肺和胃腸道癥狀：在生命的盡頭的普通物理癥狀

CommonPhysicalSymptomsattheEndofLife:PulmonaryandGISymptomsMikeMarschke,MD1Mr.M-ChronicSmokerMr.M,78YO,isalifetimesmoker.Dyspneabegan5yearsago.intubatedtwiceinthepastyear.Sincelastadmission2mosagoalwaysneeds2-3l/minnasalcannulaoxygen,evenatrest.Hehaslost15lbs,hasapersistentcough,withgrayphlegmHeisonsteroidsandnebulizers

2WhatisDyspnea?Subjectivesensethatyouneedtobreath,thatyou‘hungerair.’MechanismRespiratoryCenterofMedullaChemoreceptorssensinglowO2,hiCO2Mechanoreceptors(Jreceptors)inlung,respiratorymuscles,anddiaphragmVascularcongestion-CHFCerebralCortex3Measurements?pO2,pCO2,O2satsPeakflowsPulmonaryfunctiontestsmeasuringlungvolumesandflowPrognosis<6mos.:ClassIVrespiratoryfailure(=dyspneaatrest)FrequentER/hospitalstays,recurringpulmonaryinfections,intubationspO2<56mmHg,O2sat<89%,pCOs>504Dr.arrivesMr.Kissittinginarecliningchair.Feels“breathless”withminimalexertion.Breathingis“heavyandsuffocating”.Noapparentprecipitatinginfectionetc.

5EvaluationPhysicalexam-distantbreathsounds,coarsecracklesatbasesbilaterally,RR=32atrest,takesbreathesinmid-sentence.tachycardicat100/minRecentWeightlossof15lbs.in6months.2+edemabilaterallowerextremities6TheBargainerHasnowishtobe“brutalized”.Heknowshisemphysemawillkillhimsomeday.HehasexecutedaDNRHewantstofeelbetterbutdoesnotwanttogobackintothehospital.WhataboutCXR,labs?78AssesscauseCompleteassessment–mayleadtotreatablecondition.PleuraleffusionPneumothoraxAnemiaPECHFPneumonia9CXRFindingsMassoccludingRbronchusPostobstructionatelectasisTreatmentoptionsBronchoscopyRadiationSupportiveWeighrisk/benefitsandpatientwishes10OxygenPulseoximetrynothelpful–goonsymptomsPotentsymbolofmedicalcareExpensive,noisy,hot,uncomfortableforsomeFanmaydojustaswell11OpioidsReliefnotrelatedtorespiratoryrateNoethicalorprofessionalbarriersSmalldosesCentralandperipheralactionInhaledmorphineworksperipherallybutmayinducebronchospasm12AnxiolyticsSafeincombinationwithopioidslorazepam0.5-2mgpoq1hprnuntilsettledthendoseroutinelyq4–6htokeepsettled13Nonpharmacologicinterventions...Reassure,worktomanageanxietyBehavioralapproaches,eg,relaxation,distraction,hypnosisOtherCAM–aromatherapies(Eucalyptus,Bergomot),massage,healingtouchLimitthenumberofpeopleintheroomOpenwindow14Nonpharmacologicinterventions...EliminateenvironmentalirritantsKeeplineofsightcleartooutsideReducetheroomtemperatureAvoidexcessivetemperatures15...NonpharmacologicinterventionsIntroducehumidityRepositionelevatetheheadofthebedmovepatienttoonesideorotherEducate,supportthefamily164WeeksLaterinHospiceMoredyspneicandsemi-comatoseLotsofupperairwaynoisewithwheezesmoreprevalentGetsagitatedattimes,cyanoticDifficultswallowingpillsAttimeswhensleepingfamilyfeelsheischokingtodeath17FinalhoursofcareEducatethefamily-nosurprisesDoubleeffect?Oralsecretionscanbelessenedbykeepingpatientdry,scopalaminepatch,levsin(anti-cholenergics)Useopioids/benzodiazepamsasneededSuctioningdifficultforpatientandlikelynottobeabletogetdeepenough18GastrointestinalSx:EOLAnorexia60-80%Xerostomia55-70%Nausea15-30%Vomiting15-25%Constipation50%Diarrhea<10%19Anorexia CorticosteroidsMegestrolacetateDronabinolOthercauses–gastritis/PUD–PPIs,earlysatiety/reflux–Reglan,oralthrush–anti-fungals.RealizepatientusuallyVERYcomfortablewiththis!20DryMouth HyposalivationMouthcareandgum/candy,popsiclesArtificialsalivaOralswabs/washclothPilocarpine5mgtidMucositisDiphenhydramine,dexamethasone,lidocaine,andnystatinswishandswallow21Nausea/vomitingAnxiety,fear,anticipatory,psychologicfactors,increasedintra-cranialpressureDopaminergic(narcotic–inducedandmanyothers)Serotinergic(chemoinduced)Histamine(labrynthitis,meds)Vagallymediated(ulcers,masses,irritations…)Reflux,gastritis,regurgitation,masses,ulcers,gastricoutletobstructionSmallbowelobstruction,impactionRenal(pyelonephritis,stones),liver(hepatitis,cirrhosis),gallbladder,uterine…22AMechanisticApproachCentral–Increasedpressures(tumor,swelling,hydrocephalus)–steroids,RT,surgeryAnxiety,fear,anticipatory–benzodiazipines,psychotherapyChemo-triggerReceptorZone(narcotics,othermeds,manyGIcauses)Anti-dopaminergics–prochlorperazine(compazine),haloperidol,droperidol,trimethobenzamide(Tigan),metoclopramide(Reglan),promethazine(phenergan)CanbegivenPO,suppository,someIM/IV,someeveninapasteform23AMechanisticApproachNauseaCenter(chemotherapyinduced)–Anti-serotinergics–ondansetron(Zofran),granisetron(Kytril),dolasetron,palonosetronIV,PO,andexpensiveVestibular-ocularreflex(withvertigo)–Anti-histamines–Benedryl,Antivert,AtaraxAnti-cholinergics-ScopolamineOro-pharyngealvagal–lidocaineswishandswallow,treatthelesion24AMechanisticApproachGastro-esophageal–Reflux/regurg–prokineticagentslikemetoclopramide(reglan),H2blockers/ProtonpumpinhibitorsGastritis/ulcers–H2blockers/PPIsDelayedgastricemptying(narcotics,DM)–metoclopramideGastricoutletobstruction–NGsuction,surgery25AMechanisticApproachIntestinalObstruction–NGsuction,surgery,NPOwithOctreotide(Sandostatin)Impaction–remembertocheckrectalexam–mayneedmanualdis-impaction,enemasOtherorgans–trytotreatunderlyingcauseifpossible,mayalsorespondtomedseffectingCRZ26OtheragentsfornauseaCAM–aromas(peppermint,ginger),herbs(ginger,cola),mind-focusing(meditation),acupunctureDronabinol(marijuana)Combinationsuppositories/gelsBDR(Benadryl,Decadron,Reglan)Canaddativan,Tigan,compazineandothers27ConstipationDefined:hard,infrequentstools,needingtostrainfor10minutesUncomfortablefeelingIncidence-USnutrition-Male8%Fem.21%Hospice80%Hospiceonnarcotics90%Hospital66%;Home22%28PhysiologyMealpassesoutofstomachintosmallintestine,withtheadditionofgastric,pancreatic,andbiliarysecretionsTransittimeis1-2hrsthruthesmallintestine,wheredigestionandabsorptiontakesplaceLargeboweltransittimeis1-3days,wherebulkofwaterisremovedandstoolisformedFinalBM–whenrectalampulafills,increaseabdomenalpressure,relaxanalsphincterand“thebrownriverflows”29Constipation–causes:Medicationsopioidscalcium-channelblockersanticholinergicDecreasedmotilityIleusMechanicalobstructionDiet(lofiber,himeatandstarch)Metabolicabnormalities(hiCa)SpinalcordcompressionDehydrationAutonomicdysfunction(DM)Malignancy30OpioidsdoTwothings:BlockBowel(opioidreceptorsinmesentericplexusandbowelwall)DecreasepropulsionIncreasesphinctertoneIncreaseboweltoneBlockpain/discomfortwithpackedbowel31Management

