肺和胃肠道症状：在生命的尽头的普通物理症状课件

1、Common Physical Symptoms at the End of Life: Pulmonary and GI Symptoms Mike Marschke, MDCommon Physical Symptoms at thMr. M - Chronic SmokerMr. M, 78 YO, is a lifetime smoker. Dyspnea began 5 years ubated twice in the past year. Since last admission 2 mos ago always needs 2-3 l/min nasal cann

2、ula oxygen, even at rest. He has lost 15 lbs, has a persistent cough, with gray phlegmHe is on steroids and nebulizers Mr. M - Chronic SmokerMr. M, 7What is Dyspnea?Subjective sense that you need to breath, that you hunger air.MechanismRespiratory Center of Medulla Chemo receptors sensing low O2, hi

3、 CO2Mechano receptors (J receptors) in lung, respiratory muscles, and diaphragmVascular congestion-CHFCerebral CortexWhat is Dyspnea?Subjective senMeasurements?pO2, pCO2, O2 satsPeak flowsPulmonary function tests measuring lung volumes and flowPrognosis 6 mos. :Class IV respiratory failure (= dyspne

4、a at rest)Frequent ER/hospital stays, recurring pulmonary infections, intubationspO2 56mmHg, O2 sat 50Measurements?pO2, pCO2, O2 satDr. arrivesMr. K is sitting in a reclining chair. Feels “breathless” with minimal exertion.Breathing is “heavy and suffocating”.No apparent precipitating infection etc.

5、 Dr. arrivesMr. K is sitting inEvaluationPhysical exam- distant breath sounds, coarse crackles at bases bilaterally, RR = 32 at rest, takes breathes in mid-sentence. tachycardic at 100/minRecent Weight loss of 15lbs. in 6 months. 2+ edema bilateral lower extremitiesEvaluationPhysical exam- distaThe

6、Bargainer Has no wish to be “brutalized”. He knows his emphysema will kill him someday.He has executed a DNRHe wants to feel better but does not want to go back into the hospital.What about CXR, labs?The Bargainer Has no wish to b肺和胃肠道症状：在生命的尽头的普通物理症状课件Assess causeComplete assessment may lead to tre

7、atable condition.Pleural effusionPneumothoraxAnemiaPECHFPneumonia Assess causeComplete assessmenCXR FindingsMass occluding R bronchus Post obstruction atelectasisTreatment optionsBronchoscopyRadiationSupportiveWeigh risk/benefits and patient wishesCXR FindingsMass occluding R bOxygenPulse oximetry n

8、ot helpful go on symptomsPotent symbol of medical careExpensive, noisy, hot, uncomfortable for someFan may do just as wellOxygenPulse oximetry not helpfOpioidsRelief not related to respiratory rateNo ethical or professional barriersSmall dosesCentral and peripheral actionInhaled morphine works perip

9、herally but may induce bronchospasmOpioidsRelief not related to rAnxiolyticsSafe in combination with opioidslorazepam0.5-2 mg po q 1 h prn until settledthen dose routinely q 46 h to keep settledAnxiolyticsSafe in combinationNonpharmacologic interventions . . .Reassure, work to manage anxietyBehavior

10、al approaches, eg, relaxation, distraction, hypnosisOther CAM aromatherapies (Eucalyptus, Bergomot), massage, healing touchLimit the number of people in the roomOpen windowNonpharmacologic interventionsNonpharmacologic interventions . . .Eliminate environmental irritantsKeep line of sight clear to o

11、utside Reduce the room temperatureAvoid excessive temperaturesNonpharmacologic interventions. . . Nonpharmacologic interventionsIntroduce humidityRepositionelevate the head of the bedmove patient to one side or otherEducate, support the family. . . Nonpharmacologic interve4 Weeks Later in HospiceMor

12、e dyspneic and semi-comatoseLots of upper airway noise with wheezes more prevalentGets agitated at times, cyanoticDifficult swallowing pillsAt times when sleeping family feels he is choking to death4 Weeks Later in HospiceMore Final hours of careEducate the family- no surprisesDouble effect?Oral sec

13、retions can be lessened by keeping patient dry, scopalamine patch, levsin (anti-cholenergics)Use opioids/benzodiazepams as neededSuctioning difficult for patient and likely not to be able to get deep enoughFinal hours of careEducate theGastrointestinal Sx: EOLAnorexia 60-80%Xerostomia 55-70%Nausea 1

