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Dyspnoea

Objectives
1.Prevalence
2.Pathophysiology
3.History and Physical Examination
4.Investigations
5.Pharmacological and Non Pharmacological Management.
6.Case- study

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Definition
▪Subjective experience of breathing discomfort
that consists of qualitatively distinct sensations
that vary in intensity.(The American Thoracic Society,
1999)

▪Multidimensional and multi factorial

▪Psychosocial, social and spiritual/existential


issues can amplify the suffering.

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Prevalence and Dyspnoea symptom
burden

Cancer • 21%-79%

AIDs • 11%-62%
Acquired Immune deficiency

COPD • 90%
Chronic obstructive lung disease

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Patho physiology

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Etiologies

Brain/central control Cardiovascular Musculoskeletal system


Respiratory System Limbic system
Gas Exchange system/control Muscle
activation Ventricular filling
abnormalities Central motor drive wasting/cachexia
Airway obstruction pressures
Central chemo receptor Metabolic acidosis
Lymphatic obstruction Peripheral
stimulation chemoreceptor Accumulation of
Pleural effusion Intracranial pressure activation metabolic bi-products
Pulmonary edema due to direct tumour Anemia
effect

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Bio psychosocial Model of Dyspnea

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Total Dyspnoea

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Anxiety and Dyspnoea Cycle

D
Y
S
P
N
E
A

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History
Identification of underlying cause

Onset Description Quantification


• The • How does the • Breathless
breathlessness breathlessness mild moderate
sudden or episode feel or severe?
gradual? like?

Associations Exacerbations Relievers


• Do you have • What makes • What makes
other the breathlessness
symptoms breathlessness better?
• URTI? worse?

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History

Trajectory Impact Behavioural


and coping
• What is the • Affect sleep • How do you
breathless • Affect Eating cope with the
pattern like? • Affect Social symptoms?
• Meditation
etc.

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Dyspnoea Descriptors My chest feels
tight, I can’t
breathe
I feel like
suffocating

My breathing
My breathing
requires effort
is heavy

Gold Standard diagnosis = SELF REPORT

May not correlate with respiratory rate, oxygen saturation


and lung function test.

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Physical Examination
INSPECTION
▪Tracheal deviation (can
suggest of tension
pneumothorax

▪Chest wall deformities


Kyphosis - curvature of the
spine - anterior-posterior
Scoliosis - curvature of the
spine - lateral
Barrel chest - chest wall
increased anterior-posterior;
normal in children; typical of
hyperinflation seen in
COPD
Pectus excavatum 13
Pectus carinatum
Physical Examination
INSPECTION
• Cyanosis - person turns blue
• Pursed-lip breathing - seen in COPD (used to increase
end expiratory pressure)
• Accessory muscle use( scalene muscles
• Diaphragmatic paradox - the diaphragm moves opposite
of the normal direction on inspiration; suspect flail
segment in trauma
• Intercostals in drawing
Physical Examination
INSPECTION

Pink puffer’. Note the


Pallor Clubbing
pursed-lip
breathing
Physical Examination
Anterior and Posterior
-Symmetrical Chest expansion
-Tactile Fremitus

Percussion
-Hyper resonant
-Resonant
-Dull
-Stony Dull
Auscultation
-Vesicular, bronchial, Wheeze
-Stridor, crackles, vocal
resonance 16
Physical Signs and Interpretation
Disorder Mediastinal Chest wall Percussion Breath Adventitio
displacement movement Sounds us
Sounds
Consolidation None Reduced Crackles
Affected Dull
Collaspe Same side Reduced Nil
Dull
Pleural Opposite side Reduced Nil
Effusion Stony Dull
Pneumothorax Opposite side Hyper resonant Reduced Nil

Asthma None Normal Reduced Wheezes


Bilateral Hyper resonant
Pulmonary Same side of Normal/ Reduced Yes
Fibrosis apical lesion Bilateral Dull
Common
Investigations
Investigations

Laboratory Radiological

Arterial Chest Xray, CT


Full Blood blood scan
Count gas MRI, PET,VP scan
Urea B-type Others
Creatinine nature Pulse oximetry
tic Pulmonary function
PT/PTT
peptide
tests,
Electrocardiogram
Angiography
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Management

Step 1 Treat Cause

Identify underlying Provide


cause symptomatic
management

Reversible Irreversible

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Treat Reversible Causes

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Symptomatic Management

Pharmacological

Management
Non
Pharmacological

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Non Pharmacological Interventions
Single component
Walking aids
Chest wall vibration
Music/Relaxation
Acupressure
Non Pharmacological Acupuncture
Interventions
Multi component
Counselling
Support
Breathing Training/Fan

Cochrane Review 2009


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General Measures
▪Explain and reassure.
▪Ensure proper room
ventilation.
▪Breathing exercises
▪Positioning
-Sit upright
- Lying towards
compromised
▪Mild facial cooling
▪Relaxation therapy
–Complementary therapy eg
massage
▪Modification & adaptation
E.g sit to wash/shave. 23
Posture and Positioning

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Energy Conservation Techniques
Strategies Examples
1.Pace Activity ▪Break down activities into small
parts.
▪Alternate daily activities heavy
with light tasks.
▪Set small achievable goals

2.Plan Activity ▪Consider the times medication


is taken.
▪Use Prompters to avoids trips up
and down.
▪Modify environment.

