Breathing Plan

Chris Keogh: Specialist Palliative Care Nurse

Understand the project proposal and the best practice data available to assist in the development of the breathing plan

Identify the non-pharmacological and pharmacological management strategies for the symptom of dyspnoea for use in the breathing plan

Recognise the timely initiation of the breathing plan to effectively manage the symptom of dyspnoea

Learning Objectives

(American Thoracic Society 1999; Keenleyside and Ahmedzai 2008; Newton 2008; Booth, Bausewein et al. 2009; Dorman, Byrne et al. 2009; Palliative Care Expert Group 2010; Thomas, Bausewein et al. 2011).

Dyspnoea

Definition:

‘….a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity’

Project Proposal

Identify a need

Literature review

Audit of dyspnoea as a care plan issue

Audit of after-hours phone calls

Literature Review

Findings

Dyspnoea:

Common symptom

Not well understood

Poorly managed

Best Evidence Base

Strategies:

Pharmacological

Non pharmacological

o Self management tool

o Self manage exacerbations

o Instigate/prompt

o Improve patient wellbeing /activity

o Reduce carer anxiety and burden

Action Plan

Literature Review cont…

An audit process was undertaken:

To determine the number of clients currently registered with the palliative care service that presented at time of assessment with dyspnoea/breathlessness as a care plan issue

Calculate the percentage of palliative care clients that had contacted the after-hours phone service in the last 6 months with an exacerbation of breathlessness as the primary reason for contact

Audit Process

0

10

20

30

40

50

60

70

80

Specialist Nurse 1 Specialist Nurse 2 Specialist Nurse 3 Specialist Nurse 4

No. clients

No. breathless as care plan issue

%

No clients: indicated breathlessness as a care plan issue

Clients experiencing breathlessness as care plan issue

Nurses undertaking assessments Number of Clients seen Number of clients that have indicated breathlessness as

a care plan issue

Percentage %

1 51 30 58.8

2 54 27 50

3 43 19 44.1

4 20 15 75

Total 168 91 54.154.1%

Month Total number of after-hours calls Number of calls primary reason

for breathlessness

Percentage %

September 56 6 10.7

October 47 3 6.3

November 55 3 5.4

December 54 1 1.8

January 62 3 4.8

February 60 7 11.6

TOTAL 334 23 6.8 %

Audit: after hours call outs

6.8%

Development of Breathing plan

Non pharmacological

Fan to face

Positioning

Distraction

Breathing techniques

Pharmacological

Opioids

Strongest evidence

Benzodiazepines

Helpful adjunct

Symptoms Medication WHEN WELL

No symptoms

Exercise as tolerated

Space activities and rest between

Continue with Preventer……………………………..

and bronchodilator inhaler………….………………..

medication if prescribed CAUTION

If you experience

Cough

Breathlessness

Pain

STEP UP TREATMENT

1. Position

Stand and lean hands onto wall or table or sit

leaning forward with arms resting on knees or

over the table on a pillow

2. Try to focus on an object/pet

3. Use a fan on face or stand in front of an open

window

4. Remain calm: Take slow relaxed breaths in

breath out with pursed lips

Continue to Use inhaler medication if prescribed

5. Take …………………………………….

as prescribed (opioid)

WAIT 10 MINUTES

EXTRA CAUTION

If NO improvement at anytime with the

above treatment then ...

Continue with slow relaxed breaths/focus 1. Repeat dose ……………………………………as

prescribed (opioid)

2. If Anxious: Take ………………………………as

prescribed (anti – anxiolytic)

IF NO IMPROVEMENT WIITHIN 10 - 15

MINUTES

Call RDNS 1300 33 44 55

DANGER GET HELP WHEN

Severe Shortness of Breath

Reliever medicine is not helping

Can only speak in short sentence

Feeling frightened

IF UNABLE TO CONTACT SERVICES

DO NOT WAIT

CALL 000 FOR AN AMBULANCE

Trial of the breathing plan: 6 month period

o All breathing plans instigated to be indicated in care plan for breathlessness

Evaluation of the project:

o Audit care plans and number using breathing plan

o Audit after hours calls with primary reason nominating breathlessness

o Distribute client and carer satisfaction surveys re use of breathing plan

o Final report to completed

Where to from here?

MARCH -> JUNE 2014 DECEMBER

2015

JANUARY -> JUNE 2015

LITERATURE REVIEW AND

AUDITS: AFTERHOURS/CARE

PLANS

EDUCATION OF

NURSING STAFF

TRIAL OF BREATHING PLAN

OVER SIX MONTH PERIOD

DEVELOPMENT

BREATHING PLAN

MAY -> JUNE

2014

JULY 2015 AUGUST 2015 SEPTEMBER 2015COMPLETE FINAL

REPORT BY END OF

DECEMBER 2015AUDITS: AFTER

HOURS/CARE PLANS

DISTRIBUTE AND COLLECT CLIENT SATISFACTION SURVEYS

Time Line

Dyspnoea

Debilitating symptom -> quality of life

Conclusion

Breathing Plan:

Optimally manage

Visual aid

Multiple strategies

Individualised

Any questions ??

