The Basics of Symptom Management: Understanding, Assessment and PrinciplesDr. Leah Steinberg

Learning Objectives:

• List several good on-line resources;• Review the model of pain and

symptom management;• Describe basic management of

– Constipation, Delirium, Dyspnea• Appreciate the principles of symptom

management.

Cancer Care Ontario Guidelines• www.cancercare.on.ca

• Palliative care tools• Symptom management tools

Objective 2: Review from yesterday • Assess – rectal exam• Treat underlying causes• Treat symptoms

– pharmacological and non-pharmacological

• Monitor • Educate

Objective 3: Constipation

• Huge burden to patients• Uncomfortable, AND• Makes them stop using opioids

Constipation: Definition

• Infrequent, hard stools, difficult to pass

• Feeling of incomplete evacuation• Not just infrequency

Multiple causes: we know these!• Immobility• Disease• Neurologic abnormalities• Metabolic abnormalities (hypercalcemia)• Decreased intake• Medications (OPIOIDS, anticholinergics)• Weakness• Physical surroundings

Again, to manage – follow the steps• Assess – rectal exam• Treat underlying causes• Treat symptoms

– pharmacological and non-pharmacological

• Monitor • Educate

Management: Many products• Know the classes of laxatives to use

– Stimulant (senna)– Lubricant (mineral oil)– Osmotic (lactulose)– Opioid antagonist (methylnaltraxone)

• Usually don’t recommend:– Fibre or docusate

• Create a protocol for your practice

• Set up regular dosing of laxatives:– Sennosides or bisacodyl: 2–4 tablets at bedtime to begin plus– Lactulose 30 mL at bedtime or– PEG 3350 powder 17 g once or twice daily

• Monitor daily.  • If no bowel movement by day 2:

– Increase sennosides by 2 tablets (can be given in two doses) and increase lactulose or PEG 3350 to 30 mL twice daily

• If no bowel movement by day 3:– Perform rectal examination

• If stool in rectum:– Use phosphate enema or bisacodyl suppository

• If no stool in rectum and no contraindication:– Give oil enema followed by saline or tap water enema to clear

• Increase regular laxatives• If problems continue:

– Do flat-plate radiograph of abdomen– Switch stimulant laxative– Use regular enemas

• Set up regular dosing of laxatives:– Sennosides or bisacodyl: 2–4 tablets at bedtime to begin plus– Lactulose 30 mL at bedtime or– PEG 3350 powder 17 g once or twice daily

• Monitor daily.  • If no bowel movement by day 2:

– Increase sennosides by 2 tablets (can be given in two doses) and increase lactulose or PEG 3350 to 30 mL twice daily

• If no bowel movement by day 3:– Perform rectal examination

• If stool in rectum:– Use phosphate enema or bisacodyl suppository

• If no stool in rectum and no contraindication:– Give oil enema followed by saline or tap water enema to clear

• Increase regular laxatives• If problems continue:

– Do flat-plate radiograph of abdomen – Rule out Bowel obstruction– Switch stimulant laxative– Use regular enemas

Constipation Pearls!

• Prevent!!! • If not, treat aggressively• Myth: he’s not eating…• Regular laxatives if regular opioids

– Easier to decrease laxatives

Dyspnea:

• Frightening symptom• Often linked with anxiety, fear• Need lots of education and support

for patient with severe dyspnea

Prevalence of dyspnea

• 50% - 70% of all cancer patients • 60% of patients with NSCLC• Worsens as disease progresses• Prognostic indicator

– When patients are dysnpeic at rest, prognosis is often in the range of weeks

Etiology

• Multifactorial:• Dudgeon, Lertzman Dyspnea in the advanced cancer

patient, JPSM 1998 Oct;16(4)

• Reviewed 100 pts to determine etiology of dyspnea;

• Average number of potential causes = 5

Etiology: many many causes

From the Tumour itself;

• Compression• Obstruction• Carcinomatosis

Other Card/Resp Dx• COPD• CHF

Indirectly from tumour:

• Muscle weakness• Anemia• Thromboembolic

disease• Effusions: pleural,

pericardial, peritoneal

• Infection

Again, to manage – follow the steps• Assess: to diagnose

– Tachypnea is not dyspnea• Reverse when you can• Treat the symptoms• Monitor• Educate

Treat underlying cause if possible:• Antibiotics• Drain effusion: +/- Tenchkoff catheter• Radiotherapy• Stents• Transfusions

Non-pharmacological

• Education ++• Energy Conservation• Breathing techniques• Muscle strengthening• Cool air/fan• Positioning• Relaxation exercises

Pharmacological

• Opioids are mainstay• Methyltrimeprazine• Anxiolytics• Steroids• Inhalers/diuretics• Secretion management at EOL• Trial of oxygen

What about respiration compromise?• 11 studies looked for evidence of

respiratory compromise – no clinically relevant compromise found

• Again, related to opioid naive

Opioid dosages

• Opioid-naïve patients, mild dyspnea– codeine 30 mg q 4 hr– morphine 2.5 mg q 4 hr

• Opioid-naïve patients, moderate - severe– morphine 2.5 - 5.0 mg q 4 hr (or equivalent)– titrate 25 - 50% every 24 hrs– in COPD, start low and go slower

Opioid dosages

• Opioid tolerant patients– titrate baseline dose by 25 - 50 %

Anxiolytics: if anxiety a component• Lorazepam 1 – 2 mg sl q 8 hrs prn • Clonazpam 0.25 - 2.0 mg q 12 hr• Midazolam 0.5 - 1.0 mg s/c or iv q 20

mins prn

Steroids

• Dexamethasone 4 – 16 mg daily• Can give in one dose in the morning,

rather than qid

Dyspnea summary:

• Tachypnea is not dyspnea• Reverse when you can• Opioids are mainstay of medical

therapy• Use non-pharmacological measures

when you can

Delirium

• Palliative care emergency!• A delirious patient cannot express

their symptoms;• Distressing for patient and family• Remember:

– Hyperactive– Hypoactive

Patient’s remember their delirium50% of patients remember the experience –

It is frightening for them

To manage – follow the steps

• Assess: to diagnose– Don’t forget to do physical exam

• Reverse when you can• Treat the symptoms• Monitor• Educate

Reverse when that is the goal

• Hydration• Opioid rotation• Bisphosponates• Stop medications if possible

Non-pharmacologic measures:

• Quiet room• Decrease stimulation• Light• Visible reminders of time and date• Verbal orientation of patient

But most importantly: TREAT IT• Don’t leave patient untreated while

attempting to reverse:• First line:

– Haloperidol 0.5 mg bid plus breakthrough

– Risperidone 0.5 mg bid plus breakthrough

– Olanzipine 2.5 mg bid plus breakthrough– If severely agitated, we use

Methyltrimeprazine

Delirium summary:

• Prevent it when possible – PCUs may use daily screening tool

(CAM)• Reverse when possible• Treat always• Counsel patient after, if needed

SUMMARY

• Many symptoms• Don’t be overwhelmed• Use the model• Use the resources out there!

Opioids treat symptom of dyspnea• Cochrane review• Mechanism unclear• Systemic naloxone increases

dyspnea• Opioid receptors in tracheobronchial

tree and alveolar walls • But, no clear role for nebulized

though