DyspnoeaRobert McConnell

Specialty Doctor

St Oswalds Hospice

Aims

• Definition

• Pathophysiology

• Assessment

• Management

• Sputum

• An unpleasant sensation of breathing

• The distressing awareness of the process of breathing

• American Thoracic Society - A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors, and may induce secondary physiological and behavioural responses

• Whatever the patient describes it as

Prevalence

• COPD 90-95%

• Heart failure 88%

• Lung cancer 90%

• Advanced Malignancy (10-70%)

• End stage renal failure 60%

Pathophysiology

• Breathing Centre • Chemoreceptors • Mechanical receptors • Sensory Cortex• Motor Cortex

Breathing Centre

Sense of Tightness - Upper airway receptor- Pulmonary Receptors - Chest wall receptors

Air Hunger - Central

chemoreceptors- Peripheral chemoreceptors

Breathing Centre

Motor Cortex

Lung Disease

Sensory Cortex

Neuromechanical Dissociation

Breathlessness

Emotional Response

Anxiety

ANXIETY/ FEAR/

PANIC

INCREASED

ANXIETY

CATASTROPHIC

MISINTERPRETATION

DYSPNOEA

Total Breathlessness

PHYSICAL

TOTAL BREATHLESSNESS

PSYCHOLOGICAL SPIRITUAL

SOCIAL

Causes of Breathlessness

Direct Malignant Causes- Primary lung cancer

- Lung Metastases - Pleural Malignancy Non-Malignant Causes

- ILD, COPD, Heart failure, Pneumonina, Pneumonitis, Pulmonary oedema, Chest

wall deformity, Neuromuscular disease,

Anaemia, Anxiety

Indirect Malignant Causes- SVCO

- Pleural effusion - PE

- Ascites- Anaemia

- Airway obstruction - Lymphangitis

Carcinomatosis

Assessment

• Features • Timing

• Onset

• Precipitating factors

• Exacerbating factors

• Relieving factors

• Severity

• Associated symptoms• Cough • Pain • Wheeze• Stridor• Pain • Panic

Assessing Severity

• Impact • Disturbed sleep

• Interfere with normal conversation

• Affect ADLs

• Stairs?

• Does it stop you doing what you want to do?

Examination and Investigation

• Appropriate to • The patients wishes

• The stage of illness

• The likely benefit

Management

Non-PharmacologicalCorrect the correctable

Pharmacological

Management

Symptomatic drug treatment

Non-drug treatment

Correct the correctable

Prognosis months

to years

Prognosis weeks

to months

Prognosis days

to weeks

Case Study - Alan

• 55yr Man with Metastatic pancreatic cancer

• For best supportive care

• 6 weeks progressive breathlessness

• Worse with activity and when lying down

• O/e • Comfortable at rest, Sats 98% OA, Cachectic

• Reduced A/E Right LZ/MZ, Dull percussion

What to do?

• Drain • Therapeutic aspiration

• Chest drain

• Indwelling pleural catheter

Symptomatic drug treatment

Non-drug treatment

Correct the correctable

Prognosis months

to years

Prognosis weeks

to months

Prognosis days

to weeks

Correct the Correctable

• Infection

• PE

• Mass causing airway obstruction

• Diaphragm splinting (Ascites, Abdo mass, Obstruction)

• Anaemia

• Pulmonary Oedema

• Haemoptysis

• Respiratory Failure

Alan 8 weeks later…

• Admitted via A+E with increased SOB

• Increasing episodes of feeling breathless and “panicky”

• Unable to get up the stairs at home, needing help with washing and dressing

• Unable to get out the house due to anxiety about the breathlessness attacks

• Keen to avoid medications “Don’t want to be a

addicted”

What to do?

