Breathlessness in the ED

Palliative care workshop for EM residentsJuly 29, 2015

DisclosuresNo disclosures

Case“CTAS 1 to the resus room”

mid 70s female in acute respiratory distress

Has been placed on O2 by FM by EHS but despite this still only has O2 sats of 88% and significant WOB

Hx of severe COPD, on home O2 and max medical therapy. Frequent hospitalizations in past 3 months and steadily declining, now fully bed bound at home due to symptoms

What do you do next?

What is dyspnea?

“I feel like I am suffocating.”

“I am afraid and feel like I am drowning.”

“I have a tightness in the chest”

Total dyspnea

Cancer pts: lung, GI (esophagus), Breast, ENT, lung mets most common to have symptoms

CHF: 65% will have some dyspnea

COPD: 90% will have some dyspnea

IPF

Motor diseases: ALS, MS

Any patient with a life-threatening illness

When to think of palliative care?

Cancer, especially if metastatic or if lung, esophagus or ENT cancer

Advanced COPD: on home 02

CHF with EF <25%

Other significant co-morbidities

Recurrent ED visits/admissions for same problem in last 3 months

Poor functional status: ie ECOG 3 or 4

Pt expresses wish for comfort care or DNR

Surprise question

Goals of CareConcurrently treat the symptom while

addressing the underlying cause (if appropriate)

Outcomes are better when a palliative approach is adopted earlier in the disease process

Once those causes are no longer treatable, managing the symptom becomes the main priority

Non-pharmacologic options

fans directed towards face, open windows, cold compresses on face can help

pulmonary rehab

Acupuncture

breathing training (upright forward leaning position, controlled breathing, pursed-lip breathing)

relaxation strategies

walking aides

Home O2 criteria Arterial oxygen saturation (SpO2) less

than 88% for 6 min

Ambulatory Desaturation to less than 88% for 1 min

O2 delivery systemsNasal Prongs (NP) : 1-6 lpm , 22-40% Fi02

Simple Mask (SM) : 5-12 lpm, 35-50% FiO2

Non Rebreather Mask : 15lpm, 60-90% Fi02

High Flow Face Mask : up to 95 % Fi02

High Flow Nasal Prongs (HFNP) : 100% Fi02 with very high flowrates

Bi-Level Positive Airway Pressure (Bipap) : set Fi02 plus ventilatory support ( aka non invasive ventilation )

High Flow Nasal Prongs

NIVPP

Situations to consider HFNP/BiPAP

Time-limited trial

Goal-limited trial

Back to our casePatient’s symptom are controlled with HFNP and

opioids.

Goals of care are discussed with patient and family

Patient is clear that she does not want further life prolonging treatment

Symptoms are managed with opioids and midazolam

Patient passes away 2 days later on the palliative unit

SummaryDetermine patient’s values/goals of care

Investigate and treat underlying cause if appropriate

Oxygen has a role in palliative care, but only use it if it is helping to achieve the patient’s goals

Opioids are main treatment for refractory dyspnea and will not hasten death when used appropriately

Concept of total dyspnea – address other factors which may be contributing