breathlessness - hospice.org.nz€¦ · breathlessness plans ... of patients receiving palliative...
TRANSCRIPT
![Page 1: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/1.jpg)
Breathlessness
Dr Brian Ensor May 2016
![Page 2: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/2.jpg)
Morning
Star
Jon
Barlow
Hudson2
![Page 3: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/3.jpg)
Attend
Plan
UnderstandTherapy
3
![Page 4: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/4.jpg)
Attend
Plan
UnderstandTherapy
4
![Page 5: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/5.jpg)
Dyspnoea
Subjective experience of breathing discomfort
Intensity component
Unpleasant component
Functional component
5
![Page 6: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/6.jpg)
Roles
Communication
• Whaikorero
• MND
Independence
• Driving
• Toileting
Decision making
6
![Page 7: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/7.jpg)
Language
• Exhaustion
• Air Hunger
• Tightness
• Choking
7
![Page 8: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/8.jpg)
Measurement
• Intensity
• Unpleasantness
• Functional
• Mastery
8
![Page 9: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/9.jpg)
Total Dyspnoea
• Physical
• Psychological
• Existential
• (Social)
(Abernathy, A. P., & Wheeler J. L. (2008) Total dyspnoea. Current opinion in supportive and
palliative care 2(2), 110-113)
9
![Page 10: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/10.jpg)
Variable 0 points 1 point 2 points Total
Heart rate per
minute
< 90 90 – 109 >110
Respiratory rate
/ minute
<18 19 – 30 > 30
Restlessness None Occassional Frequent
Paradoxical
abdominal movt
None Present
Grunting None Present
Nasal flaring None Presenet
Look of fear None Eyes wide open, facial
muscles tense, brow
furrowed, mouth open,
teeth together
Total
Respiratory Distress Observation Scale © Margaret L Campbell
PhD RN, 19/2/2009
10
![Page 11: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/11.jpg)
What is normal breathing?
That depends…
Triggers that can alter breathing patterns
pain fear
Snoring URTI
posture
Excitement dancing
asthma
11
![Page 12: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/12.jpg)
“It's funny, but you never really think much about
breathing. Until it's all you ever think about.”
― Tim Winton, Breath
12
![Page 13: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/13.jpg)
• 80% diaphragmatic movement, 20 % chest,
inhale and exhale via nose
• 10-14 breaths/minute
• Inspiration:expiration 1:1.5, slight pause end
of exhale
• Gentle inhale, effortless exhale
• Feel minimal muscle activity, easy, smooth..
“Normal” breathing
at rest
13
![Page 14: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/14.jpg)
Source: Alison
McConnell,Respirat
ory Muscle Training;
Theory and
Practice, Elsevier,
Oxford, 2013)
14
![Page 15: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/15.jpg)
Symptoms of
disordered
breathing
in the
healthy
person.
15
![Page 16: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/16.jpg)
Physiology
The Guardian by Cezary Stulgis
accessed at brisstreet.com
16
![Page 17: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/17.jpg)
Dyspnoea is a mismatch
“Respiratory motor centres receive and process the information according to the ventilator requirements of the body. A ventilator ‘command’ is then given, and an ascending copy of descending motor activity sent to perceptual areas (corollary discharge).
If ventilator demand exceeds the capacity for ventilation, there is an ensuing imblanace between the motor driver to breathe as sensed by the corollary discharge and afferent feedback from mechanoreceptors of the respiratory system.
This is variously referred to as…. efferent-reafferentdissociation, neuroventilatory dissociation, …...”
Currow et al 2013 Breathlessness – current and emerging mechanisms, measurement and management: A discussion from an EAPC workshop. Pall Med 27(10) 932-938
17
![Page 18: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/18.jpg)
Dyspnoea is a mismatch
What the brain (cortex) expects, is not what it
feels it is getting.