• Correct the correctable

• Non-Pharmacological management

• Pharmacological management

Symptomatic drug treatment

Non-drug treatment

Correct the correctable

Prognosis months

to years

Prognosis weeks

to months

Prognosis days

to weeks

Non-Pharmacological Management

• Fan

• Support/Education

• OT

• Physiotherapy

• Complimentary therapy

• Nutrition

• Breathing re-training

• Positional changes

• Pulmonary rehab

Breathing techniques

• Macmillan – Relax and breath CD and booklet

• Relaxed Breathing techniques

• “Blow as you go”

• Paced breathing

• Pursed lip breathing

• Square Breathing

Fans

• Simple, Cheap, Portable

• Stimulate upper airway mechanical receptors

• Effectiveness of fan is improved with proper explanation • 15-20cm from the face

• Directed at trigeminal area (Nose and mouth)

• Best used to prevent breathlessness attack

• More effective than oxygen!

Alan...

• 1 week later breathing has improved with fan and breathing techniques

• However still suffering with panicked episodes where he becomes acutely breathless

• “Is there anything else I can try? Would oxygen help?”

Oxygen

• Only in hypoxia

• No benefit over air in non-hypoxic ptnts

• LTOT/SBOT

• Problems • Dry mouth/nose

• Hypercapnic respiratory failure

• Fire risk

• Trip/Fall risk

• Reduction in mobility

• Skin damage

• Difficult discharge

Pharmacological – Opiates

• Largest evidence base for managing breathlessness

• Occasional episodic breathlessness – Shorting acting opiates PO/SC

• General/Recurrent breathlessness – Long acting opiate/CSCI

• Side effects • Constipation

• Drowsy

• Nausea

• Resp depression

Pharmacological – Benzo’s

• Lorazepam, Diazepam, Midazolam

• No benefit in relief of breathlessness

• However recommended in reducing anxiety associated with breathlessness

• Used at the end of life for ptnts

already on an opioid for pain

ANXIETY/ FEAR/

PANIC

INCREASED

ANXIETY

CATASTROPHIC

MISINTERPRETATION

DYSPNOEA

Sputum

THICKEN THEM

LOOSEN THEM

Hyoscine ButylbromideHyoscine Hydrobromide

GlycopironiumCarbocisteineSaline Nebs

Alan …

• Had continue to deteriorate over the next week

• Called urgently to review

• Having an episode of severe breathlessness

• Panicked, Gasping for breath, Blue discolouration of lips

• Terminal event

Symptomatic drug treatment

Non-drug treatment

Correct the correctable

Prognosis months

to years

Prognosis weeks

to months

Prognosis days

to weeks

Severe Frightening Breathlessness

• ABCDE…..Midaz

• Stay with patient, Reassurance

• Midazolam• 5mg S/c

• Repeated at 30min intervals

• Once calm Midazolam 20mg/24hrs CSCI with 5mg PRNs (15-30mins)

• In the community plan if possible • Discuss with - Family/Carers/Patient

• EHCP

• Anticipatory medications (?Buccal midazolam)

Air Hunger - Central

chemoreceptors- Peripheral chemoreceptors

Breathing Centre

Motor Cortex

Lung Disease

Sensory Cortex

Neuromechanical Dissociation

Breathlessness

Sense of Tightness - Upper airway receptor- Pulmonary Receptors - Chest wall receptors Emotional Response

Opiates

Benzos

Fan

Breathing

Opiates

Benzos

Benzos

Breathing

Summary

• Breathlessness is a complex, multifactorial and very common symptom in malignant and non-malignant illnesses

• Treat the treatable, Reverse the reversable and Cloak the untreatable and irreversible

• Non-pharmacological, Psychological and Pharmacological interventions carry different weighting at different stages of illness

• Oxygen only if hypoxic

• Try to plan and prepare for breathlessness (EHCP/Breathlessness plan)

Useful resources

• Cancer Research - Patient information re breathing positions and techniques

http://www.cancerresearchuk.org/about-cancer/lung-cancer/living-with/coping-with-breathlessness

• Macmillan – Patient information, Free Breathing CD

http://www.macmillan.org.uk/information-and-support/coping/side-effects-and-symptoms/breathlessness/tips-to-help-you-breathe-more-easily.html#5002

• Deciding Right – Info on EHCP and future planning

http://www.necn.nhs.uk/common-themes/deciding-right/resources/

Thankyou!