Palliative Care:Shortness of Breath and Secretions

Hong-Phuc Tran, M.D.

Learning Objectives

•Understand pathophysiology of dyspnea

•Learn how to evaluate dyspnea

•Understand reversible causes / potential contributors of shortness of breath

•Manage shortness of breath in terminally ill patients

Introduction•Shortness of breath is common in terminally ill

patients

•“Death rattle” (noisy breathing) occurs in 23-92% of dying patients –Patients lose ability to clear secretions as

mentation worsens

•Appropriate management of excessive secretions is important in providing palliation

Pathophysiology of Dyspnea

•Multifactorial▫Increased work of breathing▫Chemical effects

Medullary chemoreceptors sense hypercapnea

Carotid and aortic body chemoreceptors sense hypoxemia

▫Neuromechanical association Mismatch between what brain desires for

respiration and sensory feedback brain receives

Evaluation of Dyspnea

•Patient’s self-report is most reliable measure

•Can have dyspnea with normal O2 saturation

•Physical exam findings▫Accessory muscle use▫Tachypnea▫Rhonchi, crackles, decreased breath

sounds, stridor▫Cyanosis (central or peripheral)

Examples of Some Reversible Causes / Potential Contributors of Shortness of Breath

•Bronchospasm

•Pleural effusion

•Anemia

•Airway obstruction

Management of Shortness of Breath (1)

First, treat underlying, reversible causes (if any)

Examples of Management of Some Reversible Causes/Potential Contributors of Shortness of Breath

•Bronchospasm–Albuterol, ipratropium, steroids

•Pleural effusion–Thoracentesis, pleurodesis, diuretics,

catheter drainage•Anemia–Transfusion

•Airway obstruction–Steroids, Clean out tracheostomy tube (if

present)

Management of Shortness of Breath (2)

•After treating reversible causes (if any), then treat symptomatically

▫Pharmacologic Opioids Benzodiazepines Anticholinergics

▫Non-pharmacologic

Opioids (1)

•Most effective for alleviating dyspnea▫Exact mechanism unclear but thought to

alter perception of dyspnea

•Common Routes: oral, parenteral

•Unlikely to hasten death or cause addiction if adhere to dosing guidelines

Opioids (2)• Opioid naïve patients– Start with Morphine 10 -15mg po q1hr prn or morphine

5mg SC q 30min prn– Titrate to patient’s relief using standard opioid dosing

guidelines

• Opioid non-naïve patients– Increase opioid dose by 25%– Titrate to patient’s relief using standard opioid dosing

guidelines– Once chronic dyspnea controlled, provide extended release

formulation and short acting formulation Short acting formulation: 10% of total dose of same opioid in

24 hr period, offered at q1hr prn

Benzodiazepines (1)

•Can relieve dyspnea associated with anxiety

•Potential side effects, especially in elderly patients– Increased risk of confusion, falls

•Can use conjunction with opioids without causing respiratory depression when dosing guidelines followed

Benzodiazepines (2)

•Common routes: oral, sublingual, subcutaneous

•Example of dosing for dyspnea▫Lorazepam 0.5 mg po / SL q 1 hr prn,

titrate to patient’s relief▫Once total dose in 24 hr period determined,

then can give 1/3 of total dose q8hrs

Anticholinergics (1)• Dries excessive secretions

• Effective for patients with weak cough reflex

• Examples: Atropine, Hyoscyamine (Levsin), Scopolamine, Glycopyrrolate (Robinul)

• Atropine, hyosyamine, scopolamine are equally effective in treatment of death rattle

• Effectiveness of medications better at lower initial rattle intensity

Anticholinergics (2)• Atropine 1% ophthalmic drops – 1-2 drops SL every 1 hr prn

• Scopolamine– 1-3 transdermal patches q72hrs – 0.1-0.4 mg SC / IV q4hrs– 10 80mcg/hr by continuous IV or SC infusion

• Hyoscyamine 0.125 mg PO / SL q8hrs prn

• Glycopyrrolate– 0.4-1.0 mg daily by SC infusion – 0.2 mg SC / IV q4-6hrs PRN

Non-pharmacologic Interventions• Educate patients, families/caregivers• Repositioning – Turning patient on side, Elevate head of bed

• Suctioning– Gentle, anterior (not deep) suctioning

• Increase airflow – Fans, open windows, oxygen nasal cannula– Stimulates V2 branch of trigeminal nerve, which has

central inhibitory effect on dyspnea• Reduce room temperature without making patient too

cold• Behavioral techniques – Relaxation, Distraction

References & Suggested Readings• EPEC (Education for Physicians on End-of-Life Care) : http://www.cancer.gov/cancertopics/cancerlibrary/epeco/selfstudy/module-3• Mercandante S, Villari P, Ferrera P. Refractory death rattle: deep aspiration

facilitates the effects of antisecretory agents. J Pain Symptom Manage. 2011 Mar;41(3):637-9.

• Pantilat SZ and Isaac M. End-of-life care for the hospitalized patient. Med Clin North Am. 2008; 92(2): 349-70.

• Quaseem A et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2008 Jan 15;148(2):141-6.

• Shinjo T, Okada M. Atropine eyedrops for death rattle in a terminal cancer patient. J Palliat Med. 2013 Feb;16(2):212-3.

• Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005177

• Wildiers H et al. Atropine, hyoscine butylbromide, or scopolamine are equally effective for the treatment of death rattle in terminal care. J Pain Symptom Manage. 2009 Jul;38(1):124-33