management of anxiety and breathlessness in a palliative

7/31/2019 Management of Anxiety and Breathlessness in a Palliative

1/46


2/46

7/5/12

MajorIssues:Anxiety

DepressionCognitive Impairment andDelirium

Psychological and PsychiatricIssues in Palliative Care


3/46


4/46

7/5/12

Fears in Palliative Care: Death Disability Disfigurement

Dependence

ANXIE

TY

Abnormal (maladaptive) anxiety isdistinguished from normal anxiety by: anxiety out of proportion to the stress persistence of symptoms for more than two

weeks severe physical symptoms or recurrent

panic attacks disruption to normal functioning


5/46

7/5/12

Anxiety is a common symptom in thosefacing life-threatening illnesses.*

At least 25% and cancer patients and 50%of CHF and COPD patients experiencesignificant anxiety. At least 3% of patientswith advanced cancer and 10% of COPDinpatients meet DSM criteria forGeneralized Anxiety Disorder.#

*Block SD. Psychological issues in end-of-life care. J Palliat Med. 2006; 9:751-772

#Mikkelsen RL, et al. Anxiety anddepression in patients with chronicobstructive pulmonary disease

(COPD). A review. Nordic J Psychiatry.2004; 58:65-70.


6/46

7/5/12

Medical Uncontrolled pain Metabolic disturbances Endocrine disorders Medications Withdrawal syndromesPsychiatric Delirium Depression

Risk

Factors:


7/46

7/5/12

Post traumatic stressdisorder

Generalized anxietydisorder

Panic disorder Phobias Obsessive compulsive

disorder

PRIMARY ANXIETYDISORDERS:


8/46

7/5/12

ETIOLOGY: Adjustment disorder with anxious mood

(reactive anxiety) Anxiety Due to Gen Medical Condition Pulmonary emboli Hormone-producing tumors: pheo, PTH,

ACTH (e.g. lung ca, insulinoma) Delirium Uncontrolled pain Abnormal metabolic states-hypoglycemia

Hypoxia

Infection Substance-Induced Anxiety Disorder Alcohol withdrawal Nicotine withdrawal


9/46

7/5/12

Medications Bronchodilators/ beta agonists Thyroid replacement Palliative Care medications Corticosteroids (dose-related, persistent) Opioid withdrawal (agitation) Neruoleptic antiemetics-e.g.

metoclopraminde, prochlorperazine(akathisia)

Psychotropic medications

Neuroleptic antipsychotics>> SSRI (akathisia) Psychostimulants Benzodiazapine withdrawal

ETIOLOGY(contd.):


10/46

7/5/12

Clinical: MR. FISC [M=muscle tension,R=restlessness, F=fatigue, I=irritability,S=sleep (difficulty falling asleep),C=concentration (difficulty concentrating)]

Structural Interview Clinician-administered Questionnaire

HAM-A (Hamilton Anxiety Rating Scale)

STAI (State-Trait Anxiety Inventory) Self-report Measures

BAI (Beck Anxiety Inventory)

Evaluation:


11/46

7/5/12

Medical Setting HADS (Hospital Anxiety and

Depression Scale) RSCL (Rotterdam Symptom

Checklist)

Others: Profile of Mood States Brief SymptomInventory


12/46

7/5/12

PSYCHOTHERAPYIndividual : Cognitive Behavioral Therapy maladaptive

beliefs/ reframing, rehearsal, mastery Behavioral-e.g. Progressive muscle

relaxation, desensitization

Mindfulness/ Mind-Body/ Hypnosis/ Imagery Supportive psychotherapy Skills Training PsychoeducationGroup :

PHARMACOTHERAPY SS/NRI (selective serotonin/norepinephrine

reuptake inhibitor)

anxiolytics

TREATMENT


13/46

7/5/12

Benzodiazepines Neuroleptics Antidepressants Antihistamines Buspirone

PHARMACOTHE

RAPY


14/46

7/5/12

Treatment: AnxiolyticBenzodiazepines

SHORT-ACTING Initial Dose (mg)Alprazolam 0.25-5.0 T-QID

Lorazepam 0.5-2.0 T-QID

Triazolam 0.125-0.25 HS

LONG-ACTING

Clonazepam 0.25-1.0 B-TID

Diazepam 5-10 BID


15/46

7/5/12

Questions to beAnswered:

Will concurrent cognitive-behavioral therapy

and pharmacotherapy be more effective thaneither alone for management of anxiety inpalliative care? How do other concurrent psychiatricdisorders impact anxiety in palliative care? Do organic or functional causes of anxietyimpact the relative efficacy of benzodiazepinesand other interventions? What role do propofol and other short acting

benzodiazepines, e.g. lorazepam, midazolamhave in managing anxiety in palliative care? Is there a role for atypical antipsychotics,e.g. olanzapine, risperidone for managinganxiety in palliative care?


16/46

7/5/12

DYSPNEA:

a subjective experience of breathingdiscomfort that consists of qualitativelydistinct sensations that vary in intensity.