ofconstipationGeneralmeasuresestablishwhatis“normal”regulartoiletinggastrocolicreflexCheckimpaction–98%inrectalvault–hardpackedinstooltolargetoevacuateDiet–hifiber(greens,fruits,bran…),fluids,additivefibers(avoidwithopioidsatEOL)Specificmeasuresstimulantsosmoticsdetergentslubricantslargevolumeenemas32StimulantlaxativesPrunejuiceSenna(Senokot)Casanthranol(Pericolace)Bisacodyl(Dulcolax)*Goodpreventativeswithopioiduse33OsmoticlaxativesLactuloseorsorbitolMilkofmagnesia(otherMgsalts)MagnesiumcitratePolyethyleneGlycol(Miralax)*Goodadd-onsifstimulantsnotenoughwithopioidinducedconstipation34Detergentlaxatives

(stoolsofteners)SodiumdocusateCalciumdocusatePhosphosodaenemaprn35ProkineticagentsMetoclopramideCisapride36LubricantstimulantsGlycerinsuppositoriesOilsmineralpeanut37Large-volumeenemasWarmwaterSoapsuds38Mr.L–62yowithColoncancerMr.Lhasend-stagemetastaticcoloncancer,diagnosed6monthsago,withlivermets,ascites,carcinomatosis.Hefailedchemo,nowinhospicefor2wks.Over2dayshehashadpersistentvomiting,unrelievedwithcompazine,steroids,ativan,withreglanmakingitworse.Overthistimehisabdomenhasbecomeverydistended,hehascrampyperi-umbilicalpain,andhehasnothadaBMin7days.Lately,hisvomitsmellsslightlyfecal-likeandisbrown.Heismiserableandwantstodienow!39Mr.L–exam,tests?PE –Indistress -Abdomendistendedandtense, tympanitic -Bowelsoundshyper -Abdomendiffuselytender -Nostoolinvaultonrectal, hemoccultnegativeTests–KUBanduprightabdx-rayshowsdilatedloopsofbowelandmultipleair-fluidlevels40ObstructionVomiting90+%,Pain75%