The Palliation of Chronic Obstructive Pulmonary Disease

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The Palliation of Chronic Obstructive Pulmonary
Disease

• May, 2007

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• The essence of a breath is filled with
  physiological, psychological and spiritual signals

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Case study

• Mr. J.D. is 87 years old from rural Manitoba
• Long time smoker smokes 2 packs per day for 60
  years
• Increasingly dyspneic over last 2 years
• COPD is suspected by the doctor and the patient
  is informed
• Pt asks you what is COPD? what do you say?

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What is Chronic Obstructive Pulmonary Disease
(COPD)?

• OBSTRUCTION to Airflow
• Airway collapse
• Bronchospasm
• Mucosal inflammation
• Edema
• Leads to air-trapping and hyperinflation

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What is COPD?

• Chronic Bronchitis
• Cough productive of sputum for 3 months of 2
  consecutive years
• Emphysema
• Destruction of airspaces distal to the terminal
  bronchus

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Normal Lung
Emphysema
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How common is it?

• Accounts for 18 hospitalizations
• 4th leading cause of death in Canada
• Affects 6 of the general population
• Most common reason for ER visits in U.K.

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Incidence

• The incidence is increasing
• By 2020
• 3rd leading cause of death
• 5th leading cause of disability
• Increased by 53 from 1988-1999 in women and is
  still rising

Sullivan, Chest 2000 Michaud, JAMA 2001 Murray,
Lancet, 1997
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Case Study

• Mr. D. is referred to a respirologist in the city
• He asks his nurse what the visit might be like
  what do you say?

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Diagnosing COPD
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Diagnosing COPD
Canadian Thoracic Society Recommendations, 2003
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Case Study

• Mr. D. returns from the city with a diagnosis
  COPD (Emphysema)
• He wants to know what life will be like with COPD
  and how long he has to live
• What do you think his symptoms will be?
• What do you think his prognosis is?

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Symptoms
Elkington, Pall med, 2005
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Natural History

• Progressive decline in lung function
• Terminal Disease
• Acute exacerbations
• Entry reentry terminal trajectory

Diagnosis
Death
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Survival

• Median survival after hospitalization for acute
  exacerbation?
• Median survival after ICU admission?
• Percentage of patients readmitted within 6 months?

• 2 years
• 224 days
• 50

• (Manino, Chest 2002) (Almagro, Chest 2002)
• (Conners, Am J Resp Med 1996) (Morray, 1995)

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Survival

• In hospital mortality?
• 1 year mortality?
• 2 year mortality?

• 11
• 43
• 49

Conners, Am J Resp Med, 1996
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Factors affecting in hospital death

• Low pO2
• High pCO2
• Cardiac disease
• Age
• Oral corticosteroids
• Overall mortality affected by
• Low albumin
• Low BMI
• FEV1 lt 30

Chua, Chest 2005 Gunen, Eur Resp J,
2005 Groenwagen, Chest 2003
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Case Study

• Mr. D. is informed that his prognosis (death and
  disability) depends mostly on .?

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Smoking Cessation
Booker, Br J Nurs, 2005
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General Treatment of COPD

• Inhalers
• B agonists
• Anticholinergics
• steroids
• Theophylline
• O2
• hypoxemic
• cor pulmonale
• Polycythemic

• Education
• Vaccines
• Flu
• Pneumococcus
• Pulmonary rehab

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General Pharmacologic Approach
Canadian Thoracic Society Recommendations, 2003
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Case Study

• Over the next 2 years, Mr. D. has 8
  hospitalizations for AECOPD/ pneumonia
• He is put on maximal doses of inhalers
• He is put on continuous oxygen
• His mood declines, his anxiety increases
• He refuses to go to his granddaughters wedding
  because of embarrassment of his illness
• How does his mental health compare to patients
  with lung cancer?

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Comparing Lung Cancer COPD
(Gore, Thorax, 2000)
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Comparing Lung Cancer COPD
(Pall. Med, Edmonds 2001)
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Comparing Lung Cancer COPD
(Gore, Thorax, 2000)
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(Gore, Thorax, 2000)
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Case Study

• Mr. D. develop shingles which breakout across
  half of his face
• He describes the pain as someone is taking a
  blow torch to my head
• His doctor struggles to manage his pain, not
  wanting to put him on opioids
• Palliative care/Pain service never consulted

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Case Study

• Mr. D. dies suddenly in hospital 2 weeks later,
  family surprised but relieved
• How commonly is prognosis not discussed with COPD
  patients/family?

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Comparing Lung Cancer COPD
(Pall. Med. Edmunds, 2001)
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Case Study

• What is the truth about opioids in COPD?
• Other than inhalers, what has shown to be
  effective for the palliation of COPD?

