Dyspnea in palliative home care Dr. Rojanasak Thongkhamcharoen M.D., RCFPT

Overview Review of dyspnea pathophysiology Evidence in dyspnea management Assessment Pharmacologic management Non-pharmacologic management Case ตัวอย่าง

การบำบัดอาการทุกข์ทรมาน (why framework) Is it reversible or irreversible? Where is the patient in disease trajectory? 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 Lynn J, Adamson DM. White Paper: Living Well at the End of Life. RAND Health, 2003: 1-19

Symptom management by Buddhist principle ทุกข์ คือ อะไร?-คนไข้และครอบครัว ทุกข์แบบองค์รวม (suffering) สมุทัย คือ อะไรคือเหตุแห่งทุกข์ นิโรธ คือ ความพ้นทุกข์ (goal of care) มรรค คือ หนทางดับทุกข์

“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: 223-228

Dyspnea 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 cancer 10-70% AIDS 11-62% Heart disease 60-88% COPD 90-95% Renal disease 11-62% Solano JP, Gomes B, Higginson IJ. A Comparison of Symptom Prevalence In Far Advanced Cancer, AIDS, Heart Disease,Chronic Obstructive Pulmonary Disease And Renal Disease. JPSM 2006;31(1) : 58-69

อาการทุกข์ทรมานของผู้ป่วยในโครงการกัลยาณมิตร ปี (ร้อยละ) 2550 2551 2552 2553 2554 (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

readmission สาเหตุการนอน รพ. Frequency Percent dyspnea 42 33% pain 38 30% confusion 7 5.5% fatigue 14 11% bleeding 13 10.2% infection other cause 6 4.8% Total 127 100

Intubation และการเสียชีวิตที่บ้าน ผู้ป่วยในโครงการ ปี 2550 ราย(ร้อยละ) 2551 2552 2553 การใส่ท่อช่วยหายใจ 6(10) 4(7) 5(9) 3(4) เสียชีวิตที่บ้าน 34(61%) 35(61%) 28(50%) 32(49%)

Ripamonti C, Bruera E. Dyspnea : Pathophysiology and assessment Ripamonti C, Bruera E. Dyspnea : Pathophysiology and assessment. JPSM1997;13(4):220-232

3 possible mechanisms increase afferent input from chemoreceptors and mechanoreceptors from upper airway, chest wall, and lung increase sense of respiratory effort afferent mismatch Oxford textbook of palliative med,4th 2010 Booth S and Dudgoen D. Dyspnoea in advanced disease: a guide to clinical management Oxford university press, New York,2006

Management of dyspnea Management of dyspnea in cancer patients involves the following stepwise approach: assessment of dyspnea management of specific dyspnea syndrome non-pharmacologic management oxygen pharmacologic treatment other potential drugs palliative sedation Oxford textbook of palliative med,4th 2010

Thomas JR, von Gunten CF. Clinical management in dyspnea 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 scale

ประเมินอาการ

จำนวนผู้ป่วยที่ใช้ morphine ปี 2551-2553 Pain level รวม (ราย) Dyspnea mild moderate severe not assess 7 ราย 4 ราย 16 ราย 25 ราย 14 ราย 66 ราย

ตั้งแต่ปี 2553-2554 dyspnea MO user Total yes no no symptom 17 10 27 not disturb 24 6 30 disturb 5 9 14 severe all time 16 22 62 31 93

คนไข้ที่ทีอาการเหนื่อยอย่างเดียวและไม่มีอาการปวด

Cachia and Ahmedzai, EJC2008 ; 44:1116 – 1123

Strong Opioids Oral and subcut. route morphine significantly improve dyspnea*,** Nebulized opioids is not enough evidence*,** Oral or Parenteral Opioids** *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 Opioids Significant improvement in the intensity of dyspnea (P=0.003) 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 normal using opioids for dyspnea was not associated with reduced survival2 1.Clemente et al. J Pain Symptom Manage 2007; 33(4): 473- 481 2. 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* Combine midazolam to morphine improved baseline dyspnea control** Cochrane review showed not enough evidence for benefit for dyspnea@ * Cachia and Ahmedzai, EJC 2008 ; 44:1116 – 1123 **Navigante et al. J Pain Symptom Manage 2006;31:38-47. @ Simon et al. Cochrane Database of Systematic Reviews 2010,Issue1.

