Palliative Dyspnea

Managing dyspnea in the palliative patient.

This comes down to 4 approaches:

• Oxygen

• Opiates

• Benzodiazepenes

• Addressing the underlying issue

• Other measures of comfort

Oxygen

• Several options here with pro's and con's to all

• Nasal Cannula 

  • Comfortable at low flows

  • Limited in how much oxygen it can deliver as it provides no reservoir of oxygen; it depends on the patient's upper airway as the reservoir of oxygen

  • at high flow rates is uncomfortable and causes dryness and bleeding unless delivered with a humidifier)

  • Many patients mouth breathe at the end of life

• Non-rebreather

  • provides more oxygen, enables oxygen delivery to mouth breathers

  • Uncomfortably noisy, must be drawn tightly against the face to be most effective

  • muffles communication at a time when it is of key importance in the dying patient

  • Dries patient's mouth and nares out

• Venturi Mask

  • An underutilized therapy

  • Addresses mouth breathing

  • Mixes oxygen with room air

  • Able to provide relatively high flow rates of oxygen 

  • Does not need to be humidified as high flow rates of oxygen are mixed with ambient room air

• High-flow nasal cannula

  • Comfortably provides humidified oxygen at extremely high rates

  • Does not provide oxygen to mouth breathers

  • If the patient is being admitted it requires admission to the MICU (or potentially PAMCU)

• Non invasive ventilation (Bipap)

  • Noisy, uncomfortable, frightening

  • Decreases the ability to commmunicate

Opioids

• THE KEY TO PALLIATIVE DYSPNEA

• Can be delivered via the subcutaneous route, another underutilized therapy

• Administer zofran to offset possible associated nausea

• Decrease the intensity of air hunger and dyspnea related anxiety

• Have been shown to NOT SHORTEN LIFE IN PALLIATIVE PATIENTS, which is important to communicate to the dying patient's family. 

Benzodiazepenes

• Anxiety leads to worsening dyspnea; managing the anxiety therefore aids in management of dyspnea

• Generally not used as monotherapy, however can be used in addition with opiates in the anxious and dyspneic patient

Other measures

• Position the patient as they wish, though generally the more upright patient is the more comfortable patient

• Death rattle: As patients lose consciousness they lose their ability to swallow and oral secretions can pool, causing gurgling noises. There is no evidence that this is disturbing to patients, but families often have a very hard time with these noises.

  • Glycopyrrolate can help mitigate this disturbing noise

Cause specific techniques = address the underlying issue

• Must weigh the benefits vs. the discomfort of performing these interventions

• Pleural effusions: Thoracentesis

• Anemia: Transfusion

• Obstructing airway mass: Steroids, palliative radiation if available

• Pneumonia: Antibiotics

• Fluid overload: Diuresis

• Bronchospasm: Bronchodilators

See:

https://first10em.com/palliative-resuscitation-dyspnea/

https://www.rtmagazine.com/products-treatment/monitoring-treatment/therapy-devices/oxygen-administration-best-choice/

COPD and antibiotics.

Welcome back to POTD. 

The weekend has come and the weekend has gone. I know you've all been holding your breath to hear about----

A message from our sponsors:

Take a deep inhale. feel some wellness. feel the firmness of your feet on the floor. hold onto your seat.   

Exhale nice and slowly......like someone with a COPD exacerbation.

Because today we're discussing antibiotic coverage in acute COPD Exacerbations. I know you've been waiting a lung time for this one. 

Background

• Acute COPD exacerbations (AECOPD) account for ~1.5 million ED visits annually in the ED.

• Many physicians routinely prescribe antibiotic coverage for AECOPD

• a 2018 review demonstrated antibiotic prescriptions given on 39% of ED visits for AECOPD between 2009-2014.

• Due to the structural changes in the bronchi of COPD patients they are more prone to bacterial colonization (as opposed to asthmatics - which have no structural change but a reactive process)

Do guidelines exist?

• Sure do. 