Theexperience derives from interactionamong multiple physiologic, psychological,social, and environmental factors and mayinduce secondary physiological and

behavioural responses

(ATS, 1999a: p.322)


17/46

7/5/12

DYSPNEA:

...the most common severesymptom in the last days of

life

Davis C.L. The therapeutics of

dyspnoeaCancer Surve s 1994 Vol.21 85 -


18/46

7/5/12

Breathlessness is very common inpatients with advanced cancer of any

primary site, occurring in 90% of patientswith lung cancer and 50-70% of all cancerpatients.

It can be a major factor in causingemergency hospital admissions in the last

year of life.

Shirley Thomas et.al. Breathlessness incancer patients - Implications,

management and challenges

Escalante et.al. Fatigue and its riskfactors in cancer patients who seekemergency care. Journal of Pain andSymptom Management 36, 2008;

358-366.


19/46

7/5/12

Both Mercadante (Mercadante et al.,2009) and Cherny (Cherny and Portenoy,

1994) reported that intractablebreathlessness is a contributing factor tothe need for palliative sedation at the endof life.

*Booth et.al. Breathlessness in cancer andchronic obstructive pulmonary disease:using a qualitative approach to describethe experience of patients and carers.Palliative & Supportive Care 1; 2003; 337-

344.

Incidence of breathless increases in thelast six weeks of life.


20/46

7/5/12

National Hospice Study

n = 1764

prospective study Incidence: 70 % during last 6 wks. of

life

Reuben DB, Mor V. Dyspnea in terminally ill

cancer patients.-


21/46

National HospiceStudy

Dyspnea Prevalence

Reuben DB, Mor V. Dyspnea in terminally ill cancer patients.Chest 1986;89(2):234-6.


22/46


23/46


24/46


25/46

DIRECT TUMOR

CAUSES Parenchymal Lymphangitic carcinomatosis

Obstruction

Pleural effusion / tumor

Pericardial effusion

Superior vena cava obstruction

Ascites, hepatomegaly

Tumor microemboli


26/46

INDIRECT CANCERCAUSES

Cachexia

Mineral & electrolyte imbalances

Infections Anemia

Pulmonary embolism

Neurologic paraneoplastic syndromes

Aspiration


27/46

TREATMENT-RELATEDCAUSES

OF DYSPNEA Surgery

Radiation pneumonitis / fibrosis

Chemotherapy-induced pulm. fibrosis (bleomycin)

Chemotherapy-induced cardiomyopathy

(adriamycin, cyclophosphamide) Neutropenic infection

A t f ti t ith


28/46

7/5/12

Assessment of patients withbreathlessness

Detailed history takingShould comprise thephysical, psycho-logical,and social domains of

the impact of thebreathlessness and theknown disease statusalong with appropriateexamination to(i) rule out any reversible

cause ofbreathlessness

(ii) to assess the impactof the symptom on the

patients and carers


29/46

7/5/12

APPROACH TO THE DYSPNEICPALLIATIVE PATIENT

Two basic intervention

types:

1. Non-specific, symptom-oriented

2. Disease-specific


30/46

7/5/12

American Thoracic Society (1999)

described four pathophysiologicalmechanisms to tackle breathlessness:

1) reduction of ventilatory demand

2) reduction of ventilatory impedance

3) reduction of resistive load

4) alteration of central perception


31/46

7/5/12

SIMPLE MEASURES INMANAGING DYSPNEA

reassurance (alter the central perception)

sitting up / semi-reclined posture

keep windows open

switching on fans (decrease central drive, thus

reducing ventilatory demand)


32/46

7/5/12

Other Non-pharmacological managementof DyspneaNeuromuscular electrical stimulations (NMES):application of electrical stimuli to a group of muscles to stimulate the

nerves in the muscle, thereby re-training the muscles to functionagain

External nasal dilator strips (ENDS): adhesive bandscontaining a central elastic strip that provides a spring action, arewidely used for prevention of

snoring and to help nasal breathing during exercises.

Anxiety reducing techniques: diaphragmatic breathing toreduce hyperventilation, cognitive behavioral therapy (CBT), selfhypnosis, relaxation techniques such as progressive muscularrelaxation, distraction techniques using visualization, music (Booth,

2008), or mindfulness/meditation

Exercise groups/fatigue groups:

Carer support/support for the family: encompassing theconcept of holistic approach in breathlessness - essential to assess

impact of breathlessness on the carers life. Management plans shouldaddress their ps cholo ical distress and anxiet .


33/46

7/5/12

PHARMACOLOGICALMANAGEMENTOpioids:

oral and parenteral opioids for reducing intractablebreathlessness. Meta-analysis (Jennings et al., 2002) has shownsmall but statistically significant positive effect of oral andparenteral opioids over nebulised opioids.

Benzodiazepines:commonly used benzodiazepines are lorazepam, diaz-epam, andmidazolam. Atnormal doses, they do not affect respiration, but at higher dosescan slightly depress ventilation. Simon et al. (2010) concludedthat there is no evidence to support the useof benzodiazepines inpalliating breathlessness. The study showed that there is only aslight but non-significant trend towards its beneficial effect butthe overall effect size is small. It showed that benzodiazepinesprobably cause less drowsiness than opioids, so may be used assecond or third line management in an individual case if opioidsand other non-pharmacological measures have failed.