Oxygen Oxygen failed to improve dyspnea in mildly-or non-hypoxaemic cancer patients two meta-analyses*,** 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*** sensory stimulation rather than correction of hypoxaemia***** *Uronis et al. British Journal of Cancer 2008;98: 294–299 **Cranston et al. Cochrane Database of Systematic Reviews 2008,Issue3. ***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 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 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

evidence Recent RCT 49 patients significant difference in the VAS scores between the two treatments, with a reduction in breathlessness when the fan was directed to the face(P = 0.003) High strength of evidence that NMES and CWV, moderate strength for the use of walking aids and breathing training Galbraith et al. J Pain Symptom Manage2010;39:831-838. Bausewein et al. Cochrane Database of Systematic Reviews 2008; 2.

Differential diagnosis Pleural effusion COPD with exacerbation Cor pulmonale or HF Pericardial effusion SVC syndrome Etc.

Family genogram 70 years old CA lung SVC syndrome 50 years old farmer DM 30 years old farmer Alcohol C C 55 years old Working in BKK 5 years old 6 month

Issue: end-stage lung cancer +SVC syndrome Medical collusion (Conspiracy of silence) Asset management issue Patient concern about alcohol abuse of younger son

Survival and complication intervention intervention Response Recurrent rate Survival and complication RT 78 % (SCLC) and 63% (NSCLC) *,** Complete response at 1-3wks (symptom relief in 72 hr )** 17 vs 19% (small cell vs NSCLC) 2 to 9.5 months chemo 80% of patients with NHL or SCLC 40 * -59** % of NSCLC Same as RT Venous stent 96% improve facial and extremities edema within 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, venous perforation. *Lynn et al. NEJM, 2007;356:1862-9. ** Oxford textbook of palliative med , 4th 2010

กรณีศึกษาที่ 2 ชายไทยอายุ 45 ปี NPC s/p radiation 2 ปีก่อนมี bone metastasis และspinal cord compression ปวดร้าวลงขา VAS =8.0, incident pain=10 Consult จาก ortho มี MST 30 mg BD และได้ morphine syr 8 mg orally x 3 rescue doses Serum creatinine= 5.2 mg%

Problem list Pain due to spinal cord compression and rib metastasis Dyspnea from chachexia, Lt. pleural effusion กลับบ้านไม่ได้ Suffering from his past

ทำอย่างไรในเวลานั้น? Recommended pain management in CKD: fentanyl1 (แพง และ ไม่มียา) Methadone 2.5 mg q 8 hr ข้อดี no active metabolite, excrete via GI tract 80%, long acting with 30min onset, good for neuropathic pain2 ข้อเสีย drug interaction, QT prolong in high dose, ปรับยายาก 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 and development of evidence-based guidelines by a United Kingdom Expert Consensus Group. Palliative Medicine 2009; 23: 103–110 2. Leppert W. The role of methadone in cancer pain treatment–a review. Int J Clin Pract 2009; 63(7):1095–1109

Management ตอนนั้นปรับ dose เป็น MST 2-0-1 every 12 hr และ morphine syr 30 นาที ก่อน bed bath 30 min วันต่อมา VAS= 6.0, VAS incident pain= 8.0 วันที่สาม VAS= 4.0, VAS incident pain= 6.0 แต่เริ่มง่วงหลับ เพ้อ ขณะคุยกับแพทย์ก็หลับไป RR= 14/min Morphine side effect จากมี co-morbidity CKD Off ยา 2 วัน คนไข้ตื่นดีอย่างเจ็บปวด VAS= 6.0, VAS incident pain= 8.0 และเริ่มมี 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

Example of non-pharmacologic measures in dyspnea management