The Center for Palliative Care Education Palliative Management of Dyspnea in HIV/AIDS.

The Center for Palliative Care Education

Palliative Management of Dyspnea in HIV/AIDS

Learning objectives

Describe the primary causes of dyspnea at the end of life

Explain the process of evaluating a patient’s dyspnea

Give examples of treatments for dyspnea and their risks and benefits

Consider the causes, evaluation and treatment of dyspnea in patients with HIV/AIDS

Understand management of dyspnea during the last hours of life

Consider a case

42-year-old HIV positive man

Presents with progressive dypnea over 6 months

PMH otherwise unremarkable

–Physical exam normal

–Cutaneous Kaposi’s Sarcoma

–CXR shows…

Outline

Causes of severe dyspnea in palliative care

Causes of dyspnea in HIV/AIDS patients

Treatment options for dyspnea

Dyspnea in the last hours of life

Causes of dyspnea

Many pulmonary and non-pulmonary diseases can cause dyspnea:–Pulmonary: COPD, asthma, pneumonia, PE, lung cancer, lymphoma, pneumothorax, pleural effusion

–Non-Pulmonary: Heart failure, anemia, acidosis

First step to managing dyspnea is to diagnose and treat underlying cause

Some causes of dyspnea in HIV/AIDS

Opportunistic Infections: PCP, Fungal, TB, Viral

Pulmonary Kaposi’s Sarcoma

Lymphoma

HIV-Related Myopathy

Initial evaluation for dyspnea

History, physical examination

Chest x-ray

Laboratory tests: CBC, chemistries, arterial blood gas

Spirometry

Approach to managing dyspnea

Identify the cause

Treat what is treatable

Manage with supportive measures

What kind of life-support do patients receive?

0

10

20

30

40

50

60

70

80

Pe

rce

nt

Mech Vent Tube feed CPR

COPD (n=115)

Lung Cancer (n=116)

Claessens, J Am Geratr Soc, 2000

p<0.05 all comparisons

What kind of life-support do patients want?

0

20

40

60

80

100

Pe

rce

nt

Prefer Comfort Prefer DNR No Mech Vent

COPDLung Cancer

Claessens, J Am Geratr Soc, 2000

p>0.05 all comparisons

Treatment of dyspnea

Oxygen

Opioids

Benxodiazepines

Anti-depressants

Non-pharmacologic measures

Oxygen

Many HIV+ patients with dyspnea do not have low O2 saturations

However, O2 therapy may relieve symptoms of dyspnea

Pro: Symptom relief, ease of use

Con: Uncomfortable, burdensome, expensive

Oxygen

Indication for oxygen therapy:

–PaO2 < 55 mmHgPaO2 55-59 + a) p pulmonale,

–b) clinical right heart failure, OR c) hct > 55%

–SaO2 < 89%

–SaO2 89% plus a, b, or c above

–Treatment of dyspnea in hospice care

Opioids

Primary pharmacologic therapy for dyspnea

Important central effects of analgesia and euphoria that palliate dyspnea

Choice of administration route (Patch, PO, parenteral)

Intermittent vs. continuous dosing

Pro: May be efficacious in improving breathlessness

Con: Sedating, may cause respiratory depression, constipation

Trials of oral opiates for dyspnea in severe COPD

Author- Year Drug Duration Dyspnea

Woodcock ’81 dh-codeine 1 dose improved

Johnson ’83 dh-codeine 1 wk improved

Light ’89 morphine 1 dose improved

Rice ’87 codeine 1 mo no change

Eiser ’91 diamorph. 2 wk no change

Poole ’98 MS-SR 6 wk no change

Manning, Resp Care, 2000; 45:1342

Other agents with little or no effect on dyspnea

Nebulized opiates:–1 positive, 4 negative controlled trials

Benzodiazepines:–1 positive, 3 negative controlled trials

Buspirone:–1 positive trial, very small effect

Phenothiazines:–1 positive, small effect; 1 negative trial

Depression and anxiety in severe COPD and stage III/IV lung cancer

0

2

4

6

8

10

12

Ho

spit

al A

nxi

ety

& D

epre

ssio

n

Sca

le

Depression Anxiety

COPD

Lung Cancer

Gore, Thorax, 2000

p<0.01 all comparisons

Benzodiazepines

Use may alleviate associated fear and anxiety

Start at low dose and titrate to dyspnea reduction

Once effective dose determined, schedule administration Q4-6H

Variety of dosing routes available

Treating depression in COPD

12-week randomized controlled trial

Two groups:

–Nortriptyline vs placebo

N=36

–Major depression (n=33)

–Residual depression (n=3)

Mean duration depression 39 months

Borson, Psychosomatics 1992

Nortriptyline improves mood

0

5

10

15

20

25

30

Ham

ilto

n-D

NT Placebo

Entry

12 weeks

NT vs Placebo p=0.01

Nortriptyline (NT) improves anxiety and somatic symptoms

0

10

20

30

40

50

60

PR

AS

ANXIETY PHYSICAL SX BREATHING SX

NT Entry

NT 12 Weeks

Placebo Entry

Placebo 12 Weeks

Differential NT treatment effects: All p < 0.05

Nonpharmacologic interventions

Minimize anxiety-producing factors in the environment

Address concerns of family members and caregivers as well as the patient

Relaxation techniques

Fan/cool air

Schwartzstein RM, et al (1987) Am Rev Respir Dis 136:58 -61

Dyspnea in the last hours of life

Same treatment modalites: oxygen, opioids, and benzodiazepines

Titrate opioid dose to patient’s respiratory signs

Consider anticholinergic agent for management of secretions

Re-consider case

42-year-old man with HIV presents with progressive dypnea over 6 months

PMH otherwise unremarkable

–Physical exam normal

–CXR consistent with KS

Summary

Dyspnea is common and disabling

Identify cause of dyspnea and treat underlying cause when possible

Trial of symptomatic treatments

–Oxygen, opiates

Recognize and treat anxiety and depression

Spend time communicating with patients and family

Contributors

The primary author of this module is Elizabeth Knauft, MD, MS, University of Washington Department of Pulmonary and Critical Care Medicine

Anthony Back, MD DirectorJ. Randall Curtis, MD, MPH Co-DirectorFrances Petracca, PhD EvaluatorLiz Stevens, MSW Project Manager

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Copyright 2003, Center for Palliative Care Education, University of Washington

This project is funded by the Health Resources and Services Administration (HRSA) and the Robert Wood Johnson Foundation (RWJF).