MANAGEMENT OF
RESPIRATORY
SYMPTOMS IN
PALLIATIVE CARE
DR JISNA VIJAY
INTRODUCTION
• END STAGE OF THE DISEASE
• RESP SYMPTOMS COMMON
• MORE DIFFICULT TO MANAGE
• AIM TO IMPROVE QUALITY OF
LIFE
• BREATHLESSNESS
• COUGH
• DEATH RATTLE
• CHESTPAIN
• HAEMOPTYSIS
• STRIDOR
BREATHLESSNESS
• Subjective experience of
breathing discomfort.
• In70% of patients with cancer
in the last few weeks before
death, and is severe in 25% of
patients in the last week of life.
• often intermittent, occurring
in episodes lasting 5–15min
precipitated by exertion,
bending over, or even just
talking
• associated with feelings of
exhaustion
• restricts activities, leading to a
loss of independence and of role,
• resulting in frustration, anger and
depression
• induces feelings of anxiety
(particularly when present at rest),
fear, panic and impending death
• If the resting respiratory rate is 30–
35/min, activity or anxiety may
increase this to 50–60/min.
CAUSES
Treatment related
Others
• Anaemia,asthma copd
• Acidosis,atelectasis,
• Pulmonary
embolism,Pneumothorax,pneu
nmonia,panic
disorder,anxiety,muscle
weakness
• breathlessness in advanced
cancer can be divided into
three categories:
• breathlessness on exertion
prognosis = months-to-years
• breathlessness at rest
prognosis = weeks-to-months
• terminal breathlessness
prognosis = days-to-weeks
TREATMENT
Correct the
correctable
• Non-drug treatment
• Drug treatment
Causes and treatment
• MORPHINE
• Reduces the respiratory
drive
• If on morphine for pain,
increase the dose by 30–
50%
• If not on oral morphine,5–
6mg q4h–q6h is a good
starting dose
• Diazepam
• if the patient remains very anxious
5–10mg stat
• in the very elderly, 2–5mg reduce
the dose after several days if the
patient becomes drowsy
• Patients who continue to
experience panic may also need
diazepam 2–5mg SOS
• Lorazepam 1mg sublingually b.d.
and SOS.
• In relatively long-term situations,
an SSRI may be helpful, either alone
or in combination
Oxygen therapy
• increases alveolar oxygen
tension and decreases the work
of breathing necessary to
maintain a given arterial oxygen
tension.
• The concentration given varies
with the underlying condition:
• 60% in asthma, pneumonia,
pulmonary embolism, fibrosing
alveolitis
• 28% in hypercapnic ventilatory
failure
Bronchodialators
In associated brochospasm
• Salbutamol
• Theoasthalin
• May increase muscle
strength
Drugs for the symptomatic
relief of breathlessness.
Nonpharmacological
treatment
• Explain the cause(s) of the
breathlessness
• explore anxiety about it.
Assure that breathlessness in
itself is not damaging or life-
threatening.
• Emphasise that the patient will
not die during an acute
exacerbation.
• Help the patient to adjust to
the loss of physical abilities and
roles
General measures
• Activity pacing- eat, rest, wash,
rest
• Loose clothing around neck dress
• Avoid very hot environment
• Help with housework
• Open window/cool draught
• Sit to do tasks, e.g. washing,
shaving
• Use of electric fan
• Cold wet flannel wiped over face
• Space around bed
Physiotherapy
• Breathing advice and exercises
• Breathing out slowly through
pursed lips can help patients with
expiratory obstruction.
• Encourage exertion to
breathlessness to increase
tolerance to breathlessness and
maintain fitness.
• Relaxation therapy/techniques:
slow regular deep breathing
• relax shoulders, back, neck and
arms/massage
Death rattle
• Rattling noise produced by
secretions in the hypopharynx
oscillating in time with
inspiration and expiration.
• Due to weak cough,inability to
clear secretion
• Generally death rattle is seen
only in patients who are
extremely weak and close to
death.