34/46

7/5/12

Other anxiolytics & antidepressants:as for example Chlorpromazine, Promethazine etc. Notrecommended as evidence-based but may be used assecond or third line management.

Furosemide:It is a loop diuretic, used in patients with heart failure, pulmonaryoedema, ascites and oedema. benefit of nebulised furosemide in

the management of breathlessness was first postulated byShimoyama and Shimoyama (2002).

Oxygen:trials have shown that both oxygen and air can have equal effect(Abernethy et.al, 2010). The exact mechanism by which oxygen

improves breathlessness is still not clear; it may be the coolingeffect on the nasal receptors, and or activation of the trigeminalnerve rather than the concentration of oxygen that gives thebenefit. Oxygen may be helpful in some patients withhypoxemia.


35/46

7/5/12

Anti-tumor: chemo/radiotherapy, hormone, laser

Infection - Antibiotics and other standard therapies

CHF

SVCO

Pleural effusion

Pulmonary embolism

Airway obstruction

TREAT THE CAUSE OFDYSPNEA -

IF POSSIBLE ANDAPPROPRIATE


36/46

7/5/12

DISEASE-SPECIFICMEDICATIONS

FOR DYSPNEA Corticosteroids obstruction: SVCO, airway lymphangitic

carcinomatosis radiation pneumonitis

Furosemide CHF lymphangitic

carcinomatosis Antibiotics - Infection/pneumonia

Anticoagulation pulm. embolism


37/46

7/5/12

Managing breathlessness at the end of liferemains a challenge.

Most advanced cancer patients experience agradual decline before a rapid decline intheir last phase of their life.

Progressive breathlessness especially withpatients getting breathless at rest can beconsidered as a bad prognostic sign

Breathlessness at theend of life


38/46

7/5/12

DYSPNEA

CRISIS Sudden onset / rapid worsening of dyspnea Often imminently terminal situation

(minutes or hours)

Examples:

pulmonary embolism

fulminant pneumonia

upper airway obstruction

hemoptysis


39/46

7/5/12

Aggressively pursue comfort Remain on site until comfortable

Ideally use intravenous route

Generally employ non-specific measures: reassurance

oxygen

opioids possibly sedatives:

CPZ, benzodiazepines (lorazepam,

midazolam)

APPROACH TO DYSPNEA

CRISIS


40/46

7/5/12

Pharmacological regimes usedin EOL (end of life)

breathlessness.


41/46

7/5/12

q10 min. IV push with escalating doses

OPIOIDS IN DYSPNEA

CRISIS

Example using morphine IV push:

5 - 10 mg

10 - 15 mg

15 - 20 mg

If no better in 10 min.

If no better in 10 min.


42/46

7/5/12

CONGESTION IN THE FINALHOURS

Death Rattle Positioning ANTISECRETORY

Scopolamine 0.3 - 0.6 mg SQ q1h prn

Atropine 0.4 - 0.8 mg SQ q1h prn

Glycopyrrolate 0.2 - 0.4 mg SQ q2h prn

less likely to cause delirium, sedation

? less effective Consider suctioning if secretions are:

distressing, proximal, accessible

not responding to antisecretory agents


43/46

7/5/12

I i h t f b th i


44/46

7/5/12

Increasing shortness of breath in a personwith life-limiting illness and estimated

prognosis of less then 3 months

Reversible causes of dyspnoea sought?

Sa02 90%on room air

Request for O2 Multidisciplinary referrals:PhysioBreathing control exercisesRelaxation exercisesWalking frameChest physioOTPhysical aidsActivity pacingSocial workSocial support/financesMeditation/relaxationPastoral Care

Medical OfficerLow dose morphineScreen for depression andanxietyNursingAdvice re positioningMoving air

Ongoing dyspnoea?Referral to palliative care

Trial of O2


45/46

7/5/12

ROLE OF SPECIALIST PALLIATIVECARE IN MANAGING BREATHLESS

PATIENTS1) Managing and supporting patients with complexuncontrolled physical, psychological symptomissues.2) Running breathlessness clinics with support fromrespiratory

teams, occupational therapists, andphysiotherapists in hospitals and hospices, toensure that patients retain their functional abilityand maintain their quality of life.

3) Encouraging discussions around end of lifeinitiatives such as advance care planning, preferredpriorities of care with patients and carers at theirrelatively best health.4) Education of generalist and other clinicians on

managing patients especially towards end of life.


46/46

FUTUREDIRECTIONS:

Research collaboration between many

individuals and groups from different clinical(respiratory medicine, oncology, palliativemedicine) and research/academicbackgrounds (e.g. respiratory physiology,neuroscience,

imaging). Effective teamwork between the oncologists,

palliative care, and other professionals likeclinical psychologists, occupational therapists

and physiotherapists. Focus research on areas such as quality of

life, effectiveness of symptom control, impactof illness on patients and their families life,benefit of non-pharmacological measures in

management of anxiety and breathlessness in a palliative

Documents