9.1 (8.2) Dyspnea and other resp symptoms in PC

Question 1

What are the two patterns of dyspnea relating to frequency that have been described?

Answer 1

Episodic dyspnea
Constant dyspnea

Question 2

List four trajectories of dyspnea in illness. Which is most common in COPD and advanced cancer?

Answer 2

Fluctuating (most common)
Increasing
Stable
Decreasing

Question 3

List three qualities that may be used to describe dyspnea and provide an example of what can induce them

Answer 3

1. Air hunger or unsatisfied inspiration - hypercapnia, hypoxia, exercise, acidosis
2. Work or effort - weakness of resp muscles
3. Tightness - bronchoconstriction

Question 4

List four impacts of dyspnea

Answer 4

Panic
Fear
Anxiety
Depression 
Hopelessness 
Sense of loss of control
Fatigue

Question 5

List 4 red flag features of dyspnea on physical exam

Answer 5

Presence of stridor
Marked tachypnea (>30/min)
Tachycardia (>130bpm)
Marked RD
Altered LOC

Question 6

Describe correlation between dyspnea and hypoxemia. Describe correlation between dyspnea and PFTs

Answer 6

No correlation

for both

Question 7

What are the three domains that a dyspnea measurement tool should address?

Answer 7

Subjective sensory experience of individual patients

Measures affective distress

symptom impact or burden

Question 8

Besides cancer and cardiopulmonary causes, name 3 systemic causes of SOB

Answer 8

Anemia
Deconditioning
Muscle weakness
Panic attack

Question 9

List four malignancy-associated causes of dyspnea that respond to steroids

Answer 9

1. SVC syndrome
2. Lymphangitic carcinomatosis
3. Major airway obstruction
4. XRT pneumonitis
5. Drug induced pneumonitis

Question 10

List five broad methods of managing dyspnea in palliative care

Answer 10

1. Specific disease management
2. Non pharm intervention
3. Pharm treatmeant
4. Palliative non invasive ventilation
5. Palliative sedation

Question 11

List three non pharmacologic management techniques for dyspnea with good evidence and two with some evidence

Answer 11

Good evidence

• breathing training (shallow breathing dynamic hyperinflation, positioning etc)
• walking aids
• neuromuscular electric stimulation (for patients too weak to exericse)
• chest wall vibration
• exercise

Some evidence - fan, nurse follow up program, acupuncture

Question 12

What is the most systematically studied usage of opioid (and dose) that is beneficial and safe?

Answer 12

Morphine sustained release 10mg daily

Question 13

Which populations derive survival benefit from supp O2 and which derive symptom benefit?

Answer 13

Hypoxemic patients of all diagnoses for symptom benefit

*copd hypoxemic patients for survival benefit

Question 14

Use of opioids for dyspnea is associated with qualitative changes. Provide 3 of these

Answer 14

Sense of calm, symptom relief, substantial improvement in QOL

Question 15

List 3 indications for non invasive positive pressure ventilation

Answer 15

1. short term survival to allow pt to meet specific goal
2. Survival prolongation in:
   - acute COPD with type 2 resp failure (high PCO2)
   - cardiogenic edema with hypoxemi
   - resp failure in the immunocompromised host
   - advanced neuromuscular disorders
3. Dyspnea palliation

Question 16

based on neuroimaging studies list two brain structures involved in the experience of dyspnea

Answer 16

right anterior insula

amygdala

Question 17

List five causes of dyspnea that can be acutely life threatening

Answer 17

PE
pericardial effusion
major airway obstruction
arrhythmia
acidosis
massive aspiration

Question 18

List two pharm treatments with clear benefit for dyspnea and list two treatments with some benefit

Answer 18

Good evidence - opioids, oxygen

some evidence - anxiolytics, nebulized furosemide