• occurs in 30–50% of patients
and is distressing for relatives,
carers and other patients
management
Non-drug treatment
• Explanation to care givers that
the semi-conscious or
unconscious patient is not
distressed by the rattle.
• Position the patient in a semi-
prone position to encourage
postural drainage.
• Most patients are distressed
by suctioning; generally this
should be reserved for
unconscious patients.
Drug treatment
• Antimuscarinic antisecretory
drug
• The rattle is reduced in 1/2–2/3
of patients
• For rattle associated with the
pooling of saliva in the pharynx
(‘real death rattle’)
• Least effective for rattle caused
by bronchial secretions (as a
result of infection or oedema) or
related to the reflux of gastric
contents (‘pseudo death rattle’).
ANTISECRETARY DRUG
FOR DEATH RATTLE
• Avoid over utilization due
to fear of adv events like
delirium,agitation ,confusio
n urinary
retention ,hyperthermia
GASPING
RESPIRATION
• Last respiratory pattern prior
to terminal apnoea.
• The duration of the gasping
respiration phase varies
• may be as brief as one or two
breaths to a prolonged period
of gasping lasting minutes or
even hours
• Agonal respiration
COUGH
• Protective reflex
• Remove mucus and foreign
materials
• Both involuntary and voluntary
control
• Vagus nerve-airways
• Glossopharyngeal-pharynx
• Mechanical and chemical
irritation
• 30-50% patients
• 80% lung ca pts
• Ineffective cough common-
pooling of secretion and
dyspnea
• Refractory cough also common
• Leads to dizziness sleep
disturbance ,fatigue,head ache
• Mild moderate and severe
CAUSES
MALIGNANT • NON
• Pulmonary MALIGNANT
mass • Cardiac disease
involvement • Pulmonary
• airway disease
obstrn,SVC • Renal disease
syndrome • Neuromuscular
• *Aspiration [MS,ALS
• Pleural • GERD
effussion • MEDICATIONS
• *Chemo radio • CVA
induced
MANAGEMENT
CORRECT THECORRECTABLES
• Non pharmacological
• Proper positioning-drainage of
secretions
• minimise GER,aspiration
• Chest physiotherapy-mobilize
difficult secretion
• Saline nebulizers
• Avoids triggers of cough
• Lozenges or candies
• PHARMACOLOGIC
TREATMENT
• Peripherally acting
• Centrally acting
• Others
• aid expectoration - wet
(productive) cough and the
patient is able to cough
effectively
• suppress expectoration - dry
(non-productive) cough or the
patient is too weak to cough
effectively
MILD COUGH
• Non pharmacologic
interventions-preferred
• Benzonatate-strech receptor
anasthetic agent
• Dextromethorphan -actn on
cough centre
• Guaifenesine-loosenig
mucus,aids expectoration
• Acetyl cystiene
• Nebuluzed saline
MODERATE TO
SEVERE COUGH
• Opioid –morphine 5mg Q4h
• Gabapentine and pregabalin
• Nebulized anasthetic agents
• Others-
antihistamines
Steroids
bronchodialators
Chemical inhalations
carbol, menthol
HICCUP
Pathological reflex -spasm of the
diaphragm
sudden inspiration followed by
abrupt closure of the glottis.
Causes In advanced cancer
gastric distension (common)
gastro-oesophageal reflux
diaphragmatic irritation
infection
uraemia
phrenic nerve irritation
CNS tumour
Acute management
• Pharyngeal stimulation
• Oropharyngeal stimulation
activates a neural ‘gating’
mechanism.
• granulated sugar (2 heaped
teaspoons) or liqueur (2
glasses) rapidly ingested
• pulling the tongue forcibly out
of the mouth massage of the
junction between hard and soft
palate with a cotton bob
• nebulised saline (2ml of 0.9%
saline over 5min).
Reduce gastric
distention
• Gastric distension probably
accounts for most cases.