18
![Page 19: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/19.jpg)
Motor
Cortex
Brain
Stem
CO2, O2, pH
Exercise,
Hyperthermia
Ventilatory
Pump
Homeostasis
19
![Page 20: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/20.jpg)
Brain Stem Breathing
• Agonal breathing
• Cheyne Stokes
• Kussmaul (acidotic)
• Apnoeic
• Ondine’s curse
NB: Brain stem circuits are serotinergic
20
![Page 21: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/21.jpg)
Motor
Cortex
Brain
Stem
CO2, O2, pH
Exercise,
Hyperthermia
Ventilatory
Pump
Sensory
Cortex
Corollary discharge
Effort demanded
21
![Page 22: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/22.jpg)
Motor
Cortex
Brain
Stem
CO2, O2, pH
Exercise,
Hyperthermia
Ventilatory
Pump
Sensory
Cortex
Multiple
Receptors
Afferent
discharge
Results
achieved
22
![Page 23: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/23.jpg)
Multiple Receptors
• CO2, O2, pH
• Muscle receptors – stretch & spindle, ergo
• Lung receptors, J receptors, C fibre, irritant
• Pressure receptors, blood vessels, lung
• Nociceptors
• Thermoreceptors (face, oropharynx)
23
![Page 24: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/24.jpg)
Motor
Cortex
Brain
Stem
CO2, O2, pH
Exercise,
Hyperthermia
Ventilatory
Pump
Multiple Other
Receptors
24
![Page 25: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/25.jpg)
Motor
Cortex
Brain
Stem
CO2, O2, pH
Exercise,
Hyperthermia
Ventilatory
Pump
Multiple Other
Receptors
25
![Page 26: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/26.jpg)
Dyspnoea is a mismatch
26
![Page 27: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/27.jpg)
Dyspnoea is a mismatch
Bridge
Engineering
Engine
27
![Page 28: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/28.jpg)
Dyspnoea is a mismatch
Bridge
Engineering
Engine
28
![Page 29: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/29.jpg)
Dyspnoea is a mismatch
Bridge
Engineering
Engine
29
![Page 30: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/30.jpg)
Multiple Receptors• CO2, O2, pH
Outcome
• Muscle receptors – stretch & spindle, ergo
• Lung receptors, J receptors, C fibre, irritant
• Pressure receptors, blood vessels, lungProcesses
• Nociceptors
• Thermoreceptors (face, oropharynx)
30
![Page 31: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/31.jpg)
CardioPulmonary causes of
dyspnoea• Obstruction / collapse / pneumothorax
• Tracheal
• Bronchial
• SVC
• Effusion
• Emboli
• Infection
• Heart failure
• Pericardial effusion, anaemia,...
31
![Page 32: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/32.jpg)
Treatment of Dyspnoea
• Drain effusions or ascites
• Antibiotics
• Transfusion
• Heart failure treatment
• Stop ß-blockers
• Steroids (+/-)
• Radiotherapy / Chemo
32
![Page 33: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/33.jpg)
33
![Page 34: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/34.jpg)
CAUSES OF DYSPNOEA
Muscle weakness, fatigue, effort of breathing
• Cachexia, MND, “inefficiencies”
Damaged lung or chest wall
Congestion, inflammation, BP issues, pain
Metabolic
• CO2 , O2, acidosis
Cortical
• Anxiety
34
![Page 35: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/35.jpg)
Management of (unfixable)dyspnoea
Alter input to the cortex (Capt James T Kirk)
Reduce respiratory drive from brain stem
Improve blood gases
Reduce noxious input from peripheral receptors
Make muscles stronger, more efficient
Reduce pointless activity / anxiety
Increase positive input from peripheral receptors
Get the chest moving, air moving across face and in lungs
Distraction
35
![Page 36: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/36.jpg)
Non-drug
Jo Graham
Physiotherapist
Acupuncturist
Tanya Loveard
Occupational Therapist
Tracey Smith
Occupational Therapist
36
![Page 37: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/37.jpg)
PositioningBreathing Recovery
• Forward lean sitting or standing with
forearms supported
• Try & keep back straight & relax your
head forward
Optimal Breathing Position
• Sitting upright with feet, back & arms
supported
http://www.cuh.org.uk/cms/addenbrookes-hospital/for-patients/patient-information-and-
consent-forms
Resting Position
• High side lying – rest your upper
arm on a pillow
Or
Sitting & relax forward onto pillows
37
![Page 38: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/38.jpg)
Breathing Retraining
Simple Breathing Techniques
• Drop your shoulders
• Focus on breathing OUT
• Useful: pursed lips breathing or “phew”
