Prof David Currow on the clinical management of breathlessness in palliative care

hi my name is David carro I'm a palliative medicine physician and hold the chair of palliative and supportive services at Flinders University welcome to this podcast about the clinical management of breathlessness in the palliative care setting a symptom that you may encounter in your care of older patients in the community including residential aged care facilities during this podcast I will cover what this mirror is the causes of breathlessness and how to manage this symptom using both pharmacological and non-pharmacological methods breathlessness as defined by the American Thoracic Society is the subjective experience of breathing discomfort there are at least two distinct components of the sensation of breathlessness the severity or intensity and an affective component or unpleasantness in human studies it is clear that the trajectory of unpleasantness worsens at a different rate to the worsening of the intensity in exercise induced breathlessness there are at least three distinct descriptions of breathlessness that have been identified in the experience of breathlessness these include the sensation of air hunger simply not getting enough air into one's lungs chest tightness and a measure of the work or effort of breathing at the same time there is often a poor correlation between many of the physiological measures of respiratory function and the subjective sensation of breathlessness as such it's imperative that we take the patient's subjective perception of breathlessness as the basis for the clinical assessment measuring respiratory rate or pulse oximetry will not assess the person's perception of their breathing breathlessness is inducible in all of us with exercise pathological breathlessness is out of proportion to the exercise required to induce it or may even happen at rest many people have breathlessness despite optimal treatment of the underlying etiology that are contributing – the sensation this defines a group of people who have chronic refractory breathlessness across the community between five and ten percent of people have breathlessness on exertion when walking at their own pace along the flat in Australia one percent of the population have breathlessness on basic activities of daily living and one in 300 people have breathlessness so severe that it precludes them from leaving the house at a population level those who have lung diseases the cause of breathlessness are likely to have had their symptom for years if not decades compared to shorter periods for other underlying etiology the predominant etiology for long term refractory breathlessness in our community relates to lung disease particularly chronic obstructive pulmonary disease cardiac failure is the next most frequent cause followed by cancer neuromuscular diseases and other respiratory diseases there are a group of people at the end of life who also have breathlessness in their last weeks with no apparent cardio respiratory disease this may be because their cardio respiratory disease isn't recognized clinically or because they are simply losing the muscles that help them breathe there is one final subgroup clinically people where an underlying cause will not be found for breathlessness despite thorough and systematic investigation the Canadian thoracic society have published a management plan for breathlessness which mirrors the World Health Organization's analgesic ladder there are three levels of treatment firstly optimizing treatment of underlying conditions that may contribute to breathlessness and thereby establish the fact that this is chronic refractory breathlessness secondly using non pharmacological interventions for which there is a very strong evidence base and finally utilizing pharmacological treatment for the symptoms if other measures have not worked for the first step on this breathlessness ladder it should not be assumed that other clinicians have identified and optimized the treatment of the underlying causal cause a number of studies suggest that often the management of underlying causes has not been optimised despite causing the patient distress breathlessness should be routinely assessed in clinical practice a simple 11-point numerical rating scale from zero to ten where zero equals no breathlessness and 10 equals worst possible breathlessness helps to evaluate initially and monitor the ongoing burden of breathlessness a clinically meaningful reduction in chronic breathlessness is a one centimeter reduction on a nought to ten numerical rating scale equally a Likert type scale none mild moderate severe can be used in people with cognitive impairment or who are unconscious an observational scale has been developed and validated this ensures there is a continued focus on the relief of breathlessness even in the terminal stages of life or when people are otherwise are unable to articulate their distress non-pharmacological measures for the symptomatic treatment of refractory breathlessness include conditioning exercises for people who are able to tolerate them and advice about how to optimize breathing this could include the use of resources such as walking aids which are thought to improve the mechanics of breathing for many people and advice about energy conservation the use of a battery-operated handheld electric fan from a dollar shop has an emerging evidence base the fan is likely to help many people it is thought that the mechanism of benefit from the fan is air blowing across the face and among other things stimulating the middle branch of the trigeminal nerve the benefits seen from using a fan are in keeping with findings from the largest randomized control trial of oxygen for people who were breathless but did not qualify for home oxygen medical air which is room air delivered at 2 liters a minute through nasal prongs was as effective as oxygen in reducing breathlessness in this patient population with both groups oxygen or air showing improvement over as and a period people who do not qualify for home oxygen under current guidelines may still be able to have a therapeutic trial of oxygen from a concentrator lent by their local palliative care service a three to five day trial will establish if there is a symptomatic benefit before commencing any pharmacological measures for each patient there needs to be a careful assessment of underlying contributing causes the aims and goals of care for that particular patient and the response to non pharmacological treatments to date pharmacological measures for the treatment of breathlessness are focused around the use of regular low-dose sustained-release systemic morphine it is not known whether other opioids have clinical benefit in reducing breathlessness in this setting there is level one evidence to support the use of morphine however all data available to date suggest that this is safe even in people with respiratory failure doses of between ten and thirty milligrams per 24 hours are required to reduce breathlessness in this clinical setting such patients should have regular laxatives introduced at the same time as their regular morphine the largest days have been in people with once daily oral sustained-release morphine as with other opioids as the medication is introduced it will need to be titrated approximately two out of three people will derive benefit from sustained release morphine in this setting of people who respond most will notice a reduction in their breathlessness with a dose of ten milligrams of sustained-release morphine daily although a smaller number will require twenty or even thirty milligrams the initiation of opioids should be done at 10 milligrams per 24 hours it's reasonable to titrate after three to five days in which time people will have achieved steady-state for long enough to respond if they are going to respond at that dose in people who have responded to opioids it's sensible to wait at least seven days before considering further upward titration of the medication by seven days it is unlikely that a person would get any additional benefit having initiated regular low dose opioids it's important to assess the patient's response to these medications have they improved their level of comfort has the quality of their sleep improved are they more comfortable at rest or able to recover more quickly when exercise induces breathlessness for them in direct contrast to intravenous doses of opioids in opioid naive patients in the emergency department or postoperatively regular low dose opioids have not been associated with respiratory depression hobb tonday shin nor hospitalizations from respiratory failure a recent large consecutive cohort study of people with chronic obstructive pulmonary disease who were oxygen-dependent demonstrated no increase in hospitalizations nor risk of death in people who were on up to 30 milligrams a day of morphine equivalents at times clinicians have understandable practical concerns about introducing the topic of morphine such considerations are largely based around the concerns of health professionals not their patients in qualitative studies patients and their caregivers are not concerned about the use of regular low dose morphine if recommended by a clinician that they trust in the same study both patients and their caregivers wanted regular low dose opioids to be continued although widely used the net benefit of benzodiazepines has still not been well-established the one place where they may be of benefit is particularly in the last hours two days of life where their role is both an ankle it ik and as an amnesiac and this may be of benefit to some patients in rare circumstances breathlessness may be sufficient to warrant sedation in the terminal hours or days of life using higher doses of benzodiazepines in combination with other sedatives overall breathlessness is highly prevalent across our community its prevalence increases dramatically in the weeks before death it's a symptom where there is good level of evidence for treating it systematically and achieving significant reductions in symptom burden as a direct result most importantly regular low dose oral sustained release morphine is safe and effective for the relief of breathlessness thank you for your time you

Glenn Chapman

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