• peppermint water, this
facilitates belching by relaxing
the lower oesophageal
sphincter (an old-fashioned
remedy)
• dimeticone, an antiflatulent
contained in some proprietary
antacids,
• metoclopramide 10mg,
tightens LOS
• Elevation of Pco2
• This inhibits processing of the
hiccup reflex in the brain stem:
• rebreathing from a paper bag
• breath-holding
• Muscle relaxant
• baclofen 5mg PO
• nifedipine 10mg PO/SL
• midazolam 2mg IV,
followed by 1–2mg
increments every 3–5min.
• Central suppression of
hiccup reflex
• haloperidol 5–10mg PO or IV if
no response
• chlorpromazine 10–25mg PO
or IV if no response
• sodium valproate 200–500mg
PO or IV if no response
CHEST PAIN
• CAN BE DUE TO TUMOR
EFFECT
• LOOK FOR TREATABLE CAUSES
LIKE INFECTIONS
STRIDOR
• Stridor is a harsh, high-pitched
wheezing or vibrating sound
that results from turbulent
airflow in the upper airways.
• inspiratiory but can also occur
during expiration.
• Due to narrowing of a central
airway or the larynx caused by
a foreign body, a tumor
pushing extrinsically or
growing intrinsically,
• infection, or edema.
• Emergency intervention to
stabilize the airway
• •When stridor is of sudden
onset, administration of
racemic epinephrine for a
potentially allergic cause of
anaphylaxis may be used in a
therapeutic trial before opioids
and benzodiazepines are
initiated.
• Endotracheal intubation is
preferred.
• •In cases of severe tracheal
obstruction, use of the open
ventilating rigid bronchoscope
is the preferred method of
airway control.
• •Occasionally, emergency
tracheostomy is needed for
palliation of upper airway
tumors so the patient does not
suffocate.
• Treatment of dyspnea and
anxiety
• Oxygen
• Stenting
• Radiation
• Sedation
HAEMOPTYSIS
• FROM RESPIRATORY TRACT
• TRACHEOBRONCHIAL
• PULMONARY PARENCHYMAL’
• VASCULAR
• MEDICATION
• CA LUNG 30%-50%
• INFECTIONS
• PULMONARY EMBOLUS
• R/O HEMETEMESIS
• NON MASSIVE
mild ,non lifethreatening
haemodynamically stable
• MASSIVE
>100 ml
Management
• Depends onseverity of
hemoptysis, the underlying
cause, and the wishes of the
patient and family
• Patient and family education.
Reassurance when the amount
of blood is small is all that is
required.
• Dark towels, dark sheets, dark
blankets, and absorptive
dressings with an impermeable
backing can be used to
diminish the visual impact
• Bronchoscopy is recommended
to identify the source of
bleeding.
• For visible central airway
lesions, endobronchial
management options are
recommended;
• for distal or parenchymal
lesions, external beam
radiotherapy .
Life-threatening hemoptysis
• Bleeding lung is in the
dependent position (eg, a
patient whose right lung is
bleeding should be placed in
the right-side down decubitus
position).
• To protect the nonbleeding
lung, since spillage of blood
into the nonbleeding lung may
prevent gas exchange by
blocking the airway with clot or
filling the alveoli with blood.
• The airway should be secured
with a single-lumen
endotracheal tube.
• Bronchoscopy is recommended
to identify the source of
bleeding, followed by
endobronchial management
options
• Bronchial artery embolization
to temporize the bleeding.
• Urgent palliative sedation – If
severe hemodynamic
instability
• midazolam at 0.2 mg/kg
administered intravenously or
subcutaneously will be
effective in the patient who is
not chronically taking
benzodiazepines
• This is generally administered
in 5 mg increments every five
minutes until sedation is
achieved.
• Tolerant to benzodiazepines,
an alternative agent, such as a
barbiturate, will be effective .
phenobarbital loading dose of
10 mg/kg intramuscularly.
• If sedation is not achieved, the
loading dose of 10 mg/kg can
be repeated every two hours
to a maximum of 30 mg/kg
total in the first 24 hours.
•
CONCLUSION
THERE IS AN END TO
CURE;
THERE IS NO END TO
CARE