Palliative care approaches to symptom management in advanced respiratory disease: anxiety and breathlessness

Dr Jonathan MartinConsultant in Palliative Medicine, St Joseph's HospiceVisiting Fellow, Harris Manchester College, University of Oxford28th June 2013

Thanks to:Rebecca Jennings, St Joseph’s HospiceDr Sara Booth, Cambridge Breathlessness Intervention Service

Balance of Management Approaches

Pharm

NonPhNonPh

Pharm

NonPh

Pharm

Dyspnoea at rest

Non-

pharmacological

Pharmacological

Terminaldyspnoe

a

Wilcock, 1998

Non-pharmacological interventions are the most effective interventions currently available to palliate breathlessness in the mobile patient Booth et al 2011

Dyspnoea on exercise

Focus of non-pharmacological management in advanced disease is not on decreasing

breathlessness but helping individuals to feel more in control of their breathing and be as

independent as possible

Anxiety

Total dyspnoea

Physical Psychological

Spiritual Social

Cancer

Non-cancer

Therapy

Hopelessness

Fear

Loss of jobFatigue

Faith questioned

Why me? Isolation

Depression

Anxiety and breathlessness are probably linked

CBTThoughts

I might die

How will my wife cope?

Feelings

Fear/anxiety

Physical

Breathless

Deconditioned

Weight loss

Behaviours

Staying in the house

Not talking to wife

Not eating well

Vicious daisy

Fear / anxiety

I might die Breathless

How will my wife cope?

Not talking to wife

Staying at home

Deconditioned

Breathless

Not eating well

Weight loss

Anxiety (and depression)

• Non-drug treatments: good evidence for effect:– Pulmonary rehabilitation. (Withers 1999, Paz 2007, Coventry 2009)

– Cognitive behavioural therapy (CBT). (Coventry 2008, Heslop 2009, Kunik 2008, Livermore 2010) [N.B. No RCT evidence]

• Drug treatments: limited contradictory evidence in COPD:– TCAs, SSRIs (Lacasse 2004, Yohannes 2001)

Breathlessness

Non-pharmacological and Pharmacological Approaches Breathlessness

Non-pharmacological • Personalised

goals of care

• Symptom orientated

• Multidisciplinary Approach

• Maximise quality of life for patients and their families

• Involve patient and family in care planning

• Maximise physical function and emotional wellbeing

• Holistic

Pharmacological

* Beware the hypercapnic patient

- Education: Physiology and Anatomy

- Positioning

- Hand Held Fan

- Breathing Control Techniques

- Functional Exercise

- Walking Aid (4 wheel rollator)

-Maximise usual treatments as appropriate eg: inhalers

-Manage exacerbations actively as appropriate

-Consider oxygen for hypoxia*

-Cautious use of opioids* and benzodiazepines*

Non-pharmacological Management

Intervention Rationale Summary of Evidence

Education: simple anatomy and physiology of breathing

Empowers patient and carer to understand condition, why they become breathlessness. Reduces fear and promotes self management

Insufficient evidence Bausewein 2009

Positioning: Forward leanHigh sitting

Increase efficient use of accessory musclesOffload diaphragmImprove ventilation/ perfusion ratio

Limited. Recommended in clinical practice but further research needed. Booth et al 2011

Handheld Fan Stimulates nasal receptors altering the signal to brainstem respiratory complex and changing respiratory pattern Abernethey et al 2010

Strong evidence. Crossover RCT 51 patients with chronic breathlessness. Significant decrease in breathlessness measured on VAS when fan directed to cheeks vs leg (p=0.003) Galbraith et al 2010

Breathing Control Techniques

Promotes efficient breathing pattern, decrease distressing symptoms of hyperventilation

Moderate quality evidence to support Bausewein 2009 Cochrane Systematic Review

Compounded by variation in definition of techniques Booth et al 2011

Recovery breathing

• “Rescue breathing”• A three-part behaviour for use in distressing

dyspnoeic episodes– Positioning: to allow use of accessory muscles– Focus on breathing out– Use of a fan

Cambridge Breathlessness Intervention Service

Pharmacological Management

• Opioids• Oxygen• Benzodiazepines e.g. lorazepam• Antidepressants (direct & indirect)• Major tranquillizers e.g. levomepromazine• Others: furosemide, heliox, cannabinoids

Booth et al, Expert Review of Respiratory Medicine, 2009

Opioids• Consistent evidence of benefit (Jennings 2002, Abernethy 2003, Currow 2011)

• Safety:– Entrenched societal and professional misconceptions– No evidence for respiratory depression from low dose oral opioids– Some evidence for safety (Clemens 2008, Estfan 2007, Chan 2004)

– Some evidence against• Benefit may be limited to a few sensitive subjects (Pauwels 2001/2005)• Longer term adverse effects on endocrine system, falls and cognitive

function (Freynhagen 2013)

– Need adequately powered safety studies– Particular caution with:

• Type 2 respiratory failure – no data specifically relating to this group• Transdermal fentanyl

Opioids in Breathlessness

When should they be considered?• Use them for breathlessness at rest • Use them at the end of life• Consider them in anyone with severe SOB• Consider in moderate breathlessness after other

interventions

Breathlessness: opioid palliation

Two approaches:• Currow and colleagues start on 10mgs modified

release (Currow et al , 2010)

• Booth, Rocker and colleagues start on 1mg NR o.d. (Rocker et al, 2010)

Oxygen

• Individual assessment essential for use for dyspnoea– Some evidence in non-malignant disease – related to

desaturation on exercise and hypoxia at rest– Very little evidence in cancer that better than air – use

according to clinical benefit in an individual

• Use the fan first

Booth et al, Respiratory Med, 2004 Cranston et al, Cochrane Systematic Reviews, 2008

Benzodiazepines, buspirone

• Benzodiazepines:– Recent Cochrane review. (Simon 2010)

• Non-significant trend for benefit.

• Buspirone:– Anxiolytic and respiratory stimulant with

theoretical benefits (Smoller 1996)

– Two RCTs with conflicting results (Singh 1993, Argyropoulou 1993)

Could antidepressants work?

Possibly by:• By treating depression • By treating anxiety/panic disorder• By an effect on serotonin-mediated pathways in the

brainstem

Detecting and treating depression essential Brenes, Psychosom Med, 2003

Summary of the evidence

Good evidence for:• Pulmonary rehabilitation• Breathing training• Walking aids• Exercise• CBT• Fan• Opioids

Limited evidence for:• Benzodiazepines• Oxygen• Antidepressants