Upload
pearl-morton
View
213
Download
0
Tags:
Embed Size (px)
Citation preview
Life is not measured by
the number of breaths we take,
but by the moments that take
our breath away....
Anonymous
Objectives
Review the common treatments that our colleagues have already tried
Explore more creative modalities that our colleagues expect of us
Share our expertise
Create an update for WMMD manual
Dyspnea is not....
Tachypnea which is rapid breathing
Hyperpnea which is increased ventilation in proportion to metabolism
Hyperventilation which is ventilation in excess of metabolic requirement
Comroe 1966
Dyspnea is instead….
….difficult, labored, uncomfortable breathing; it is an unpleasant type of breathing, though it is not painful in the usual sense of the word.
Comroe 1966
Dyspnea
It is subjective, and like pain, it involves both the perception of the sensation by the patient and their reaction to the sensation….
Comroe 1966
Prevalence
• Reported to occur in 21-70% of all terminally ill patients
• National Hospice Study
• 25% patients experiencing breathlessness did not have underlying pulmonary diseases
Oxygen
Should be offered in any circumstance of dyspnea but no studies that show it to be any more effective than….
Environmental changes:
Cool humidified air
Circulating fan
Fowler’s position
Pursed lip breathing
Reassurance
Calming, relaxation techniques
Breathing exercises
Music therapy
Aromatherapy
Social Work
Chaplain
Nebs
Duonebs q 3hrs & prn
Decadron
4mgs q 4hrs
For Pulmonary Edema 4 mls 50% Ethyl Alcohol/Vodka
3 treatments q 15 minutes & repeat 6-8 hrs
Nebulized Furosemide
• Bronchodilatory effects
• Inhibition of irritant-receptors of the lung
• Rocker, Horton 2010
• Inhibition of stretch receptors (vagal nerve)
• Shimoyama, JPSM 2002
• Anti-inflamatory effect
• Prandota, Am J Ther 2002
• 40 mgs IV soln dye free per neb prn
CorticosteroidsDexamethasone
Start 4 mgs bid and titrate up24 mgs to 96 mgs/day IVP
SolumedrolIVP 550 mgs qid
PrednsoneStart 40 mgs/day and titrate up
Benzos• Are they effective?
• Breaks Anxiety-Dyspnea Cycle….prevalence of
fear, anxiety, or panic?• Short Acting preferred….Versed is the
shortest
• No studies that show effectiveness in Advanced Cancer or ES COPD
• Cause more drowsiness than Morphine
• Use 2nd line or in combination with Opiods
• Ativan Infusion 1-5 mg's/hr starts to accumulate in 3 days and may have to cutback
Opiods
Nebulized Morphine does not work…studies too small
Oral opiods work but with the usual side effects
Lack of adverse effect on blood gasses
Jennings, Thorax 2002
Do decrease the perception of Air Hunger & ↓ventilatory response to ↓ O2 & ↑CO2
Cause vasodilation of pulmonary vessels: ↓ preload to the Heart
Improve Dyspnea without causing Respiratory Depression
Opiod Phobia
Opiod Responsive Dyspnea
• Parallels to opiod responsive and opiod non responsive type of pain
• Dyspnea may have varying degrees of opiod responsiveness dependent on several specific factors
Opiod Delivery
Class Preparation Onset Duration
Short Acting
MorphineHydromorphoneOxycodone
30-60Minutes
3-4 hours
Long Acting
Morphine SRHydromorphone SROxycodone SR
3-4Hours
8-12hours
Rapid Onset
Fentanyl
Oral Transmucosal Buccal TabletSublingual TabletIntranasal Spray
10-15minutes
1-3hours
Canadian Dyspnea Protocol
Steps Medication # mcgs SL(50 mcg/ml)
1 Fentanyl 25
2 Fentanyl 50
3 Sufentanil 10
4 Sufentanil 15
Terminal SectretionsNon- pharmacologic Interventions
– Reposition the patient first….basic Nursing Technique
– Suction is rarely useful
– Secretions re-accumulate rapidly & is overstimulating
Anticholinergic / Antimuscarinics
– 1% Atropine Opthalmic Gtts
4 gtts SL q 15mins X 4 then prn
– Transdermal Scopolamine Patches
– Robinol 0.2 mgs q 1 hr subQ/IVP
If secretions become wet/rattling but not foamy
-Atropine Aerosol 1mg with Albuterol 2.5 mgs q 4hrs prn