3. Assessment and Management of Non-pain Symptoms Flashcards
State some non-pain symptoms commonly seen in Palliative Care patients.
- Breathlessness
- Nausea and Vomiting
- Constipation
- Delirium
Breathlessness is commonly seen in patients with …….. before their deaths?
Organ failure, Cancer, Frailty and others
Define dyspnea.
It is a subjective experience of breathing discomfort that consists of qualitatively distinct sensations varying in intensity.
Name some diseases in which dyspnea has a high percentage of prevalence.
- Lung cancer
- Advanced COPD
- Advanced Heart Diseases
- Dementia
- Cancers
What is the pathophysiology behind dyspnea?
Perception that the respiratory muscle response is inadequate or unsustainable due to impairment of the mechanical process of ventilation leading to an increased ventilatory demand.
Describe the BTF model of Breathlessness.
It is a vicious cycle of 3 criteria which influences breathlessness in a patient. The first criteria is BREATHING. Increased Resp. Rate, inappropriate accessory muscle use and dynamic hyperinflation of the patient’s lung leads to inefficient breathing and increased breathing labour. The second criteria is THINKING. Attention to the sensation, memories of past exp., misconceptions and thoughts of dying in turn lead to anxiety, panic, frustration and anger in the patient. The third criteria is FUNCTIONING. Reduced stimulation, social isolation and heavy reliance on help leads to cardiovascular and muscular deconditioning in the patient.
Why is the BTS model important?
To understand the severity of breathlessness in a patient
How do you assess dyspnea?
According to these 4 criteria :
- Quality
- Intensity
- Impact
- Distress
How do you assess the intensity of Breathlessness in a patient?
Using the Dalhousie Dyspnea Assessment Scale which has 3 criteria (Exertion before dyspnea, Lung Constriction, Bronchial Constriction) in which the patient has to grade (0-7).
State 2 other scales used to assess Breathlessness
- Medical Research Council Dyspnea Scale (MRC)
2. Modified Borg Dyspnea Scale
How do you grade a patient with the MRC Dyspnea Scale?
GRADE 1 : Breathless with strenuous exercise
GRADE 2 : Shortness of breath on hurried walking on a level or uphill
GRADE 3 : Walks slower than people of the same age, stops for breath when walking at own pace.
GRADE 4 : Cannot walk for more than 100 yards without stopping to breath
GRADE 5 : Too breathless to leave the house or carry out daily activities
How do you assess the impact of breathlessness in a patient?
Using a Oxygen-Cost Diagram.
What do you use to assess distress due to breathlessness in a patient and what are the important criteria to be observed?
Use a Respiratory Distress Observation Scale (RDOS)
- HR per min (0 points : Baseline + 5 beats, 1p : B + 6-10, 2p : B + >10)
- RR per min (0p : B + 3, 1p : B + 3-6, 2p : B + >6)
- Restlessness (0p : none, 1p : occasionally, 2p : frequent)
- Accessory muscle use (0p : none, 1p : slight, 2p : pronounced)
- Grunting at the end of respiration (0p : none, 2p : present)
- Nasal flaring (0p : none, 2p : present)
- Look of fear (0p : none, 2p : present)
How do you manage a case of Dyspnea?
- Correct the reversible causes
- Do not conduct futile treatments
- Do not add distress/financial burden
- Discuss all options with the patient and their family
- Prioritise quality over longevity
- Reduction of symptoms
State 4 ways to reduce symptoms in a patient.
- Minimise production of symptoms
- Diminish perception of symptoms
- Reduce the impact of symptoms
- Modify the impact of symptoms
How do you minimise symptoms of breathlessness?
- Conduct exercise training
- Teach breathing techniques (pursed lips)
- Provide supplemental oxygen
- Recommend proper nutrition
How do you diminish perception of breathlessness symptoms?
- Placing a fan in front of the patient
- Pharmacotherapy (Opioids,BZDs)
- Distract the patient with music, CBD, images
- Stimulate the afferent nerve by chest wall vibrations
How do you reduce the impact of breathlessness symptoms?
- Conserve energy
- Maintain posture and ergonomics
- Modify lifestyle
How do you modify the impact of breathlessness symptoms?
- Make a plan of action when patient is exacerbated
- Treat the underlying mood disorder
- Change patients interpretation of the symptom
What are the preferred drugs in management of Dyspnea?
- Opioids
- Benzodiazepines
- Bronchodilators (oral/nebulized)
- Phenothiazine
- Diuretics
- Steroids (oral/inhaled)
- Anticholinergics
- Non-invasive ventilation
What are the mechanisms by which opioids reduce Dyspnea?
- Analgesic action
- Anxiolytic effect
- Suppression of respiratory awareness
- Alters neurotransmission with medullary Resp. Centre
- Blunts afferent transmission from pulm. mechanoreceptors to CNS
- Blunts medullary sensitivity and response to hypercarbia/hypoxia
- Decreases metabolic rate and ventilatory requirements
- Cause vasodilation and improves cardiac functions
Name the benzodiazepines preferred in breathlessness.
Short acting BZDs (Midazolam, Oxazepam)
Name the phenothiazine preferred in breathlessness.
Promethazine
When is bronchodilators preferred and name some.
When there is reversible airway obstruction.
- Methyl Xanthine
- Beta 2 agonists