Palliative Dyspnea

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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/

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POTD: The Transgender Patient

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FAST FACTS

  • A transgender person is someone whose gender identity differs from their sex assigned at birth

  • “Gender identity” is self-identified and different from “sex” (i.e. “Sex is what’s between your legs, gender is what’s between your ears”)

  • Some people identify outside of the male-female binary (gender nonbinary, or gender fluid) and this includes people who identify as both, neither, or in between

  • Transgender identity is not a mental disorder 

  • 28% of transgender patients report postponing necessary medical care due to prior negative experiences

  • 19% of transgender patients reported being denied care because they are transgender


HOW TO GREET THE TRANSGENDER PATIENT

  • “Hello, My name is Dr. ____________. What name do you go by? What pronouns do you use?”


PATIENT HISTORY and EXAMINATION

  • Prepare the patient for difficult questions by contextualizing why you’re asking them

  • Ask about gender-affirming hormones and surgeries if relevant

  • Determine sexual activity and pregnancy risk

  • As with any patient, do not perform invasive physical exams if not medically warranted (i.e., don’t do a genital exam on a patient presenting with a nose bleed)


HORMONES

  • Not every patient uses hormones for a variety of reasons, including lack of access

  • Masculinizing hormone: Testosterone - suppresses menses, increases libido, increases clitoral size, deepens voice, produces male pattern fat, muscle, and hair distribution, increases energy

  • Feminizing hormones: 17-beta-estradiol and anti-androgens such as spironolactone, finasteride, and gonadotropin-releasing hormone analogues

  • Testosterone does not provide a form of birth control


GENDER-AFFIRMING HORMONE THERAPY-RELATED COMPLICATIONS

  • Masculinizing Hormone Therapy

    • Erythrocytosis - can increase risk of VTE and cerebrovascular disease

  • Feminizing Hormone Therapy 

    • Hypercoagulability (VTE)

    • Electrolyte imbalances (hyperkalemia with spironolactone use)

    • Prolactinoma

    • Cardiovascular disease risk increase

  • Non-medically prescribed hormones

    • Patients may take these due to lack of access

    • Shared injectable hormones increase risk of HIV and hepatitis

    • Birth control pills often used in place of prescribed estrogen


ISSUES AFFECTING TRANSGENDER PATIENTS

  • HIV and other STIs

  • Substance abuse (drug and alcohol)

  • Mental health disorders (depression, anxiety, SI)

  • Physical assault

  • Homelessness

Source: Tintinalli's Emergency Medicine, 9th Edition pp 1997-2000

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