肺和胃腸道癥狀：在生命的盡頭的普通物理癥狀.ppt

1、Common Physical Symptoms at the End of Life: Pulmonary and GI Symptoms,Mike Marschke, MD,Mr. M - Chronic Smoker,Mr. M, 78 YO, is a lifetime smoker. Dyspnea began 5 years ago. intubated twice in the past year. Since last admission 2 mos ago always needs 2-3 l/min nasal cannula oxygen, even at rest. H

2、e has lost 15 lbs, has a persistent cough, with gray phlegm He is on steroids and nebulizers,What is Dyspnea,Subjective sense that you need to breath, that you hunger air. Mechanism Respiratory Center of Medulla Chemo receptors sensing low O2, hi CO2 Mechano receptors (J receptors) in lung, respirat

3、ory muscles, and diaphragm Vascular congestion-CHF Cerebral Cortex,Measurements,pO2, pCO2, O2 sats Peak flows Pulmonary function tests measuring lung volumes and flow Prognosis 50,Dr. arrives,Mr. K is sitting in a reclining chair. Feels “breathless” with minimal exertion. Breathing is “heavy and suf

4、focating”. No apparent precipitating infection etc,Evaluation,Physical exam- distant breath sounds, coarse crackles at bases bilaterally, RR = 32 at rest, takes breathes in mid-sentence. tachycardic at 100/min Recent Weight loss of 15lbs. in 6 months. 2+ edema bilateral lower extremities,The Bargain

5、er,Has no wish to be “brutalized”. He knows his emphysema will kill him someday. He has executed a DNR He wants to feel better but does not want to go back into the hospital. What about CXR, labs,Assess cause,Complete assessment may lead to treatable condition. Pleural effusion Pneumothorax Anemia P

6、E CHF Pneumonia,CXR Findings,Mass occluding R bronchus Post obstruction atelectasis Treatment options Bronchoscopy Radiation Supportive Weigh risk/benefits and patient wishes,Oxygen,Pulse oximetry not helpful go on symptoms Potent symbol of medical care Expensive, noisy, hot, uncomfortable for some

7、Fan may do just as well,Opioids,Relief not related to respiratory rate No ethical or professional barriers Small doses Central and peripheral action Inhaled morphine works peripherally but may induce bronchospasm,Anxiolytics,Safe in combination with opioids lorazepam 0.5-2 mg po q 1 h prn until sett

8、led then dose routinely q 46 h to keep settled,Nonpharmacologic interventions . .,Reassure, work to manage anxiety Behavioral approaches, eg, relaxation, distraction, hypnosis Other CAM aromatherapies (Eucalyptus, Bergomot), massage, healing touch Limit the number of people in the room Open window,N

9、onpharmacologic interventions . .,Eliminate environmental irritants Keep line of sight clear to outside Reduce the room temperature Avoid excessive temperatures,. . Nonpharmacologic interventions,Introduce humidity Reposition elevate the head of the bed move patient to one side or other Educate, sup

10、port the family,4 Weeks Later in Hospice,More dyspneic and semi-comatose Lots of upper airway noise with wheezes more prevalent Gets agitated at times, cyanotic Difficult swallowing pills At times when sleeping family feels he is choking to death,Final hours of care,Educate the family- no surprises

11、Double effect? Oral secretions can be lessened by keeping patient dry, scopalamine patch, levsin (anti-cholenergics) Use opioids/benzodiazepams as needed Suctioning difficult for patient and likely not to be able to get deep enough,Gastrointestinal Sx: EOL,Anorexia 60-80% Xerostomia 55-70% Nausea 15

12、-30% Vomiting 15-25% Constipation 50% Diarrhea 10,Anorexia,Corticosteroids Megestrol acetate Dronabinol Other causes gastritis/PUD PPIs, early satiety/reflux Reglan, oral thrush anti-fungals. Realize patient usually VERY comfortable with this,Dry Mouth,Hyposalivation Mouth care and gum/candy, popsic

13、les Artificial saliva Oral swabs/wash cloth Pilocarpine 5mg tid Mucositis Diphenhydramine, dexamethasone, lidocaine, and nystatin swish and swallow,Nausea/vomiting,Anxiety, fear, anticipatory, psychologic factors, increased intra-cranial pressure Dopaminergic (narcotic induced and many others) Serot

14、inergic (chemo induced) Histamine (labrynthitis, meds) Vagally mediated (ulcers, masses, irritations) Reflux, gastritis, regurgitation, masses, ulcers, gastric outlet obstruction Small bowel obstruction, impaction Renal (pyelonephritis, stones), liver (hepatitis, cirrhosis), gall bladder, uterine,A

