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1. Symptom Respiratory.pdf
- 2. Objectives 1. Review the general principles in symptom care in paediatric palliative care 2. Present the five Golden Rules in symptom management in paediatric palliative care 3. Describe respiratory, neurological and bleeding symptoms that pediatric palliative care patients may experience 4. Present an approach to symptom assessment and management in paediatric palliative care
- 3. • Establish clear goals of care • Focus on physical, psychological, emotional, spiritual, and social suffering • Child’s report is the “gold standard” • Use developmentally appropriate language • Anticipate, educate and discuss potential symptoms • Open communication and access to the health care practitioner may lead to positive satisfaction with symptom experience • An Interprofessional is key to managing these symptoms General Principles
- 4. Goals of Care • Focus on improved quality of life (QOL) and decreased suffering • Identify and address symptoms according to patient’s priority • Symptom management should be driven by family goals of care for the child • Interventions must be compatible with understanding of where the child is in the disease trajectory
- 5. Five Golden Rules 1. DO NOT PANIC 2. Impeccable assessment 3. Hope for the best, prepare for the worst 4. Treat what you can treat 5. Utilize the Inter‐Professional team
- 6. Dyspnea • Defined as the sense that breathing has become unpleasant • A subjective phenomenon with multiple contributing factors ‐ Physical factors (fluid, tumor, weakness, injury) ‐ Psychosocial (fears about function, inability to carry out normal activity such as walking or feeding) ‐ Existential or spiritual (interference with respiratory function carries implication of imminent death, fear of suffocation)
- 7. Pathophysiology of Dyspnea Chloe Chin, and Sara Booth Postgrad Med J 2016;92:393- 400 Copyright © The Fellowship of Postgraduate Medicine. All rights reserved.
- 8. General Approach ‐ Assessment of Dyspnea • High index of suspicion • Establish whether breathing problems are a concern to the child • Explore what the breathing problem may mean to the child • Take a careful history of the nature of the symptom • Perform a careful physical examination • Construct a rational therapeutic approach Subjective report Clinical assessment Specialized assessment tools Physical examination Diagnostic tests
- 9. Dyspnea – Non‐pharmacological Management • Explore psychological influences on breathlessness • Correct positioning • Suctioning • Relaxation techniques and breathing exercises • Increase airflow‐ fan or open window • Complementary therapies • Chest physiotherapy • Distraction techniques
- 10. Dyspnea – Pharmacologic Management • Saline Nebulizers: help loosen secretions • Bronchodilators • Hyoscine butylbromide (buscopan): dries secretions • Benzodiazepine: addresses anxiety, Midazolam (buccal or IV or subcutaneous) • Morphine (Dyspnoea dose 1/2 to 1/3 normal oral dose for pain) • Oxygen: if hypoxic
- 11. Morphine and Breathlessness • Decreases sensitivity of respiratory centre to CO2 therefore decreases awareness of breathlessness • In heart failure it causes vasodilatation which decreases the load on the heart • Sedative effect reduces anxiety • Dyspnea doses of morphine will not suppress breathing (common misconception)
- 13. Interventions that may be Helpful for Anna • Conserve energy • Teach relaxation techniques • Prescribe opioid • Give oxygen as needed • Ensure she is not fluid overloaded
- 14. Cough • A physiological reflex designed to expel particles and excess mucus from the airways • Pathological cough is when its ineffective and when it adversely affects sleep, rest, eating or social activity • Persistent cough can precipitate vomiting, exhaustion, chest or abdominal pain, rib fracture and syncope
- 15. Cough Assessment Assessment • Duration‐ acute or chronic • Pattern‐ constant, on and off, worsening, diurnal variation • Associated symptoms‐ e.g. night sweats • Impeccable assessment When to Intervene? • Severe cough spasms • Cough interfering with feeding and or sleep, or leading to exhaustion
- 16. Cough Management • Treat underlying cause • Opioids ‐ Effective at reducing coughing and the distress associated with cough • Air humidification • Chest physiotherapy • Management of secretions: Suctioning, saline nebulization • Safe home remedies ‐ Hot water + I tsp honey + squeeze lemon
- 17. Hiccups • An involuntary spastic contraction of the diaphragm and intercostal muscles on inspiration by abrupt closure of vocal cords • Classified by duration: ‐ Hiccup bout: <48 hours ‐ Persistent hiccup: 48 hours – 1 month ‐ Intractable hiccup: >1 month • Prevalence: ‐ 9% in cohort of palliative care patients Jeon YS, Kearney AM, Baker PG. (2018). Management of hiccups in palliative care patients. BMJ Supportive & Palliative Care, 8:1‐6.
- 18. Hiccup‐ Sequellae • Persistent or intractable hiccups can affect eating, drinking, sleep, mood, and worsen pain • Associated with malnutrition, weight loss, fatigue, dehydration, insomnia, stress, and decreased QOL Jeon YS, Kearney AM, Baker PG. (2018). Management of hiccups in palliative care patients. BMJ Supportive & Palliative Care, 8:1‐6.
- 19. Hiccup Causes • Gastro‐instestinal ‐ Gastroesophageal reflux disease ‐ Gastric distension ‐ Diaphragmatic irritation ‐ Phrenic nerve irritation • Biochemical ‐ Uraemia ‐ Hyponatraemia ‐ Hypocalcaemia • Liver dysfunction • Stress and insomnia • Pyrexia • Infection • Intracranial lesion • Drugs ‐ Corticosteriods ‐ Antidepressants ‐ Antibiotics ‐ Analgesics • Many drugs used to treat hiccup may also induce it
- 20. Hiccup Management Gastric distension • Deforming anti‐flatulent agents plus Prokinetic drug that tightens the lower oesophageal sphincter such as metoclopramide • Peppermint water relaxes the lower oesophageal sphincter to aid belching Gastro‐esophageal reflux • Metoclopromide • H2 antagonist • Proton pump inhibitors Jeon YS, Kearney AM, Baker PG. (2018). Management of hiccups in palliative care patients. BMJ Supportive & Palliative Care, 8:1‐6.
- 21. Hiccup Management Diaphragmatic irritation • Baclofen as a muscle relaxant • Chlorpromazine • Haldol • Vagal stimulation Normal saline, 2ml nebulized over 5 mins Oropharyngeal stimulation with nasogastric tube • Massage at the junction of the hard and soft palate with cotton bud Forced retraction of the tongue to induce a gag reflex Central suppression of hiccup reflex • Metoclopramide • Chlorpromazine • Baclofen • Sodium valproate, phenytoin, or carbamazepine • Elevating the Pco2, in the brainstem by breath holding or breathing in and out of a paper bag
- 22. Resources • Princess Marina Hospital Treatment Guidelines. Gaborone, Botswana. • Malawi Ministry of Health. (2015). Introduction to Children Palliative Care; Manual for service providers, Malawi Government. • Hospice Africa Uganda. (2015). Palliative Care Manual for Initiator of Palliative Care in Africa, 3rd Ed. Kampala, Uganda. • End‐of‐Life Nursing Education Consortium (ELNEC), based at the City of Hope in Duarte, California, initially established the pediatric end‐of‐life curriculum to train nurses throughout the United States. The authors of ELNEC have given Global HOPE permission to use their materials in this course for health care providers in Sub‐Saharan Africa.