3.Be energy efficient ▪Push rather than pull items.


▪Correcting lifting techniques/Sit
down.25
Fan
Facial cooling in the areas by the
second and third branches of the
trigeminal nerve.

Airflow
▪Encourage cool airflow over
the face.
▪Open window and proper
ventilation.
Schwartzstein RM et al. (1987) Cold facial stimulation reduces breathlessness induced in normal subjects. Am Rev Respir Dis 136:
58–61

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Oxygen Therapy

Trial if hypoxic Sao2<90%.

Sa02 >90% may be offered a


trial if desired.

Trial for a fixed period e.g 15-


30mins is recommended then
reassess.

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Anxiety Reduction
Interventions
▪ Diaphragmatic
breathing/purse lip
breathing

▪Visualization/imaginary

▪Distraction

▪Relaxation

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Assess Psychological Factors
Listen
Understand
Address

Relaxation Written Plan for


Techniques carers

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Pharmacological Mechanism of Opioids
▪Exact mode of action unknown

Postulations
-Depress opioid receptors in lungs, spinal and
central respiratory centres.
-Reduces central perception
-Diminishes ventilation response to hypoxia and
hypercapnia.
-Venodilation of pulmonary vessels

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Opioids
For Opioids Naive/Elderly
▪Start oral morphine 2.5mg p.o or
regularly 4-h if dyspnea is
continuous.

▪Escalate by 30% if breathlessness not controlled and


causing distress.

▪Fentanyl is the preferred choice of opioid for severe


renal and liverImpairment.

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Benzodiazepines

▪Diazepam 2-5mg and when


necessary.

▪Lorazepam or midazolam; shorter


half lives can be used in crisis
situations.

▪Lorazepam 1-2mg when necessary.

▪Midazolam 5-10mg subcutaneous or


buccal stat.
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Bronchodilators
▪For reversible bronchoconstriction.

▪Try Salbutamol 2.5-5mg 6h via


nebuliser or 2 puffs via spacer
device.

▪Ipratropium bromide 250-500mcg


6h via nebuliser or 2 puffs q.d.s
via spacer device.

▪Sodium chloride 0.9 per cent via a


nebuliser.
(liquidize secretions)

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Corticosteroids
▪Reduce the oedema and
inflammation.

▪Particularly for
-Multiple lung metastases
-Stridor due to tracheal obstruction
-Superior vena cava obstruction Superior Vena Cava obstruction
-Lymphangities carcinomatosis.

Benefit :within seven days.


If no improvement, to stop
▪Dexamethasone 4-8mg per oral
daily for one week

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Management of Dyspnoea
Chronic Obstructive Lung Disease

Palliation of dyspnea in advanced COPD:revisiting a role for opioids


G Rocker,R Horton, D Currow, D Goodridge, J Young, S Booth
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Case Study
Mr J is a 48 years old ex mechanic.

Non Small Cell lung carcinoma.

Married with two school going children aged 10 years old and 4 years old.

Has completed radiotherapy. Disease has progressed. Breathlessness


getting worse. Unable to sleep at night.

You are his community palliative nurse who visits him at home.

How can you help him?

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Questions

▪ What questions will you ask in history taking?


▪ What are the clinical signs you will look out for in
the physical examination?
▪Based on your history and physical examination
what are your probable causes?
▪What are your pharmacological measures?
▪What are your non pharmacological measures?

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Case Study: Hyperlink slide

History Physical
Examination

Identify
reversible
cause
Pleural
Effusion

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History
▪Dyspnea getting progressively worse past
few days.
▪Feels like “Drowning”.
▪Mild at rest, worsen with movement and lying
down.
▪No upper respiratory tract symptoms.
▪Sometimes relieves with rest.
▪Affects sleep and appetite.

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Chest X-ray

Physical
Examination
Dyspnoeic
Reduced Air Entry Lt
lung
Auscultation Stony
Dullness

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Management
• Symptom • Coop
Loop

Medical Nursing

Functional Psychosocial

• ADLs • Financial

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Medical
Non
Pharmacological
Pharmacological

Fan
Start mist morphine Deep breathing
2.5mg Q4 prn. exercise

Start lorazepam 1mg


Energy conservation
ON

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