15、Mechanistic Approach,Central Increased pressures (tumor, swelling, hydrocephalus) steroids, RT, surgery Anxiety, fear, anticipatory benzodiazipines, psychotherapy Chemo-trigger Receptor Zone (narcotics, other meds, many GI causes) Anti-dopaminergics prochlorperazine (compazine), haloperidol, droperi

16、dol, trimethobenzamide (Tigan), metoclopramide (Reglan), promethazine (phenergan) Can be given PO, suppository, some IM/IV, some even in a paste form,A Mechanistic Approach,Nausea Center (chemotherapy induced) Anti-serotinergics ondansetron (Zofran), granisetron (Kytril), dolasetron, palonosetron IV

17、, PO, and expensive Vestibular-ocular reflex (with vertigo) Anti-histamines Benedryl, Antivert, Atarax Anti-cholinergics - Scopolamine Oro-pharyngeal vagal lidocaine swish and swallow, treat the lesion,A Mechanistic Approach,Gastro-esophageal Reflux/regurg prokinetic agents like metoclopramide (regl

18、an), H2 blockers/Proton pump inhibitors Gastritis/ulcers H2 blockers/PPIs Delayed gastric emptying (narcotics, DM) metoclopramide Gastric outlet obstruction NG suction, surgery,A Mechanistic Approach,Intestinal Obstruction NG suction, surgery, NPO with Octreotide (Sandostatin) Impaction remember to

19、check rectal exam may need manual dis-impaction, enemas Other organs try to treat underlying cause if possible, may also respond to meds effecting CRZ,Other agents for nausea,CAM aromas (peppermint, ginger), herbs (ginger, cola), mind-focusing (meditation), acupuncture Dronabinol (marijuana) Combina

20、tion suppositories/gels BDR (Benadryl, Decadron, Reglan) Can add ativan, Tigan, compazine and others,Constipation,Defined: hard, infrequent stools, needing to strain for 10 minutes Uncomfortable feeling Incidence- US nutrition- Male 8% Fem. 21% Hospice 80% Hospice on narcotics 90% Hospital 66%; Home

21、 22,Physiology,Meal passes out of stomach into small intestine, with the addition of gastric, pancreatic, and biliary secretions Transit time is 1-2 hrs thru the small intestine, where digestion and absorption takes place Large bowel transit time is 1-3 days, where bulk of water is removed and stool

22、 is formed Final BM when rectal ampula fills, increase abdomenal pressure, relax anal sphincter and “the brown river flows,Constipation causes,Medications opioids calcium-channel blockers anticholinergic Decreased motility Ileus Mechanical obstruction Diet (lo fiber, hi meat and starch,Metabolic abn

23、ormalities (hi Ca) Spinal cord compression Dehydration Autonomic dysfunction (DM) Malignancy,Opioids do Two things,Block Bowel (opioid receptors in mesenteric plexus and bowel wall) Decrease propulsion Increase sphincter tone Increase bowel tone Block pain/discomfort with packed bowel,Managementof c

24、onstipation,General measures establish what is “normal” regular toileting gastrocolic reflex Check impaction 98% in rectal vault hard packed in stool to large to evacuate,Diet hi fiber (greens, fruits, bran), fluids, additive fibers (avoid with opioids at EOL) Specific measures stimulants osmotics d

25、etergents lubricants large volume enemas,Stimulant laxatives,Prune juice Senna (Senokot) Casanthranol (Pericolace) Bisacodyl (Dulcolax) * Good preventatives with opioid use,Osmotic laxatives,Lactulose or sorbitol Milk of magnesia (other Mg salts) Magnesium citrate Polyethylene Glycol (Miralax) * Goo

26、d add-ons if stimulants not enough with opioid induced constipation,Detergent laxatives(stool softeners,Sodium docusate Calcium docusate Phosphosoda enema prn,Prokinetic agents,Metoclopramide Cisapride,Lubricant stimulants,Glycerin suppositories Oils mineral peanut,Large-volume enemas,Warm water Soa

27、p suds,Mr. L 62 yo with Colon cancer,Mr. L has end-stage metastatic colon cancer, diagnosed 6 months ago, with liver mets, ascites, carcinomatosis. He failed chemo, now in hospice for 2 wks. Over 2 days he has had persistent vomiting, unrelieved with compazine, steroids, ativan, with reglan making i

28、t worse. Over this time his abdomen has become very distended, he has crampy peri-umbilical pain, and he has not had a BM in 7 days. Lately, his vomit smells slightly fecal-like and is brown. He is miserable and wants to die now,Mr. L exam, tests,PE In distress - Abdomen distended and tense, tympanitic - Bowel sounds hyper - Abdomen diffusely tender - No stool in vault on rectal, hemoccult negative Tests KUB and upright abd x-ray shows dilated loops of bowel and multiple air-fluid levels,Obstruction,Vomiting 90+%, Pain 75% Hyperparastalsis