Palliation in Respiratory Disease

Abstract

Palliative care plays an important role in pulmonary disease; a common cause of acute and chronic terminal illness. Its role is well recognised in lung cancer but less so in other respiratory disease (Johnson. Clin Med 10(3):286–289, 2010). It can sometimes be difficult to differentiate between what is considered palliation and what is considered routine care. It is important therefore for the physician caring for patients with respiratory symptoms or disease to be able to integrate restorative/curative management and palliative measures as appropriate on an individual patient basis. This needs to be incorporated as part of their routine management plan. Similarly patients primarily receiving palliation benefit from curative and restorative measures such as treating pneumonia or wheeze in terminal care. Hence patients benefit from a holistic, multi-disciplinary team approach to their management which focuses on the patient and their family’s needs, wishes and expectations. The American Thoracic Society (ATS) have laid out a clinical policy statement related to palliative care for patients with respiratory diseases alluding to this in some detail (Lanken et al. Am J Respir Crit Care Med 177(8):912–927, 2008). This chapter outlines a symptom and disease-specific approach to palliation in respiratory disease.

Appendices

Review Questions

• 1. Treatments of proven benefit in dyspnoea do not include:

  • (a) Opioids

  • (b) Oxygen for patients with hypoxia

  • (c) Benzodiazepines

  • (d) Heliox

• 2. Treatment of symptomatic cough includes:

  • (a) Bronchodilator therapy

  • (b) Physiotherapy

  • (c) Dextromethorphan

  • (d) All of the above

• 3. Patients with hemoptysis:

  • (a) Suffer underlying lung conditions

  • (b) Need to be managed as inpatients

  • (c) Have massive hemoptysis if they exporate  >  50 ml of blood over 24 h

  • (d) If massive, may have up to 80% mortality

• 4. For the effective treatment of dyspnoea, opioids may be give

  • (a) Orally

  • (b) Intravenously

  • (c) Transdermally

  • (d) All of the above

• 5. Stridor:

  • (a) Is a medical emergency

  • (b) Can be alleviated quickly by i.v steroids

  • (c) Can only be treated by physical means, e.g. stenting/tracheostomy

  • (d) Should be treated by administering back to back salbutamol nebulisers

• 6. In haemoptysis:

  • (a) A CXR is usually sufficient to diagnose cause and aetiology

  • (b) Patients should receive high flow oxygen therapy

  • (c) “Massive” bleeds are defined as blood loss  >  50 ml

  • (d) Patients should receive nebulised therapy

• 7. The treatment of lung infections in immunosuppressed patients should include:

  • (a) Broad spectrum antibiotics

  • (b) The use of mucolytics

  • (c) Physiotherapy

  • (d) All of the above

• 8. Patients with respiratory muscle weakness are most likely to hypoventilate:

  • (a) When awake

  • (b) In Stage 1  +  2 sleep

  • (c) In Stage 3  +  4 sleep

  • (d) In REM sleep

• 9. Poor prognosis in lung cancer compared to other malignancies is typically due to:

  • (a) Late presentation of disease

  • (b) Advanced stage of disease at presentation

  • (c) Poor performance status of patients due to co-existing medical conditions

  • (d) All of the above

Answers

• 1. (c). While opioids have been shown to be effective in a number of trials, as have oxygen for hypoxic patients or heliox, particularly for patients with large airway obstruction, there is little evidence for the use of benzodiazepines. However, treatment of dyspnoea often includes benzodiazepines such as midazolam, as it is felt that patients may still benefit.

• 2. (d). Treatment of symptomatic cough is important as it can be a disabling feature of many illnesses. Treatment of cough requires the diagnosis and management of the underlying condition—which may be pulmonary or extra-pulmonary, such as post-nasal drip and gastro-esophageal reflux disease. Cough, particularly caused by airways disease such as asthma or COPD may respond to bronchodilator therapy. Physiotherapy can be important in teaching cough suppression techniques. Dextromethorphan is a pharmacological cough suppressant.

• 3. (d). In patients presenting with hemoptysis, it is important to rule out bleeding from other sites, such as the oral cavity or nose, which can present as hemoptysis without any overt epistaxis or pooling of blood in the mouth. Not all hemoptysis needs to be managed as an inpatient, and patients with mild hemoptysis who are haemodynamically stable and have little co-morbidities may be managed as outpatients after thorough assessment. Massive hemoptysis is defined as expectoration over 100 ml of blood over 24 h. Massive hemoptysis may be fatal and requires intensive management and resuscitation, if appropriate. However, the mortality of massive hemoptysis may approach 80%.

• 4. (d). In terms of pharmacological treatment of dyspnoea, opioids are still considered first line. Opioids may be administered in a number of different routes, including orally, subcutaneously, transdermally or intravenously. However, it is important that in the treatment of dyspnoea a patient centred multi-disciplinary team approach is taken. This will include the treatment of patients with non-pharmacological methods such as psychological support, exercise, nutritional advice and other methods, such as cooling fans.

• 5. (a). Stridor is considered to be a medical emergency which can rapidly progress to death due to complete airway obstruction. Although steroids are beneficial, their mode of action means that they usually take a few hours to work. Treatment of stridor is dependent on the cause, i.e. small cell lung cancer or lymphoma causing airway obstruction due to mediastinal lymphadenopathy may respond to chemotherapy agents. Tracheostomy is only helpful in high tumours, i.e. those above the vocal cords. Nebulised therapy with epinephrine has been shown to be beneficial.

• 6. (b). A CXR is often quick and easy to arrange. However, more detailed radiology such as CT scanning is often necessary in order to determine the cause for haemoptysis. Patients with haemoptysis should be treated with high flow oxygen and cough suppressant medications such as opiates. They should be managed in a calm, relaxed manner, positioned lying on the side of the diseased lung, so protecting the “good” lung. Nebulised therapy can lead to coughing which can precipitate further bleeding. Massive haemotysis is defined as blood loss of 100–600 ml in a 24-h period.

• 7. (d). All of the above are suggested. Physiotherapy can help clear secretions. Mucolytics such as carbocysteine and nebulised saline can help loosen secretions to help expectoration. Infections in immunosuppressed patients maybe due to atypical or unusual pathogens, therefore, initial treatment with broad spectrum antibiotics is recommended whilst culture results are awaited.

• 8. (d). During REM sleep flaccid paralysis occurs meaning breathing is via the diaphragm only. If a patient has a neuromuscular weakness affecting the diaphragms, they will breathe less effectively during this phase of sleep. Stage 1  +  2 is defined as light sleep, Stage 3  +  4 is defined as deep sleep.

• 9. (d). Patients with lung cancer often present late and with advanced disease. They often have co-existent COPD and cardiac disease due to their shared aetiology (i.e. smoking).