Pulmonary Disease palliative肺疾病.pptVIP

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * Opioids in COPD – Early 2000’s Improvement in dyspnea and sleep over placebo with SR Morphine (Abernethy, BMJ 2003) 2 systematic reviews: 18 double-blind, randomized, controlled trials, showed significant relief of dyspnea with oral or parenteral opioids (Tomas, Curr Opin Pulm Med, 2004) Opioids in COPD – Later 2000’s  Reduction in breathlessness with oral or parenteral opioids. Better than oxygen in reducing dyspnea (Clemens, Supp Care Cancer, 2009) Reduce work of breathing but do not affect ventilation, or increase CO2 (Clemens, J Pall Med, 2008) Opioids do not shorten life (Portenoy, J Pain Symp Mange, 2006) The Evolution of the Palliation of COPD Continues… Anxiolytics are used in Cancer Dyspnea – What about COPD? Respiratory Rate decreased with opioid and anxiolytic without an increase in PaCO2 in Cancer Patients (Clemens, Supp Care Cancer 2011) Midazolam improves dyspnea above morphine alone in terminally ill cancer patients (Navigante, J Pain and Symp Management, 2006) Anxiolytics for Dyspnea in COPD – Current Literature Benzodiazipines 4 small studies in COPD – conflicting reports SSRI’s and Tricyclic Antidepressants Did not improve dyspnea in 43 studies of COPD when used for psychiatric symptoms Palliation of Dyspnea in COPDWith Oxygen (Expert Working Group of the scientific committee of palliative medicine, 2004) Summary of Evidence - COPD (Uronis, International J of COPD, 2006) 2011 Canadian Thoracic Society (CTS) Recommendations for Dyspnea in COPD Anxiolytics Antidepressants not routinely used for dyspnea (2B) Oral opioids be used for dyspnea in advanced COPD (2C) NMES and chest wall vibration are helpful (2B) Walking aids are helpful (2B) Pursed-lip breathing may be helpful should be taught (2B) Continuous oxygen for hypoxemic patients reduced mortality and may reduce dyspnea (2B) Grade 2 = weak recommendations B = randomized trials with limitations C = observati