Dyspnea in lung cancer.7 oct2011

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Dyspnea in lung cancer.7 oct2011

  1. 1. Wissam Abouzgheib, MD, FCCP Pulmonary / Critical Care and Interventional Pulmonary Sparks Health System, Fort Smith, AR Dyspnea in Lung cancer
  2. 2. Disclosures <ul><li>None </li></ul>
  3. 3. 56 y.o male presented with significant dyspnea and abnormal CXR
  4. 4. 56 y.o male presented with significant dyspnea and abnormal CXR
  5. 5. 56 y.o male presented with significant dyspnea and abnormal CXR
  6. 6. 56 y.o male presented with significant dyspnea and abnormal CXR
  7. 7. Definition <ul><li>Subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. </li></ul><ul><li>Derives from interaction among multiple physiologic, psychological and environmental factors </li></ul><ul><li>May induce 2 ndary physiological and behavioral responses </li></ul>
  8. 8. Prevalence <ul><li>Common and prevalence increases as death approaches </li></ul><ul><li>70% last 6 wks of life </li></ul><ul><li>60% of pts at diagnosis </li></ul><ul><li>90% advanced disease </li></ul>Dyspnea in terminally ill cancer patients. Chest 89:234-236
  9. 9. Etiologies <ul><li>In advanced cancer: usually multifactorial </li></ul><ul><li>Majority of underlying causes irreversible </li></ul><ul><li>Palliative treatments partially successful </li></ul><ul><li>Important to reverse what is reversible </li></ul><ul><li>Relatively small improvement in different parameters may give significant relief </li></ul>
  10. 10. Burden/Benefit <ul><li>Burden/Benefit of the intervention for the patient needs to be evaluated by them </li></ul><ul><li>If extra visits to hospital are required, will the relief provided exceed the exhaustion incurred? </li></ul>
  11. 11. Investigate <ul><li>Should be investigated </li></ul><ul><li>Certain causes easily identifiable and reversible </li></ul><ul><li>Minimal intervention </li></ul><ul><li>Rapid symptom improvement </li></ul>
  12. 12. Etiologies Co-morbidities Cancer Treatment
  13. 13. Co-morbidities <ul><li>Infection/pneumonia </li></ul><ul><li>Increased dead space: COPD, pulmonary vascular disease </li></ul><ul><li>Resp muscle weakness: myasthenia gravis, lambert-Eaton </li></ul>
  14. 14. Cancer related <ul><li>Anemia </li></ul><ul><li>Cachexia </li></ul><ul><li>Lymphangitic spread </li></ul><ul><li>Tumor obstructing an airway </li></ul><ul><li>Malignant pleural effusion </li></ul><ul><li>Trapped lung </li></ul><ul><li>Pulmonary embolism </li></ul><ul><li>Conditions affecting chest wall compliance: hepatomegaly, ascites, pleural diseases </li></ul><ul><li>Pulmonary congestion: SVCO, pericardial effusion </li></ul><ul><li>Anxiety </li></ul>
  15. 15. Treatment-related <ul><li>Infection/pneumonia </li></ul><ul><li>Deconditioning </li></ul><ul><li>Anemia </li></ul><ul><li>Pulmonary fibrosis </li></ul>
  16. 16. Clinical Management <ul><li>Non Pharmacological interventions </li></ul><ul><li>Pharmacological interventions </li></ul>
  17. 17. Treatable conditions - Pneumonia <ul><li>CAP and MDR pathogens </li></ul><ul><li>Broad spectrum then deescalate </li></ul>
  18. 18. <ul><li>Initial management: Therapeutic thoracentesis </li></ul><ul><li>MPEs inevitably re-accumulate </li></ul><ul><li>Pleurodesis : Medical pleuroscopy vs chest tube slurry talc pleurodesis </li></ul><ul><li>Advanced disease = poor performance status </li></ul>Treatable conditions Malignant pleural effusion
  19. 19. Treatable conditions Malignant pleural effusion
  20. 20. <ul><li>Medical Pleuroscopy available </li></ul><ul><li>Diagnostic and therapeutic </li></ul><ul><li>Lung / breast > slurry talc </li></ul><ul><li>Perceived more comfortable and less painful </li></ul>Treatable conditions Malignant pleural effusion Chest 2005;127;909-915
  21. 22. Treatable conditions Malignant pleural effusion <ul><li>Pleurx Catheter : minimally invasive, outpt procedure, easily managed @ home or hospice </li></ul><ul><li>Effective, relief of dyspnea > 90 % pts </li></ul><ul><li>Pleurodesis can be achieved in 42-58% within 4 wks </li></ul><ul><li>Easily removable </li></ul>Curr Opin Pulm Med 2002
  22. 23. <ul><li>20-30% lung cancer during course of disease </li></ul><ul><li>Bronchial > tracheal but more serious </li></ul><ul><li>Endobronchial tumor, extrinsic compression, or combination </li></ul><ul><li>Endobronchial interventions quicker than radiation or PDT </li></ul>Treatable conditions Central Airway Obstruction
