Managing other symptoms

Question 1

How is normal breathing controlled?

Answer 1

Controlled by the respiratory centre in the brain stem.
Stimulated by stretch receptors in the airways, IC muscles and diaphragm and chemoreceptors (pick up hypoxia/hypercapnia)

Question 2

What are some of the pharmacological options for managing breathlessness?

Answer 2

Opioids (limited evidence of benefit)
Bronchodilators (Salbutamol, ipratropium, saline nebs for thick sputum)
Dexamethasone (reduced peri-tumour oedema)
Benzodiazepines (anxiety related)
Oxygen (mostly for pts with SpO2 <90%)

Question 3

At what dose are opioids not felt to be of benefit with furhter increase?

Answer 3

More than 30mg/24 hrs

Question 4

What are some non-pharmacological techniques which might help with breathlessness?

Answer 4

Breathing techniques
Secretion management suport (physios)
NIV
OT support with managing energy
“The Calming Hand”
Handheld fans/opening a window

Question 5

What are some skin symptoms that patients note when nearing the end of life?

Answer 5

Pruritis
Lymphoedema
Wound care issues
Pressure sores
Sweating

Question 6

What can cause itch in a palliative poputation?

Answer 6

Carcinoma in situ
Haematological cancers (CLL, lymphoma, multiple myeloma)
Paraneoplastic syndrome
Breast, lung, stomach cancers
Metastatic infiltration of the skin
Cholestasis
Psychogenic causes, associated with anxiety

Question 7

What can be used to manage uraemic itch?

Answer 7

Aluminium hydrochloride 1-3 capsules, TDS
Opioid antagonists (can reverse pain control)
Ondansetron (5-HT antagonist)
Low dose gabepentin

Question 8

What can be used to manage opiod induce itch?

Answer 8

Switching opioids
Ondansetron