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Palliation of Dyspnea

• Toll of Dyspnea
• Physical
• Fatigue, loss of concentration, loss of appetite,
  loss of memory, sweating, constipation, nausea,
  insomnia, difficulty weight bearing
• Emotional
• Anxiety, nervousness, fear, panic, depression
• Social
• Barrier to all activities

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Mechanisms of dyspnea

• 1) Increase afferent input from chemoreceptors
  and lung receptors
• (pH, PO2, PCO2, stretch/irritant and J receptors)
• 2) Increase sense of respiratory effort
• Ratio of the pressure generated by respiratory
  muscles to the maximum pressure-generating
  capacity of the muscles
• 3)afferent mismatch
• Not enough displacement of muscle fibers per
  tidal volume (length-tension inappropriateness)

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Treatment of Dyspnea

• Non pharmacologic
• Vaccines
• Moving Air
• Nutrition
• Physiotherapy
• Psychosocial support
• Pulmonary rehab
• Non-invasive ventilation
• Surgery

• Pharmacologic
• Oxygen
• Opioids?
• Benzodiazipines?
• Antidepressants
• Mucolytics

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Booker, Br J Nurs, 2005
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Palliation of Dyspnea in COPDOpioids

• Opioids in COPD Controversial!
• Improvement in dyspnea and sleep over placebo
  with SR Morphine (Abernethy, BMJ 2003)
• 2 systematic reviews 18 double-blind,
  randomized, controlled trials, showed significant
  relief of dyspnea with oral or parenteral opioids
  (Tomas, Curr Opin Pulm Med, 2004)
• No significant effect of nebulized opioids.
  (Tomas, Curr Opin Pulm Med, 2004)

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Palliation of Dyspnea in COPDOpioids
BUT..
(Global Strategy for the Diagnosis, Management
and Prevention of COPD - GOLD recommendations
Am J Resp Crit Care Med, 2001)
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Palliation of Dyspnea in COPDBenzodiazipines

• Benzodiazipines
• NO literature on benzos in COPD
• Midazolam 5.0 mg improves dyspnea above the
  improvement seen from morphine alone in dyspneic
  terminally ill cancer patients (Navigante, J Pain
  and Symp Management, 2006)

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Palliation of Dyspnea in COPDOxygen
(Expert Working Group of the scientific committee
of palliative medicine, 2004)
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Palliation of Dyspnea in COPD

• Oxygen
• Current recommendation is that it should be used
  with
• Hypoxemia (improves survival)
• Cor pulmonale
• Polycythemia
• During and after ambulation if symptomatic
• ? At rest

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Palliation of Dyspnea in COPD

• Take home message
• Continue previously prescribed inhalers
• Can use opioids in palliation depending on
  patients goals of care
• Try benzos if dyspnea refractory depending on
  goals of care
• Oxygen during ambulation
• Can try oxygen at rest

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Management of Cough

• Protussive therapy
• Hydration
• Physiotherapy
• Suctioning
• Tracheostomy
• Aerosolized hypertonic saline
• N-acetylcysteine
• B-agonists
• Guafenisen

• Antitussive therapy
• Dextromethorphan
• Hydrocodone/codeine?
• Po and aerosolized local anaesthetics
• Theophylline
• B- agonists
• Anticholinergics

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Case Study

• Why do you think palliative care was never
  consulted for Mr. D.?

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Patient Barriers to Palliative Care

• Would rather concentrate on staying alive
• Not sure which doctor will take care of me
• I dont know what kind of care I want
• I dont like to talk about getting very sick
• My ideas about care change at different times
• Doctors look down on me because of smoking
• I am not ready to talk about it
• My doctor doesnt want to talk about it

(Chest, 2005)
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Physician Barriers to Palliative Care

• Too little time in our appointments
• Dont want to take away hope
• Patient is not ready to talk about it
• Patient has not been very sick yet
• Patient doesnt know what kind of care they want
• Patient ideas about care change over time
• My role as a doctor is to make pt feel better

(Chest, 2005)
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Murray, Prim Care Resp J, 2006
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Palliative Care Discussion Starters

• If things got worse, where would you like to be
  cared for?
• Whats the most important issue in your life
  right now?
• What helps you keep going?
• What is your greatest problem?
• You seem cheerful at present, but do you ever
  feel down?

(Murray, Prim Care Resp J, 2006)
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Palliative Care Symptom Management - Dyspnea

• Very personal experience for the patient
• Heavy, gasping, hunger, effort
• Shortness of breath, hard to move air, not
  getting enough air, somebody taking the breath
  away, choking, panting, suffocation

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Non-Malignant End stage Respiratory Disease

• COPD
• Pulmonary Fibrosis
• Cystic Fibrosis/Bronchiectasis
• Pneumoconiosis
• TB
• Sarcoidosis
• Circulatory Disease
• Neuromuscular/ Chest Wall Disease

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Prognostic Factors

• Cystic Fibrosis
• Worse prognosis if
• Intubated
• Large annual decrease in FEV1(Texeraeu 2006)
• FEV1 gt 30 predicted
• Colonization with Burkholderia
• Worse hypoxemia and hypercapnia
• Poor nutritional status
• 1 yr survival 52 for patients in the ICU
• (Ellaffi 2005)

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Cystic Fibrosis

• Lung Transplant Survival

(Quatrucci 2005)
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Summary

• Palliative treatment of respiratory symptoms the
  same regardless of type of pulmonary illness
• Nonmalignant pulmonary diseases can be very
  symptomatic
• Little evidence to support palliative management
• Many barriers to palliative care in nonmalignant
  disease
• Prognostication for nonmalignant diseases is
  difficult