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Dyspnea and End of Life Care - Coggle Diagram
Dyspnea and End of Life Care
Causes of Dyspnea
Chemoreceptors: pH via CO2, O2, Hypercarbia
Mechanoreceptors: Trigeminal nerve, upper airway, lung parenchyma, respiratory muscles
Projection to respiratory centre: Autonomic Control
Projection to the cortex: Awareness
Pulmonary: AIrway obstruction, volume loss, pneumonia, Tumor/Metastases
Neuromsucular: Cachexia, ALS, Pain
CV: CHF, Pericardial effusion, arrythmia, Ishcemia, SVC obstruction
Metabolic: Anything affecting pH, CO2, O2, Anemia
Psychological: Anxiety
Clinical Implications
Negative prognostic indicator, functional decline, reduced QOL, strongest association with anxiety/panic
Dyspnea Management plan
Oxygen
Benefit with hypoxia, and no benefit when compared to medical air in palliative care
Management
Assess pt, address cuase, relieve symptom
Drainage of Pleural Effusions (Thoracentesis, indwelling pleural catheters)
Pharmacologic
Opioids first line for pure-symptom management
Non-Pharm
Fan directed toward face, relaxing environment, positioning, cool humid air
Signs of Death
Prognosis
Trends of decline - How frequent each noticeable decline occurs
Functional Status
Palliative/Performance Scale
Objective Prognostic Score
Hypoalbuminemia
Functional Status Declines
Ambulation: Bed bound, Activity: Little to none, Self Care: Total dependence, Intake: Minimal, Consciousness: Somnolent, variable, possible delirium
Finals Hours-Days
Neuro: Decreased/Fluctuating LOC, delirium, Skin: Cool, mottled, pale, CV: Decreased cap refill, weak+rapid pulse, Resp: Rate pattern, upper airway congestion, GU/GI: Reduced output
Breathing Patterns
Cheyne-Stokes Breathing
Upper Respiratory Congestion
Poorly coined "death rattle", pooling of respiratory secretions and relaxation of the pharynx, Patients often unconscious,
Pharmacological Manamagment (Anticholinergics - Glycopyrolate, Scopolamine)
Management: Trial light oral suctioning,
Management of End of life symptoms
Agitation/Delirium: Midazolam, Haloperidol, Methotrimeprazine
Anxiety/Dyspnea/Sz: Midazolam
Pain/Dyspnea: Morphine
Mouth Care: Moisture Spray
Upper Resp Congestion: Glycopyrrolate
GI: Constipation (bisacodyl), GERD (Ranitidine), Nausea (Metoclopramide, Haloperidol, Ondanestron, Dimenhydrinate)
Preparing for Death
Clinical management
Vitals, Investigations, Life prolonging treatments, comfort treatments