Palliative Dyspnea

Managing dyspnea in the palliative patient.

This comes down to 4 approaches:

• Oxygen

• Opiates

• Benzodiazepenes

• Addressing the underlying issue

• Other measures of comfort

Oxygen

• Several options here with pro's and con's to all

• Nasal Cannula 

  • Comfortable at low flows

  • Limited in how much oxygen it can deliver as it provides no reservoir of oxygen; it depends on the patient's upper airway as the reservoir of oxygen

  • at high flow rates is uncomfortable and causes dryness and bleeding unless delivered with a humidifier)

  • Many patients mouth breathe at the end of life

• Non-rebreather

  • provides more oxygen, enables oxygen delivery to mouth breathers

  • Uncomfortably noisy, must be drawn tightly against the face to be most effective

  • muffles communication at a time when it is of key importance in the dying patient

  • Dries patient's mouth and nares out

• Venturi Mask

  • An underutilized therapy

  • Addresses mouth breathing

  • Mixes oxygen with room air

  • Able to provide relatively high flow rates of oxygen 

  • Does not need to be humidified as high flow rates of oxygen are mixed with ambient room air

• High-flow nasal cannula

  • Comfortably provides humidified oxygen at extremely high rates

  • Does not provide oxygen to mouth breathers

  • If the patient is being admitted it requires admission to the MICU (or potentially PAMCU)

• Non invasive ventilation (Bipap)

  • Noisy, uncomfortable, frightening

  • Decreases the ability to commmunicate

Opioids

• THE KEY TO PALLIATIVE DYSPNEA

• Can be delivered via the subcutaneous route, another underutilized therapy

• Administer zofran to offset possible associated nausea

• Decrease the intensity of air hunger and dyspnea related anxiety

• Have been shown to NOT SHORTEN LIFE IN PALLIATIVE PATIENTS, which is important to communicate to the dying patient's family. 

Benzodiazepenes

• Anxiety leads to worsening dyspnea; managing the anxiety therefore aids in management of dyspnea

• Generally not used as monotherapy, however can be used in addition with opiates in the anxious and dyspneic patient

Other measures

• Position the patient as they wish, though generally the more upright patient is the more comfortable patient

• Death rattle: As patients lose consciousness they lose their ability to swallow and oral secretions can pool, causing gurgling noises. There is no evidence that this is disturbing to patients, but families often have a very hard time with these noises.

  • Glycopyrrolate can help mitigate this disturbing noise

Cause specific techniques = address the underlying issue

• Must weigh the benefits vs. the discomfort of performing these interventions

• Pleural effusions: Thoracentesis

• Anemia: Transfusion

• Obstructing airway mass: Steroids, palliative radiation if available

• Pneumonia: Antibiotics

• Fluid overload: Diuresis

• Bronchospasm: Bronchodilators

See:

https://first10em.com/palliative-resuscitation-dyspnea/

https://www.rtmagazine.com/products-treatment/monitoring-treatment/therapy-devices/oxygen-administration-best-choice/

Transfusion Reactions. The facts (and opinions)

Welcome to Tuesday. POTD. 

Question: Why do nurses use red pens? ---- answer at the bottom of this e-mail.

Have you ever been sickle to your stomach about consenting patients about the risks of transfusions? Well today we're going to iron out all the details about transfusion reactions 

Facts about transfusions

• ~20,000,000 units of pRBC's are transfused in the US per year

• In 2011, 8,000,000 people in America received a transfusion

• There were 51,000 reported transfusion reactions (0.64% of transfusions)

• 317 of them required pressor support, intubation, or ICU care

• While screening techniques have reduced the risk of viral transmission, they still exist. in 2010, the risks of viral transmission were estimated:

  • HIV: 1:1,467,000 units

  • Hep C: 1:1,149,00 units

  • Hep B: 1:357,000 units

The initial therapy for ALL transfusion reactions is to STOP THE TRANSFUSION

Types of transfusion reactions and therapies:

• Acute Hemolytic Reaction

  • most severe, easiest to prevent

  • due to ABO compatibility 2/2 human/lab error ---> patient antibodies attack donor blood

  • presentation:

    • within minutes of transfusion initiation

    • fever, agitation, tachycardia, hypotension, diffuse pain

      • can progress to jaundice and bleeding 2/2 coagulopathy and DIC

  • intervention

    • STOP the TRANSFUSION

    • IVF to maintain renal perfusion, loop diuretics to maintain urine output, pressors for refractory hypotension

  • work up

    • notify blood bank, send a type and screen from the patient AND the bag of donor blood to the blood bank

    • send labs

      • peripheral smear, LDH, haptoglobin, bilirubin, direct coombs to assess for hemolysis

      • repeat CBC, BMP, UA

      • fibrinogen, D-dimer, coags if concerned for DIC

• Febrile non-hemolytic transfusion reaction (FNHTR)

  • most common, usually due to recipient antibodies against donor leukocytes

  • STOP the TRANSFUSION

    • while FNHTR is a benign process, more severe reactions must be ruled out

  • assess the patient to ensure a more severe reaction isn't occurring (monitor vital signs, assess for pain indicative of acute hemolytic reaction)

  • Tylenol is the mainstay of treatment

  • patient's with a history of this can receive leuko-reduced or washed cells for future transfusions

