Name:
A 68-Year-Old with Dyspnea
Description:
A 68-Year-Old with Dyspnea
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/32a14ce9-bfd1-460b-9c18-a21e61a797ff/thumbnails/32a14ce9-bfd1-460b-9c18-a21e61a797ff.jpg?sv=2019-02-02&sr=c&sig=GdKH7%2FAWW0Yq%2BVTHbRVtZ%2BtS98HrFC%2BAINc46CX3viA%3D&st=2024-05-04T08%3A30%3A21Z&se=2024-05-04T12%3A35%3A21Z&sp=r
Duration:
T00H05M56S
Embed URL:
https://stream.cadmore.media/player/32a14ce9-bfd1-460b-9c18-a21e61a797ff
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/32a14ce9-bfd1-460b-9c18-a21e61a797ff/17395306.mp3?sv=2019-02-02&sr=c&sig=ztycPeBvuWbnIpBscRISL1j1oZSA4jockEriPwlJ3tE%3D&st=2024-05-04T08%3A30%3A21Z&se=2024-05-04T10%3A35%3A21Z&sp=r
Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
♪ (music) ♪
CATHY: Hi, welcome to Harrison's Podclass, where we discuss important concepts in internal medicine. I'm Cathy Handy.
CHARLIE: And I'm Charlie Wiener,
CHARLIE: and we're coming to you from the Johns Hopkins School of Medicine.
CATHY: Welcome to Episode 34: A 68-Year-Old with Dyspnea.
CHARLIE: Here's the question. You're caring for a 68-year-old man with end-stage idiopathic pulmonary fibrosis. His performance status currently is zero. He is bedbound, and he's starting home hospice.
CATHY: Well, I do commend the provider on enrolling this patient in hospice, which can be very helpful for managing symptoms, especially at the end of life. And fortunately, we've seen an increase in enrollment in hospice, which can be good for many patients.
CHARLIE: Okay, let me continue. He's chronically on nasal oxygen at 4L/min, with saturation of 94% while at rest. He does not ambulate at all. The patient reports relentless and severe dyspnea that has worsened over the last one to two months. It is now his most notable complaint. Physical examination is notable for normal vital signs other than a respiratory rate of 25/min. Cathy, any thoughts on the approach to the diagnosis in this patient?
CATHY: It's common for patients with end-stage lung and heart disease to develop debilitating dyspnea, and it can be an extremely distressing symptom, even worse than pain for some patients. The symptoms often don't correlate with objective parameters either, like oxygen or carbon dioxide.
CHARLIE: Yeah, and in fact, in this case, he's having all these symptoms with saturations [unintelligible] are reportedly consistently above 94%.
CATHY: Right, so that's a perfect example of that. And the other thing to remember, too, is that there can be potentially reversible or treatable causes of dyspnea. Some examples would be infection, pleural effusions, pulmonary emboli, pulmonary edema, asthma, or, if there was some malignancy, you can get tumor encroachment on the airway. And depending on the diagnosis and the overall prognosis, specific therapy to address whatever the underlying issue is may be indicated in some cases. But the risk-versus-benefit ratio of the diagnostic and therapeutic interventions for patients, especially at the end of life, must be considered carefully before you undertake any of these diagnostic steps.
CHARLIE: Okay. So, in this case, there's no evidence of ongoing infection or other acute pulmonary process. His weight has not increased in the last two to four weeks; in fact, he's lost eight pounds in the past month.
CATHY: All right, so it sounds like he doesn't have an acute infection or volume overload, which could be treated and would provide some symptomatic benefit as well.
CHARLIE: What other symptoms do you generally ask about in patients like this?
CATHY: So, other common symptoms that I would want to know about-- any pain, fatigue, or weakness, insomnia, anorexia. These can all be very disturbing, and approaches to managing can vary but also vary sometimes by the underlying disease that's contributing to the symptoms.
CHARLIE: Why do patients with interstitial lung disease typically have so much discomfort and dyspnea?
CATHY: So, the mechanisms are multifactorial. But, as I said, many of these patients don't have a reduced oxygen saturation or elevated pCO2 to explain the symptoms. One mechanism that's likely in these patients is activation of the respiratory center, due to the small lung volumes and reduced lung compliance. And the sensation of air hunger due to small lung volumes can be remarkably uncomfortable, and the patient feels as though they're suffocating.
CHARLIE: Okay, so the question asks: "Which of the following interventions would be a reasonable first step to improve the comfort for this patient?" Option A is albuterol; option B is codeine; option C is increase the nasal oxygen to 8L/min; option D is lorazepam; and option E is nebulized morphine.
CATHY: It's unlikely that an increase in oxygen will benefit this patient's dyspnea, given that he's already on 4-6 L/min and his oxygen saturation is already 94%. Since his functional status is zero, I don't think he's having enough exertion to desaturate, and he's telling us that his dyspnea is mostly bothersome at rest, so I would remove that one from the possible choices.
CHARLIE: So, the other options are all medications. Which of those do you like best?
CATHY: Well, codeine is the best first choice, so for this question, I would say the answer is B, codeine. Opioids reduce the sensitivity of the central respiratory drive center and often reduce the sensation of dyspnea. In patients who are already on opioids, morphine or another strong opioid may be used in place of codeine. This patient isn't on any opioid, so it's reasonable to start with codeine. Hydrocodone would be another option in this patient.
CHARLIE: What dose do you start with, typically, in these patients?
CATHY: Typically about 30 mg every four hours as needed for patients who, again, haven't had opioids. But it really can depend on the degree of severity and how much opioids they've been taking historically. The goal is to suppress the respiratory center enough to control the dyspnea. You could also start with morphine 5 mg every four hours.
CHARLIE: What are your thoughts on the other answers-- lorazepam, albuterol, and nebulized morphine?
CATHY: So, in the absence of bronchospasm, albuterol could worsen the dyspnea as a respiratory stimulant, so that should be avoided. Benzodiazepines-- in this question we mention lorazepam-- could be helpful if there is concurrent anxiety, but it shouldn't be used as the sole therapy for dyspnea. They may be added to a narcotic, if needed. There are no data supporting the use of nebulized morphine for dyspnea at the end of life, so I also wouldn't use that.
CHARLIE: Okay, so the teaching point in this case is that dyspnea can be severe and is very common in the end of life. It's often not associated with elevations in pCO2 or reductions in SaO2. In the absence of a reversible cause, such as volume overload, it is reasonable to treat the patients for symptom control only. Opioids are an appropriate place to start to decrease the symptoms of increased respiratory drive and air hunger.
CATHY: And if you want to learn more, you can read about this in Harrison's chapter on Palliative and End-of-Life Care. ♪ (music) ♪