Ahmedzai, S. H. and S. P. Shrivastav (2004). "Breathlessness." Medicine 32(4): 14-16.

American Thoracic Society (1999). "Dyspnea. Mechanisms, assessment, and management: a consensus statement. American Thoracic Society." American journal of respiratory and critical care medicine 159(1): 321.

Bailey, C. D., R. Wagland, et al. (2010). "An integrative review of systematic reviews related to the management of breathlessness in respiratory illnesses." BMC pulmonary medicine 10(1): 63-63.

Bausewein, C., S. Booth, et al. (2008). "Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases (Review)." The Cochrane database of systematic reviews(2): CD005623.

Bausewein, C., S. Booth, et al. (2011). "Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases (Review)." The Cochrane database of systematic reviews(2).

Bausewein, C., C. De Biase, et al. (2012). "Development, effectiveness and cost-effectiveness of a new out-patient Breathlessness Support Service: study protocol of a phase III fast-track randomised controlled trial." BMC pulmonary medicine 12(1): 58-58.

Bausewein, C., M. Farquhar, et al. (2007). Measurement of breathlessness in advanced disease: A systematic review. England, Elsevier Limited. 101: 399-410.

Bentsen, S. B., E. Langeland, et al. (2012). "Evaluation of self-management interventions for chronic obstructive pulmonary disease." Journal of Nursing Management, 20: 802-813.

Booth, S., C. Bausewein, et al. (2009). Pharmacological treatment of refractory breathlessness. London, UK, Expert Reviews Ltd. 3: 21-36.

Booth, S., M. Farquhar, et al. (2006). "The impact of a breathlessness intervention service (BIS) on the lives of patients with intractable dyspnea: a qualitative phase 1 study." Palliative & supportive care 4(3): 287-293.Booth, S., C. Moffat, et al. (2011). "Developing a breathlessness intervention service for patients with palliative and supportive care needs, irrespective of diagnosis." Journal of palliative care 27(1): 28.

Booth, S., S. Moosavi, et al. (2008). "The etiology and management of intractable breathlessness in patients with advanced cancer; a systematic review of pharmacological therapy." Nature Clinical Practice Oncology 5(2): 90-100.

Booth, S., S. Silvester, et al. (2003). "Breathlessness in cancer and chronic obstructive pulmonary disease: using a qualitative approach to describe the experience of patients and carers." Palliative & supportive care 1(4): 337-344.

Bourbeau, J. (2009). "The Role of Collaborative Self-Management in Pulmonary Rehabilitation " Seminars in Respiratory and Critical Care Medicine 30(6): 700-707.

Brandt, C. L. (2013). "Study of Older Adult's use of Self-Regulation for COPD Self-Management Informs An Evidence-Based Patient Teaching Plan " Rehabilitation Nursing 38(2): 11-23.

Chan, K.-S., T. D.M.W, et al. (2011). Palliative Medicine in malignant respiratory diseases. Oxford Textbook of Palliative Medicine G. Hanks, N. Cherny, N. Christakiset al. Oxford New York, Oxford University Press Fourth edition

Choi, J. Y., H.-I. C. Chung, et al. (2014). "Patient outcomes according to COPD action plan adherence." Journal of Clinical Nursing 23(5-6): 883-891.

Clemens, K. E. and E. Klaschik (2008). "Effect of hydromorphone on ventilation in palliative care patients with dyspnea." Supportive Care in Cancer 16(1): 93-99.

References

Clemens, K. E., I. Quednau, et al. (2009). "Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study." Supportive care in cancer : official journal of the Multinational Association of Supportive Care in Cancer 17(4): 367-377.

Costi, S., D. Brooks, et al. (2006). "Perspectives that influence action plans for chronic obstructive pulmonary disease." Canadian respiratory journal : journal of the Canadian Thoracic Society13(7): 362-368.

Currow, D. C., M. Agar, et al. (2009). "Does palliative home oxygen improve dyspnoea? A consecutive cohort study." Palliative medicine 23(4): 309-316.

Davidson, P. M. and D. C. Currow (2010). "Management of Refractory Dyspnoea: Evidence-based Interventions." Cancer Forum 34(2): 86-90.

Dorman, S., A. Byrne, et al. (2009). Researching breathlessness in palliative care: consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup. Palliative medicine. England, SAGE PUBLICATIONS, INC. 23: 213-227.

Dudgeon, D. and J. Shadd (2014). "Assessment and Management of dyspnea in palliative care." Up to Date. Retrieved 20 March, 2014.

Faull, C., S. de Caestecker, et al. (2012). Handbook of Palliative Care. Hoboken, Wiley.

Gysels, M., C. Bausewein, et al. (2007). "Experiences of breathlessness: A systematic review of the qualitative literature." Palliative and Supportive Care 5(3): 281-302.

Herigstad, M., A. Hayen, et al. (2011). Dyspnoea and the brain. England, Elsevier B.V. 105: 809-817.