• Allergic reactions/anaphylaxis

  • within minutes the patient will have symptoms of a typical allergic reaction: rash, urticarial, itching. Can progress to an anaphylactic reaction with hypotension, angioedema, and respiratory distress

  • Treat as an allergic reaction with H1-blockers, adding epinephrine if signs of anaphylaxis are present

  • If no signs of anaphylaxis, can continue the transfusion

• Transfusion-associated Circulatory Overload (TACO)

  • typically within 6 hours of transfusion initiation, due to fluid overload

  • may show signs similar to a CHF exacerbation: crackles, peripheral edema, B-lines on US, infiltrate on CXR, hypoxia

  • obtain an EKG to assess for ACS

  • positioning (sit upright), diuresis, nitrates, respiratory support as needed

  • BNP can be helpful if a pre-transfusion BNP was drawn 

  • prevent this by transfusions SLOWLY in at risk patients (Heart failure, renal failure patients)

• Transfusion Related Acute Lung Injury (TRALI)

  • Similar presentation to TACO, within the same 6 hour timeframe

  • both present with dyspnea, crackles, hypoxia, bilateral infiltrates on CXR 

  • TRALI is non-cardiogenic pulmonary edema due to donor antibodies attacking recipient leukocytes causing cytokine release --> increased permeability in pulmonary capillary membranes -- > ARDS

  • so will not have signs of cardiogenic fluid overload = NO peripheral edema, normal cardiac function

  • STOP the transfusion

  • manage as an ARDS patient

    • respiratory support

    • if intubation is required, use lung protective ventilation strategies

    • diuretics are NOT helpful. but if there is concern for an underlying cardiac problem you may administer them 

• Sepsis

  • due to bacterial contamination of donor blood

  • will show signs of septic shock. 

  • can be confused with early stages of acute hemolytic reaction --> send the appropriate labs to rule that our

  • send cultures from patient and from donor blood

  • manage sepsis as per usual, broad antibiotic coverage

  • IVF, sepsis protocols, get your eyes on that lactate measuring and re-measuring 

There are also several delayed reactions

• Graft Versus Host Disease (GVHD)

  • 7-10 days after transfusion

  • due to donor lymphocytes attacking an immunocompromised patient’s cells or when immunologically similar lymphocytes are transfused and not recognized as donor/foreign cells by the patient’s immune system

  • fever, jaundice, pancytopenia, transaminitis

  • prevented by using irradiated blood products in high-risk populations (immunocompromised

  • supportive treatment, though nearly 100% fatality rate

  • immunosuppressants, steroids, cytotoxic agents, and stem cell transplantation rescue have been used, though with questionable efficacy

• Delayed hemolysis

  • 5-10 days after transfusion

  • less severe form of acute hemolytic reaction due to antibodies against minor RBC antigens

  • typically minor hemolysis and progressive anemia

  • supportive care, transfuse as necessary; discuss with blood bank 

And a brief word on effects of massive transfusion

• Coagulopathy can occur from dilutional effect of administering pRBC alone without clotting factors. prevent by using MTP

• Hypothermia can result form using cold blood products. Prevent by warming products

• hypocalcemia can result from citrate binding. Can administer empiric calcium gluconate

• hyperkalemia can result. monitor potassium levels and treat accordingly 

• Acidosis can result from large amounts of lactic acid in stored blood

Why do nurses use red pens?

---

---

Because they draw blood!!!!

Thank you Ankit and Rebecca of our pharmacy department for your insight into today's Pearl. 

-Elly

COPD and antibiotics.

Welcome back to POTD. 

The weekend has come and the weekend has gone. I know you've all been holding your breath to hear about----

A message from our sponsors:

Take a deep inhale. feel some wellness. feel the firmness of your feet on the floor. hold onto your seat.   

Exhale nice and slowly......like someone with a COPD exacerbation.

Because today we're discussing antibiotic coverage in acute COPD Exacerbations. I know you've been waiting a lung time for this one. 

Background

• Acute COPD exacerbations (AECOPD) account for ~1.5 million ED visits annually in the ED.

• Many physicians routinely prescribe antibiotic coverage for AECOPD

• a 2018 review demonstrated antibiotic prescriptions given on 39% of ED visits for AECOPD between 2009-2014.

• Due to the structural changes in the bronchi of COPD patients they are more prone to bacterial colonization (as opposed to asthmatics - which have no structural change but a reactive process)

Do guidelines exist?

• Sure do. 

• if the patient appears infectious (think fever) administer antibiotics. This is understandable given their risk factors and bronchial structural changes.

• Several guidelines exist for more subtle cases, they exist as follows: (see chart below)

  • Global initiative for Chronic Obstructive Lung Disease:

    • Antibiotics should be given to

      • patients with all 3 of the following cardinal symptom

      1. increased dyspnea

      2. increased sputum volume

      3. increased sputum purulence

      • patients with 2 cardinal symptoms, if there is increased purulence

      • patients requiring noninvasive or invasive ventilation

  • American Thoracic Society/European Respiratory Society

    • hospitalized patients with chanegs in sputum characteristics

    • all patients admitted to an ICU

  • Canadian Thoracic Society

    • patients with severe purulent AECOPD

  • National Institute for Health and Clinical Excellence

    • patients with more purulent sputum

• Basically, pay attention to that sputum. take a thorough history and discuss changes in sputum production. 

-Elly