• if the patient appears infectious (think fever) administer antibiotics. This is understandable given their risk factors and bronchial structural changes.

• Several guidelines exist for more subtle cases, they exist as follows: (see chart below)

  • Global initiative for Chronic Obstructive Lung Disease:

    • Antibiotics should be given to

      • patients with all 3 of the following cardinal symptom

      1. increased dyspnea

      2. increased sputum volume

      3. increased sputum purulence

      • patients with 2 cardinal symptoms, if there is increased purulence

      • patients requiring noninvasive or invasive ventilation

  • American Thoracic Society/European Respiratory Society

    • hospitalized patients with chanegs in sputum characteristics

    • all patients admitted to an ICU

  • Canadian Thoracic Society

    • patients with severe purulent AECOPD

  • National Institute for Health and Clinical Excellence

    • patients with more purulent sputum

• Basically, pay attention to that sputum. take a thorough history and discuss changes in sputum production. 

-Elly

ARDS

Acute respiratory distress syndrome (ARDS) 

acute inflammatory lung injury that causes non-cardiogenic pulmonary edema by increasing alveolar capillary permeability. 

The thickened diffusion barrier leads to hypoxemia via:

decreased lung compliance

inefficient gas exchange

Pulmonary hypertension

increased physiological dead space

Predisposing factors:

Direct lung injury: pneumonia, gastric aspiration, pulmonary contusion, near drowning, inhalation injury, transfusion-related acute lung injury

Indirect lung injury: sepsis, shock, acute pancreatitis, burns, crush injury, fat embolism, and massive transfusion

Diagnosis criteria for ARDS – Berlin definition (all 4 components must be present):

1. Acute onset (1 week or less)

2. Hypoxemia (PF ratio* < 200 mmHg with a minimum of 5 cmH2O PEEP (or CPAP))

3. Pulmonary edema (bilateral opacities on CXR)

4. Non-cardiogenic (not caused by cardiac failure)

*PF (PaO2/FiO2) ratio is the ratio of arterial oxygen partial pressure to fractional inspired oxygen. PaO2 value can be obtained from ABG, and FiO2 is 0.21 at sea level (room air) or depends on supplemental O2.

ARDS is a diagnosis of exclusion so consider first: 

Cardiogenic pulmonary edema, severe multilobar pneumonia, acute exacerbation of pulmonary fibrosis, diffuse alveolar hemorrhage, idiopathic acute eosinophilic pneumonia, dissemination of lymphoma/leukemia, and several others. 

Workup:

Labs: CBC, BMP, LFTs, Coags, VBG followed by ABG, troponin, BNP, lipase, consider DD

Imaging: CXR, POCUS US ECHO and CHEST and consider CT

ED Management:

Supplemental O2

Treat the underlying condition (pneumonia, sepsis, etc.)

Tempered diuresis – non-cardiogenic pulmonary edema takes much longer to respond to treatment than cardiogenic CHF, so avoid being overly aggressive with diuresis, as this may worsen underlying shock and increase likelihood of multi-organ failure

Glucocorticoids — consider steroids when ARDS precipitated by a steroid-responsive process (eg, acute eosinophilic pneumonia)

Be cautious when using non-invasive positive pressure ventilation – the benefit of NIPPV in the initial management of ARDS remains controversial. 

Mostlikely patient will end up being intubated, for vent management suggested strategies are:

Use low tidal volume (6-8 mL/kg) to avoid barotrauma (ideal body weight should be calculated)

And careful FiO2:PEEP ratio titration:

ARDS severity (mortality) predictor 

Mild ARDS – The PaO2/FiO2 is >200 mmHg, but ≤300 mmHg, on ventilator settings that include positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP) ≥5 cm H2O

Moderate ARDS – The PaO2/FiO2 is >100 mmHg, but ≤200 mmHg, on ventilator settings that include PEEP ≥5 cm H2O

Severe ARDS – The PaO2/FiO2 is ≤100 mmHg on ventilator settings that include PEEP ≥5 cm H2O.