Indelicato, R. A. (2006). "The Advanced Practice Nurse's Role in Palliative are and the Management of Dyspnea " Topics in Advanced Practice Nursing eJournal 6(4).

Jones, C. (2012). The Management of Respiratory Symptoms and Advanced COPD. Handbook of Palliative Care. C. Faull, de Caestecker, S. Nicholson and F. A. Black, John Wiley & Sons, Inc.

Keenleyside, G. and S. H. Ahmedzai (2008). "Breathlessness in advanced disease." Medicine 36(2): 82-87.

Khdour, M. R., J. C. Kidney, et al. (2009). "Clinical pharmacy-led disease and medicine management programme for patients with COPD." British journal of clinical pharmacology 68(4): 588-588.

Kruis, A. L., N. Smidt, et al. (2013). "Integrated disease management interventions for patients with chronic obstructive pulmonary disease (Review)." the Cochrane database of systematic reviews(10).

Mahler, D. A., M. Campbell, et al. (2010). "American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease." Chest137(3): 674-691.

Miriam, J. J., C. C. David, et al. (2014). "Prevalence and assessment of breathlessness in the clinical setting." Expert Review of Respiratory Medicine 8(2): 151.

Newton, P. J. (2008). The Management of Dyspnoea in Advanced Heart Failure College of Health and Science: School of Nursing Sydney Western Sydney Doctor of Philosophy.

Nguyen, H. Q., D. Donesky, et

References cont …

Palliative Care Expert Group (2010). Therapeutic Guidelines: Palliative Care Melbourne, Australia, Therapeutic Guidelines Limited.

Rueda, J.-R., I. Solà, et al. (2011). "Non-invasive interventions for improving well-being and quality of life in patients with lung cancer." The Cochrane database of systematic reviews (9): CD004282.

Schwartzstein, R. M., K. Lahive, et al. (1987). "Cold facial stimulation reduces breathlessness induced in normal subjects." The American review of respiratory disease 136(1): 58.

Sedeno, M. F., D. Nault, et al. (2009). "A self-management education program including an action plan for acute COPD exacerbations." Journal of Chronic Obstructive Pulmonary Disease 6(5): 352-352.Simon, S. T. and C. Bausewein (2009). "Management of refractory breathlessness in patients with advanced cancer." Wiener Medizinische Wochenschrift 159(23): 591-598.

Simon, S. T., I. J. Higginson, et al. (2010). "Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults." The Cochrane database of systematic reviews (1): CD007354.

Stephenson, D. and A. McHugh (2004). "CPD: The non-pharmacological nursing management of dyspnoea in end-stage respiratory disease and palliative care populations." Collegian 11(2): 37-41.

Thomas, J. R. and C. F. von Gunten (2002). "Clinical management of dyspnoea." Lancet Oncology 3(4): 223-228.

Thomas, S., C. Bausewein, et al. (2011). "Breathlessness in cancer patients - implications, management and challenges." European journal of oncology nursing : the official journal of European Oncology Nursing Society 15(5): 459.

Uronis, H. E., D. C. Currow, et al. (2006). "Palliative management of refractory dyspnea in COPD." International journal of chronic obstructive pulmonary disease 1(3): 289-304.

Usmani, Z. A., K. V. Carson, et al. (2011). "Pharmacological interventions for the treatment of anxiety disorders in chronic obstructive pulmonary disease." The Cochrane database of systematic reviews(11): CD008483.

Walters, J. A. E., A. C. Turnock, et al. (2010). "Action plans with limited patient education only for exacerbations of chronic obstructive pulmonary disease (Review)." The Cochrane database of systematic reviews(5).

Wilson, J. S., B. O’Neill, et al. (2007). "Education in Pulmonary Rehabilitation: The Patient’s Perspective." Archives of Physical Medicine and Rehabilitation 88(12): 1704-1709.

Working Group of the South African Pulmonary Society (1998). "Guidelines for the management of chronic obstructive pulmonary disease. Working Group of the South African Pulmonology Society." South African medical journal = Suid-Afrikaanse tydskrif vir geneeskunde 88(8): 999.Yates, P., P. Schofield, et al. (2013). "Supportive and palliative care for lung cancer patients " Journal of Thoracic Disease 5(Supplement 5): S623-S628.

Yorke, J. and J. Roberts (2013). Managing Breathlessness in the Community. Keswick, M&K Update Ltd.

Zhao, I. and P. Yates (2008). "Non-pharmacological interventions for breathlessness management in patients with lung cancer: a systematic review." Palliative medicine 22(6): 693-701.

Zwerink, M., M. Brusse-Keizer, et al. (2014). "Self management for patients with chronic obstructive pulmonary disease." The Cochrane database of systematic reviews 3(Journal Article): CD002990.

Zwerink, M., M. Brusse-Keizer, et al. (2014). "Self management for patients with chronic obstructive pulmonary disease (Review)." The Cochrane database of systematic reviews(3).

References cont …