  23. 24. <ul><li>Electrocautery, APC, Nd-Yag,cryotherapy </li></ul><ul><li>Debulking : certainly improves dyspnea but ? survival compared with historical controls </li></ul><ul><li>Debulking alone unlikely affects survival </li></ul><ul><li>Rapid / effective restoration of airway patency and elimination of associated high morbidity and mortality of CAO were more likely responsible for this survival advantage. </li></ul>Treatable conditions Central Airway Obstruction
  24. 25. <ul><li>20 pts </li></ul><ul><li>Prospective </li></ul><ul><li>Absence of concurrent therapy </li></ul><ul><li>Nd-Yag laser, Cryotherapy, stents, laser and mechanical debulking </li></ul>Treatable conditions Central Airway Obstruction Respiration 2008;76:421–428
  25. 27. Superior Vena Cava syndrome <ul><li>Facial and upper thoracic edema </li></ul><ul><li>Often associated with dyspnea and cough </li></ul><ul><li>Traditional trts: EBRT ± chemo, 60-75 % reponse rate 2 weeks later </li></ul><ul><li>Endovascular stenting 95-100% relief of obstruction within 72 hrs </li></ul>Ann Thorac Surg . 2003
  26. 28. Non Pharmacological interventions <ul><li>Eclectic range of interventions </li></ul><ul><li>Not systematically validated </li></ul><ul><li>self initiated </li></ul><ul><li>Promotes self efficacy </li></ul>
  27. 29. The fan <ul><li>Facial cooling 2nd and 3rd branches </li></ul><ul><li>Reduces sensation of dyspnea </li></ul><ul><li>Cheap </li></ul><ul><li>Small </li></ul><ul><li>Self initiated </li></ul>Am Rev Respir Dis. 1987 Jul;136(1):58-61.
  28. 30. Anxiety-reduction training <ul><li>Learning diaphragmatic breathing </li></ul><ul><li>Reducing hyperventilation </li></ul><ul><li>Relaxation technique </li></ul><ul><li>Self hypnosis </li></ul><ul><li>Visualization and guided imagery </li></ul><ul><li>Distraction </li></ul><ul><li>“ Dyspnea not harmful” may reduce anxiety </li></ul><ul><li>Methods need to fit with patient’s and relative’s philosophy of care </li></ul><ul><li>Part of “dyspnea management program” </li></ul>
  29. 31. Physical rehabilitation <ul><li>Pulmonary rehab reduces dyspnea and improves QOL COPD </li></ul><ul><li>Even severely disabled </li></ul><ul><li>No comparable research in cancer </li></ul><ul><li>Exercise training associated with reduction in lactate levels and minute ventilation </li></ul>
  30. 32. Non invasive ventilation <ul><li>Reserved for patients with “reversible cause and to prolong life in order to achieve a specific goal </li></ul><ul><li>COPD data: NIV might have a role in symptom control </li></ul>Crit Rev Oncol Hematol. 2004 Aug;51(2):91-103.
  31. 33. Pharmacological management - Opioids <ul><li>Most case reports or series </li></ul><ul><li>Jenings et al: metanalysis double blinded, randomized, placebo controlled trials </li></ul><ul><li>Nebulized opioids = placebo </li></ul>Thorax. 2002 Nov;57(11):939-44. Review.
  32. 34. Pharmacological management - Opioids Thorax. 2002 Nov;57(11):939-44. Review.
  33. 35. Pharmacological management - Opioids <ul><li>Randomized, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnea. </li></ul><ul><li>6/38 pts had cancer </li></ul><ul><li>20mg modified-release morphine 4 days followed by 4 days placebo or vice versa </li></ul><ul><li>5-10% improvement in dyspnea over baseline all pts </li></ul><ul><li>Better sleep during treatment period </li></ul><ul><li>No respiratory depression </li></ul>BMJ. 2003 Sep 6;327(7414):523-8.
  34. 36. Phenothiazines and benzodiazepines <ul><li>No randomized controlled trials </li></ul><ul><li>Phenothiazines preferred- less resp depression </li></ul><ul><li>beneficial effects of morphine in controlling baseline levels of dyspnea could be improved with the addition of midazolam to the treatment. </li></ul><ul><li>morphine (2.5 mg Q4hrs for opioid-naïve or a 25% increment over daily dose for pts receiving baseline opioids) plus midazolam (5 mg Q4hrs) with morphine rescue doses (2.5 mg) </li></ul>J Pain Symptom Manage. 2006 Jan;31(1):38-47.
  35. 37. Oxygen <ul><li>Mechanism uncertain </li></ul><ul><li>Correction of hypoxemia may not alleviate dyspnea </li></ul><ul><li>May be activation trigeminal nerve </li></ul><ul><li>Randomized trials suggest that both O2 and air can reduce dyspnea in cancer patients </li></ul>
  36. 38. Heliox <ul><li>Less dense than air </li></ul><ul><li>When mixed with O2, reduces turbulent flow in narrowed airways </li></ul><ul><li>Reduces work of breathing and improves alveolar ventilation </li></ul><ul><li>One randomized controlled trial, Heliox reduced DOE and increased exercise capacity and SaO2 at rest and exertion </li></ul>Br J Cancer. 2004 Jan 26;90(2):366-71.
  37. 39. Inhaled furosemide <ul><li>Randomized, double-blined, placebo controlled in cancer patients </li></ul><ul><li>No beneficial effect </li></ul>Thorax. 2008 Oct;63(10):872-5. Epub 2008 Apr 11.
  38. 40. Thank you

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