• Centre the breath in the belly
Other Techniques – useful to clear secretions
• Active Cycle Breathing Techniques (ACBT)
• Forced expiratory technique (FET)
38
![Page 39: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/39.jpg)
ACBT
Taken from: http://www.guysandstthomas.nhs.uk/resources/patient-
information/therapies/physiotherapy/active-cycles-of-breathing-techniques.pdf
39
![Page 40: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/40.jpg)
Energy Conservation
The 3 P’s of energy conservation:
• Planning
• Prioritising
• Pacing
40
![Page 41: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/41.jpg)
Anxiety Management
• Recognise triggers for anxiety
• Relaxation
• Visualisation
• Positive phrases
• Distraction
41
![Page 42: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/42.jpg)
Environmental
Assessment /Equipment
• Adapting patients environment
• Provision of equipment/aids
42
![Page 43: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/43.jpg)
Use of Handheld Fan
A handheld fan directed at the
face may reduce the sensation
of breathlessness
43
![Page 44: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/44.jpg)
Acupuncture
Two approaches
- Western or Traditional Chinese Medicine
Used for anxiety & breathlessness
Extensive use in UK Hospices focusing on ASAD
(anxiety, sickness & dyspnoea) points
44
![Page 45: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/45.jpg)
Acupressure
• Can be used in conjunction with
acupuncture
• Patients can self massage points or press
needles/seeds (left in situ)
• Use of auricular(ear)points –these
can be left in situ for 5-7 days
45
![Page 46: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/46.jpg)
Education/Reassurance
• Communication
• Imparting basic knowledge/use of handouts
• Carer involvement
• Breathless groups/clinics
Avoid overload of information
46
![Page 47: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/47.jpg)
Breathlessness Plans
• Quick reference summary of MDT
interventions
• Individually designed for each patient &
their carer
• Discuss plan with patient & their carer
47
![Page 48: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/48.jpg)
Breathing Plan for David
1. Support yourself in your
breathing recovery position
2. Try using your fan
3. Take 1-2 puffs of midazolam
spray into the mouth
4. Take your Oxynorm
5. Focus on breathing out
6. Listen to your music or, if
you are able, work on
crossword
Continue with this for 15
minutes, then
7. If feeling no better,
repeat the midazolam
spray
8. Continue your focus on
breathing out
9. If you feel no better after
a further 15 minutes
phone the hospice on
801-0006 for advice
48
![Page 49: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/49.jpg)
Exercise
Exercise is inherent in all activities of daily
living
• Patients set own goals
• International move to individualised planned
exercise programme
49
![Page 50: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/50.jpg)
Summary
Effective symptom management
=
Patients participating in activities
they value
50
![Page 51: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/51.jpg)
References Bausewein, C., Booth, S., Gysels, M., & Higginson, I. (2008). Non-pharmacological interventions for
breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of
Systematic Reviews (Online), CD005623. doi:10.1188/12.CJON.320
Cooper, J. (Ed.).(2003). Occupational Therapy in Oncology and Palliative Care.(3rd ed.) England. Whurr.
Corner, J.& O”Driscoll, M.(1999). Development of a breathlessness assessment guide for use in palliative care.
Palliative Medicine,13,375-384.
Galbraith, S., Fagan, P., Perkins, P., Lynch, A., & Booth, S. (2010). Does the use of a handheld fan improve
chronic dyspnea? A randomized, controlled, crossover trial. Journal of Pain and Symptom Management,
39(5), 831–8. doi:10.1016/j.jpainsymman.2009.09.024
http://www.cuh.org.uk/cms/addenbrookes-hospital/for-patients/patient-information-and-consent-forms .
Filshie, J., Penn, K., Ashley, S., & Davis, C. L. (1996). Acupuncture for the relief of cancer-related
breathlessness. Palliative Medicine, 10, 145–150. doi:10.1177/026921639601000209
Kumar. S.P., & Jim, A. ( S.2010). Physical therapy in palliative care: from symptom control; to quality of life- a
critical review. Indian Journal of Palliative Care . 16.3.138-146.
Lewis,L.K., Willaims, M.T., & Olds, T.S.(2012). The active cycle of breathing technique: A systematic review and
meta analylsis. Respiratory Medicine 106. 155-172.
