Dyspnea: Definition. Common Respiratory Issues Near the End of Life. Dyspnea: A subjective Feeling. Module 3: Nonpain Symptoms at the End of Life
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1 L N C nd-of-life Nursing ducation Consortium Geriatric Curriculum Respiratory Issues at nd-of-life Jerry Boltz, FNP January 27, 2012 Module 3: Nonpain Symptoms at the nd of Life Part I L N C Geriatric Curriculum Common Respiratory Issues Near the nd of Life Cough Changes in respiratory rate & rhythm Increased Respiratory secretions : Definition Distressing shortness of breath, air hunger, or difficulty breathing Associated with anxiety, depression, and decreased quality of life Can be acute or chronic Sometimes occurs or worsens only with activity L N C Geriatric Curriculum L N C Geriatric Curriculum : A subjective Feeling refers to the sensation of difficult or uncomfortable breathing. It is a subjective experience perceived and reported by an affected patient. L N C Geriatric Curriculum L N C Geriatric Curriculum 1
2 Major Pulmonary Causes Tumor Infiltration Pleural ffusion Aspiration COPD Pneumonia Bronchospasm Pulmonary mbolism Pulmonary Fibrosis Superior Vena Cava Syndrome Thick Secretions caused by infectious diseases or dehydration Thick secretions caused by Us? Later Major Cardiac causes Congestive Heart Failure Pulmonary edema Pulmonary Hypertension Pericardial ffusion Cardiac disease - arrhythmias L N C Geriatric Curriculum L N C Geriatric Curriculum Cancer Related Causes Metastatic disease from any primary site Obstruction of Bronchus Malignant Ascites Anemia (Anemia of chronic disease) Superior Vena cava Syndrome Pneumonectomy Major Neuromuscular Causes Amyotrophic Lateral Sclerosis (ALS) Muscular dystrophy Myasthenia Gravis Cerebrovascular Disease Trauma as a result of physical injury L N C Geriatric Curriculum L N C Geriatric Curriculum Assessment of Other causes Generalized weakness Anorexia Hyperventilation Uncontrolled Pain Obesity Cachexia Anxiety Hyperthyroid Spiritual issues Subjective report Clinical assessment Physical exam Diagnostic tests Derby et al., 2010; Dudgeon, 2010 L N C Geriatric Curriculum L N C Geriatric Curriculum 2
3 Assessment Subjective Report Subjective Assessment Is like a Pain Assessment. The subjective report of the patient is the only reliable indicator of this symptom. The patient s respiratory rate & Oxygenation status Do Not always correlate with the symptom of breathlessness. Impact on Function & Quality of Life Ability to sleep Ability to perform ADL s (get dressed, talk, eat, sleep, etc.) The patient may report breathlessness in spite of good oxygenation status or limited disease state. L N C Geriatric Curriculum L N C Geriatric Curriculum Clinical Assessment of Clinical Assessment of Determine history of: Physical xamination Acute or chronic dyspnea Smoking levated Jugular Pressure Lung Sounds Heart Disease or Lung Disease Concurrent Medical Conditions Respiratory Rate, Depth Use of Accessory Muscles Peripheral dema L N C Geriatric Curriculum L N C Geriatric Curriculum Non-Pharmacologic Treatments for ducation, ducation, ducation Pursed lip breathing nergy conservation Fans, elevating head of the bed Prayer, Music, Calm environment Dudgeon, 2010 Other Non-Pharmacologic Treatments for Transfusion of PRBC s Thoracentesis Paracentesis Radiation therapy to shrink tumor Stent tube placement to open an occluded airway L N C Geriatric Curriculum L N C Geriatric Curriculum 3
4 Oxygen Therapy for ffectiveness has not been established by research Worth trying especially if oxygen saturation is low Trial O L per nasal prongs; reassess 2 hours after each change in liter flow Pharmacologic Treatment of Opioids Bronchodilators Diuretics Other Clemens & Klaschik, 2007; Derby et al., 2010; Dudgeon, 2010; Jacobs, 2003 Derby et al., 2010; Dudgeon, 2010; Gallagher & Roberts, 2004; Pan, 2003 L N C Geriatric Curriculum L N C Geriatric Curriculum Opioids for Can be administered by oral, subcutaneous, sublingual, or intravenous routes Studies show that Opioids have a small, but positive effect on reducing dyspnea Significant respiratory depression is uncommon Nebulized opioids are no more effective than opioids given by other routes How do Opioids work for? Possible Mechanisms They interrupt the neural pathways that give rise to the sensation of dyspnea They have a sedative & anxiolytic effect to relieve the discomfort of dyspnea Vasodilatation Reduce Preload L N C Geriatric Curriculum L N C Geriatric Curriculum What Opioids do not do Opioids do not relax the respiratory muscles, allowing the patient to breathe easier. This explanation could be easily be misconstrued by patients and families. Is there a role for Anxiolytics in? Sedation and reduction of anxiety are side effects of Opioids. Like all side effects, (except for constipation), These side effects may disappear over time. If an anxiety component is identified, anxiolytics may be helpful. L N C Geriatric Curriculum L N C Geriatric Curriculum 4
