41
evidenceevidence• Recent RCT 49 patients significant differenceRecent RCT 49 patients significant difference in the VAS scores between the two treatments with a reduction in breathlessnesstreatments, with a reduction in breathlessness when the fan was directed to the face(P = 0 003)0.003)
• High strength of evidence that NMES and g gCWV, moderate strength for the use of walking aids and breathing trainingwalking aids and breathing training
Galbraith et al. J Pain Symptom Manage2010;39:831-838.Bausewein et al Cochrane Database of Systematic Reviews 2008; 2Bausewein et al. Cochrane Database of Systematic Reviews 2008; 2.
Framework of advance care plan
Illness trajectory (โรคมากแคไหนมทางเลอกอะไรบาง)Patient as a person
เรมตนPatient illness experience
Symptom vs suffering
Patient as a personWish plan Goal hope
Dx and prognosis understanding
Formulate goal of care บคคลกรการแพทยผปวยและครอบครว
Advance directive บคคลกรการแพทย
ป ใ ไ ไ ใ
ทบทวนเปนระยะเรมใชจรงเมอคนไขไมสามารถตดสนใจ
Adapt from Palliative medicine A case-based manual, 2nd Ed, 2005
Differential diagnosisDifferential diagnosis
• Pleural effusion
• COPD with exacerbationCOPD with exacerbation
• Cor pulmonale or HF
• Pericardial effusion
• SVC syndromeSVC syndrome• Etc.
Family genogramFamily genogram70 years oldCA lung
50 ld SVC syndrome50 years old
farmer30 ld
CDM C
30 years old
farmer
5 years oldAlcohol55 years old
Working in
6 month
Working in BKK
Issue:1. end-stage lung cancer +SVC syndrome2. Medical collusion (Conspiracy of silence)3. Asset management issue4 P ti t b t l h l b f 4. Patient concern about alcohol abuse of
younger sonyounger son
managementmanagement• Explore her perception of Dx and prognosis: she
’ f D B h k h di i iwasn’t aware of Dx. But she know that disease is quit serious and may not cureE i i h• Encourage patient to communicate concern to her familyDi i h i d f il b RT i• Discuss with patient and family about RT, patient don’t need this choice
• Prednisolone 60 mg/d+ lasix20 mg/d+ ativan 1 mg/d• Positioning and beware of pressure sore• Morphine syr and O2 weren’t available at that time
interventionintervention Response Recurrent
rateSurvival and complication
RT 78 % (SCLC) and 63% (NSCLC) *,**Complete response at 1-3wks
17 vs 19%(small cell vs
NSCLC)
2 to 9.5 months
Complete response at 1-3wks(symptom relief in 72 hr )**
NSCLC)
chemo 80% of patients with NHL Same as RT Same as RTor SCLC40 * -59** % of NSCLC
Venous 96% improve facial and 13% 5 8% ( 3-7%)Venous stent
96% improve facial and extremities edemawithin 24 hr, 72 hr**
13%Median 1-2
mo.
5.8% ( 3-7%)infection, pulmonary embolus, stent migration, insertion site hematoma, bleeding, and, very rarely venousvery rarely, venous perforation.
*Lynn et al. NEJM, 2007;356:1862-9.** Oxford textbook of palliative med , 4th 2010
กรณศกษาท 2 ชายไทยอาย 45 ปกรณศกษาท 2 ชายไทยอาย 45 ป
/ d b• NPC s/p radiation 2 ปกอนม bone metastasis และspinal cord compressionp p
• ปวดราวลงขา VAS =8.0, incident pain=10C lt th MST 30 BD ไ • Consult จาก ortho ม MST 30 mg BD และได morphine syr 8 mg orally x 3 rescue doses
• Serum creatinine= 5.2 mg%
Problem listProblem list
• Pain due to spinal cord compression and rib metastasis
• Dyspnea from chachexia, Lt. pleural effusion ไ ไ • กลบบานไมได
• Suffering from his past g p
ทาอยางไรในเวลานน?
• Recommended pain management in CKD: fentanyl1Recommended pain management in CKD: fentanyl(แพง และ ไมมยา)
• Methadone 2 5 mg q 8 hr• Methadone 2.5 mg q 8 hr• ขอด no active metabolite, excrete via GI tract 80%, l ti ith 30 i t d f thilong acting with 30min onset, good for neuropathic pain2
l h h• ขอเสย drug interaction, QT prolong in high dose, ปรบยายาก due to pharmacokinetic, respiratory depression2
1. Douglas C et al. Symptom management for the adult patient dying with Advanced chronic kidney disease: A review of the literature g y g y g yand development of evidence-based guidelines by a United Kingdom Expert Consensus Group. Palliative Medicine 2009; 23: 103–1102. Leppert W. The role of methadone in cancer pain treatment–a review. Int J Clin Pract 2009; 63(7):1095–1109
ManagementManagement
d S 2 0 1 12 h hi• ตอนนนปรบ dose เปน MST 2‐0‐1 every 12 hr และ morphine syr 30 นาท กอน bed bath 30 min
• วนตอมา VAS= 6.0, VAS incident pain= 8.0• วนทสาม VAS= 4.0, VAS incident pain= 6.0 แตเรมงวงหลบ เพอ , p
ขณะคยกบแพทยกหลบไป RR= 14/min
• Morphine side effect จากม co‐morbidity CKDMorphine side effect จากม co morbidity CKD
• Off ยา 2 วน คนไขตนดอยางเจบปวด VAS= 6.0, VAS incident pain= 8 0 และเรมม pressure sorepain= 8.0 และเรมม pressure sore
Pollock A, et al. Morphine to Methadone Conversion: An Interpretation of Published Data. American Journal of Hospice& Palliative Medicine ;28(2): 135-140
Palliative care in COPDPalliative care in COPD
• Patient received inadequate palliative care
1. Poor communication2 Difficult predicting of prognosis2. Difficult predicting of prognosis
• Patients and their families frequently do not understand that Severe COPD is often a progressive and terminal illnessp g
Gysels et al J Pain Symptom Manage 2008;36:451 460Gysels et al. J Pain Symptom Manage 2008;36:451-460.Curtis JR, Palliative and end-of-life care for patients with severe COPD. Eur Respir J 2008 ;32:796–803
Curtis JR, Palliative and end-of-life care for patients with severe COPD. Eur Respir J 2008 ;32:796–803
COPD vs Lung cancerCOPD vs Lung cancer
• Significantly more patients with CLD than LC experienced breathlessness in the final year (94% CLD vs 78% LC,P<0.001) and final week (91% CLD vs 69% LC, P<0.001) of life
• the CLD patients were more likely to have experienced these symptoms for longerexperienced these symptoms for longer(>6 months 83.6% CLD VS 57.1% LC, P<0.001, all symptoms)all symptoms)
Edmonds P et al. A comparison of the palliative care needs of patients dying from chronic respiratory diseases and lung cancer.Palliative Medicine 2001; 15: 287–295
Evidence of Palliative Rx in COPD
Uronis HE, Currow D, Albernethy AP. Palliative management of refractory dyspnea in COPD. International Journal of COPD 2006:1(3) 289–304
Rocker et Al. Advanced Chronic Obstructive Pulmonary Disease: Innovative Approaches to Palliation. Journal of Palliative Medicine 2007;10(3): 783-797
Example of non‐pharmacologic measures inExample of non pharmacologic measures in dyspnea management