Lim, J. T. W., Wong, E. T., & Aung, S. K. H. (2011). Is there a role for acupuncture in the symptom management
of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with
nurse-led supportive care. Acupuncture in Medicine : Journal of the British Medical Acupuncture Society,
29(3), 173–9. doi:10.1136/aim.2011.004044
Maa, S.H, Gauthier, D., & Turner, M.(1997). Acupressure as an adjunct to a pulmonary rehabilitation program.
Journal of Cardiopulmonary Rehabilitation.17.4 286-276.
51
![Page 52: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/52.jpg)
General Drug Treatments
• Opioids
• oral or subcut
• Nebulised
• Long acting and short acting.
• Benzodiazepines (Anxiety)
• Oxygen
• Steroids
• Levomepromazine
• Furosemide nebulised
52
![Page 53: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/53.jpg)
Morphine
• Good evidence that low dose morphine relieves dyspnoea
• Pain reverses that relief
• Dose finding: 10mg to 30mg daily, long acting NNT=1.6
• Role of short acting morphine is reduced
• It is not depressing respiration
• Expectation that Oxycodone works in a similar fashion.
• Methadone used uncommonly
53
![Page 54: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/54.jpg)
Fentanyl
• Randomised double blinded studies show it
works (up to 350mcg prn sc)
• Nebulised vs subcut vs sublingual
• It is serotinergic
54
![Page 55: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/55.jpg)
Evidence Free Zone
• Fentanyl will not treat tachypnoea from
brainstem activation at the very end of life.
• SSRIs may aggravate tachypnoea.
• Consider anti-serotinergic medication:
Nozinan, quetiapine.
• End of life tachypnoea is different from
dyspnoea, which requires consciousness. The
aim (arguably) is then respiratory depression,
requiring much bigger doses of opioids.55
![Page 56: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/56.jpg)
Benzodiazepines
• Good anxiolytics
• There may be a place of midazolam nasal
spray
• Consider long acting benzodiazepines
• Remember cognitive / psychological
interventions
• Anxiety is not the cause of dyspnoea.
56
![Page 57: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/57.jpg)
Evidence Free Zone
• Anxiety is not the cause of dypsnoea in our
population.
• Dyspnoea is the cause of anxiety.
• Admission is a very good intervention.
57
![Page 58: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/58.jpg)
Oxygen
• No better than room air for patients without
hypoxia.
• Hypoxic COPD patients gain some long term
survival benefit
58
![Page 59: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/59.jpg)
Miscellaneous
Levomepromazine
12.5 – 25mg prn q1h
Radiotherapy, oncology, pleural drains, surgery,
laser, cryotherapy,
Furosemide nebulised
Non Invasive Ventilation
59
![Page 60: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/60.jpg)
Summary
Effective symptom management
=
Comfortable at rest, and the ability to
get there.
60
![Page 61: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/61.jpg)
End of life
Tachypnoea / “struggling to breath”
Secretions
• Buscopan
• Aspiration / Reflux
• Pneumonic
• Cardiac
Grunting
• Purse lip breathing for the unconscious.
61
![Page 62: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/62.jpg)
Evidence Free Zone
• Gross aspiration might deserve a naso-gastric
tube, certainly not buscopan
• Pneumonic secretions might deserve some
gentamicin or steroids
• I would choose to die hypovolaemic rather
than in congestive failure
• We might consider more aggressive treatment
of tachypnoea, with opioids, and anti
serotonin medications.
62
![Page 63: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/63.jpg)
Multidisciplinary Team
“An integrated palliative and
respiratory care service for
patients with advanced disease
and refractory breathlessness:
a randomised controlled trial”
Higginson I, Bausenwein C et al
Lancet Respiratory Medicine
Dec 2014 12 (12) 979-987
63
![Page 64: Breathlessness - hospice.org.nz€¦ · Breathlessness Plans ... of patients receiving palliative care for cancer? A pilot study of 20 patients comparing acupuncture with nurse-led](https://reader034.vdocuments.site/reader034/viewer/2022051512/603d7d989c22b63f093d5d79/html5/thumbnails/64.jpg)
www.ReubenBloodmoney.com64