HX3.1 Palliative Care in Non-Malignant Disease Flashcards
What are the issues in palliative care in non-malignant disease-problems?
Longer duration
Greater symptom burden
Different disease trajectory- less predictable
Less expectation of death
Traditionally always something else to try
Failure to regard diseases as progressive
Lack of research re symptom control
How is COPD classified?
Stage 0 chronic symptoms/normal spirometry Stage 1( mild) = >80% of FEV1 Stage 2( moderate) = ≤80% of FEV1 Stage 3( severe ) = ≤50% of FEV1 Stage 4 (very severe) = ≤30% of FEV1 (or <50% with respiratory failure/right heart failure)
How does COPD compare to lung cancer?
Symptom burden the same as lung cancer but …..
Suffering is greater
Time longer/uncertainty re dying on each exacerbation/social isolation/alienation from doctors
Stigma of being/having been a smoker-”their own fault”
What are the symptoms of COPD?
Dyspnoea
Cough/sputum
Wheeze
Airway irritability
Fatigue/ reduced appetite /weight loss if severe
Anxiety/panic attacks/depression/poor sleep
Functional limitation
Thirst
What are the characteristics on the last year of life in pt w/COPD
High users of primary care services High burden on carers 80% housebound 30% chair bound Only group that most (52%)prefer to die in hospital ?Most not formally recognised as dying
What is the “Tx” in advanced COPD?
Stop smoking Antibiotics (?maintainance) Inhaled bronchodilators (b2 agonists (LABA) and anti-cholinergics(LAMA)) Flu/strep pneumonia vaccine Trial of oral steroids Treatment of exacerbations (including non invasive ventilation) Mucolytics Small amount of exercise LTOT
What is name of the curve displaying the relationship between the onset of COPD symptoms and ages at smoking cessation?
Fletchers Curve.
What is the efficacy of Long Term Oxygen Therapy in COPD?
Long-term oxygen therapy(LTOT) improves survival in advanced COPD.
What are the indications for LTOT in COPD?
STABLE SEVERE DISEASE
NON SMOKERS
Chronic arterial oxygen saturation <88% with sleep or exercise
GIVEN FOR 15+HRS A DAY
How is LTOT delivered?
Oxygen given via home concentrator or ambulatory O2 via cylinder
Give at 2-3L/min
Short burst O2 used if not on LTOT and may give some relief for exercise related dyspnoea
Target range is 88-92% saturation in acute exacerbations, NOT higher.
What is NIPPV?
Non-Invasive Positive Pressure Ventilation
Ventilatory support triggered by patient’s own breathing
Reduces need to intubate by 58%(NNT 5)
Palliates severe breathlessness
?need for nocturnal NIPPV
What is the TX for breathlessness in COPD?
OPIOIDS –reduce tachypnoeic response to hypercapnia /hypoxia /exercise. Safe
?BENZODIAZEPINES
Fan
Which type of COPDer is worse?
Pink Puffers more breathless than blue bloaters and have less risk of respiratory depression
What discussion need to take place between doctor an pt in advanced stage COPD?
Pulmonary rehabilitation programmes
Discussions re palliative care/end of life care - patients prefer this discussion to be with respiratory physician or GP, and not in the midst of an exacerbaton(Taylor etal)
Discussions re symptom control / recurrent admissions /resuscitation
What is the typical prognosis in COPD?
5YR Survival overall 40-70%
22-43% die within 1 yr of admission for acute exacerbation
36-50% die within 2 yrs
50%(STAGE II)= 90% 3yr survival
>60y.o. and FEV1 < 50% (STAGE III)=75% 3yr survival
Age-weight loss-declining FEV1-cvs problems
What is the trigger for SPC in COPD?
- Severe disease STAGE IV -FEV1 <12months (and 1 of the following:
- Advanced age / multiple co-morbidity / severe systemic manifestations/complications)
Long term O2 therapy (LTOT)?
The housebound?