5 Bronchodilators Diuretics Albuterol (relaxes bronchial smooth muscle by action on the Beta-2 receptors). Atrovent (Anti-cholinergic agent that causes bronchodilation) Given by SVN is more effective than if given by metered dose inhalers. Reduce pre-load on the heart May reduce the sensation of dyspnea that may be caused by congestive heart failure. L N C Geriatric Curriculum L N C Geriatric Curriculum Other Pharmacologic treatments Cough Chlorpromazine (Thorazine) There is some evidence that low doses of Chlorpromazine (25mg q 4 hours) may relieve the symptoms of dyspnea. Antibiotics Pneumonia Steroids Reduce inflammation Cough is: A Common Symptom in advanced disease Cough causes: Pain, Fatigue, Insomnia Dudgeon, 2010 L N C Geriatric Curriculum L N C Geriatric Curriculum Some Causes of Cough Assess the Type of Cough Post Nasal Drip Asthma Bronchitis Obstruction Pleural effusion P.. Pneumothorax Allergens Cigarette Smoking nvironmental irritants Medications (AC Inhibitors) Acute Cough Often caused by: Allergens, nvironmental irritants, Post- Nasal drip, GRD, Lung lesions, TB, Pneumonia, Foreign Body Chronic Cough: Allergens, Chronic diseases (COPD, Bronchitis, Airway Inflammation) Nocturnal: GRD, Asthma, CHF L N C Geriatric Curriculum L N C Geriatric Curriculum 5
6 Treatment Decisions Patient s condition Where are they on the trajectory of their illness. Does the patient have a strong or a weak cough? Suppress by night xpectorate by day Do we really want to dry it up? Pharmacologic Interventions for Cough Suppressants/Anesthetics xpectorants Antibiotics Steroids Anticholinergics Lingerfelt et al., 2007 L N C Geriatric Curriculum L N C Geriatric Curriculum Cough Suppressants Cough Suppressants Opiates Non-Opioid Morphine Sulfate Codeine Metabolized to Morphine Hydrocodone & Homatropine Opioids in general - Bind to opiate receptors & suppress cough in the medullary center Dextromethorphan Structurally related to Codeine, Depresses Medullary cough center. Benzonatate (Tessalon Perles) Suppresses cough by topical anesthetic action on the respiratory stretch receptors L N C Geriatric Curriculum L N C Geriatric Curriculum Non-Pharmacologic Interventions for Cough Changes in Respiratory Rate and Rhythm Chest PT Humidifier Positioning L N C Geriatric Curriculum ducation, ducation, ducation Autonomic Nervous System - Normal Respiratory rate breaths per minute. The term Normal changes depending on where the patient is at on their Journey L N C Geriatric Curriculum 6
7 They are Breathing So Fast!! Kussmaul Breathing Deep Rapid respirations Acidosis Blowing off Carbon Dioxide. Body is trying to maintain acid / base balance Some Things to Think About When the Patient s Respiratory Rate is Fast and labored Do we need to slow down the patient s respiratory rate? How much Morphine (Opioid) does it take to slow down a person s respiratory rate? Who are we treating when we try to slow down the respiratory rate? L N C Geriatric Curriculum L N C Geriatric Curriculum Other nd of Life Breathing Patterns Apnea Cheyne Stokes Breathing Guppy Breathing Death Rattle Death Rattle Now that is an uncomfortable couple of words! Increased Respiratory Secretions Why is the terminology problematic? Who are treating? L N C Geriatric Curriculum L N C Geriatric Curriculum Non-Pharmacologic Treatments Pharmacologic Treatments ducation, ducation, ducation Tell family members what to expect Ask them not to feed their loved ones unless they are wide awake, and able to swallow. Patient Positioning Scopolamine Patch Crosses the blood brain barrier - Mad as a Hatter. Glycopyrrolate Atropine drops Hyoscyamine L N C Geriatric Curriculum L N C Geriatric Curriculum 7
8 Just a Thought Key Nursing Roles Asking for Refills on these medications should be a rare event. # 1 Patient Advocacy We all believe in patient determined end of life care As long as they agree with our plan Charles von Gunten, M.D. L N C Geriatric Curriculum L N C Geriatric Curriculum Key Nursing Roles Patient/Family Teaching Assessment Pharmacologic treatments Non-pharmacologic treatments Presence L N C Geriatric Curriculum 8
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