14、5-30%Vomiting 15-25%Constipation 50%Diarrhea 10%Gastrointestinal Sx: EOLAnoreAnorexiaCorticosteroidsMegestrol acetateDronabinol Other causes gastritis/PUD PPIs, early satiety/reflux Reglan, oral thrush anti-fungals.Realize patient usually VERY comfortable with this!AnorexiaCorticosteroidsDry MouthHy

15、posalivationMouth care and gum/candy, popsiclesArtificial salivaOral swabs/wash clothPilocarpine 5mg tidMucositisDiphenhydramine, dexamethasone, lidocaine, and nystatin swish and swallowDry MouthHyposalivationNausea/vomitingAnxiety, fear, anticipatory, psychologic factors, increased intra-cranial pr

16、essureDopaminergic (narcotic induced and many others)Serotinergic (chemo induced)Histamine (labrynthitis, meds)Vagally mediated (ulcers, masses, irritations)Reflux, gastritis, regurgitation, masses, ulcers, gastric outlet obstructionSmall bowel obstruction, impactionRenal (pyelonephritis, stones), l

17、iver (hepatitis, cirrhosis), gall bladder, uterineNausea/vomitingAnxiety, fear, A Mechanistic ApproachCentral Increased pressures (tumor, swelling, hydrocephalus) steroids, RT, surgeryAnxiety, fear, anticipatory benzodiazipines, psychotherapyChemo-trigger Receptor Zone (narcotics, other meds, many G

18、I causes)Anti-dopaminergics prochlorperazine (compazine), haloperidol, droperidol, trimethobenzamide (Tigan), metoclopramide (Reglan), promethazine (phenergan)Can be given PO, suppository, some IM/IV, some even in a paste formA Mechanistic ApproachCentral A Mechanistic ApproachNausea Center (chemoth

19、erapy induced) Anti-serotinergics ondansetron (Zofran), granisetron (Kytril), dolasetron, palonosetronIV, PO, and expensiveVestibular-ocular reflex (with vertigo) Anti-histamines Benedryl, Antivert, AtaraxAnti-cholinergics - ScopolamineOro-pharyngeal vagal lidocaine swish and swallow, treat the lesi

20、onA Mechanistic ApproachNausea CA Mechanistic ApproachGastro-esophageal Reflux/regurg prokinetic agents like metoclopramide (reglan), H2 blockers/Proton pump inhibitorsGastritis/ulcers H2 blockers/PPIsDelayed gastric emptying (narcotics, DM) metoclopramideGastric outlet obstruction NG suction, surge

21、ryA Mechanistic ApproachGastro-eA Mechanistic ApproachIntestinalObstruction NG suction, surgery, NPO with Octreotide (Sandostatin)Impaction remember to check rectal exam may need manual dis-impaction, enemasOther organs try to treat underlying cause if possible, may also respond to meds effecting CR

22、ZA Mechanistic ApproachIntestinOther agents for nauseaCAM aromas (peppermint, ginger), herbs (ginger, cola), mind-focusing (meditation), acupunctureDronabinol (marijuana)Combination suppositories/gels BDR (Benadryl, Decadron, Reglan)Can add ativan, Tigan, compazine and othersOther agents for nauseaC

23、AM aConstipationDefined:hard, infrequent stools, needing to strain for 10 minutesUncomfortable feelingIncidence- US nutrition- Male 8% Fem. 21%Hospice 80%Hospice on narcotics 90%Hospital 66%; Home 22%ConstipationDefined:PhysiologyMeal passes out of stomach into small intestine, with the addition of

24、gastric, pancreatic, and biliary secretionsTransit time is 1-2 hrs thru the small intestine, where digestion and absorption takes placeLarge bowel transit time is 1-3 days, where bulk of water is removed and stool is formedFinal BM when rectal ampula fills, increase abdomenal pressure, relax anal sp

25、hincter and “the brown river flows”PhysiologyMeal passes out of sConstipation causes:Medicationsopioidscalcium-channel blockersanticholinergicDecreased motilityIleusMechanical obstructionDiet (lo fiber, hi meat and starch)Metabolic abnormalities (hi Ca)Spinal cord compressionDehydrationAutonomic dys

26、function (DM)MalignancyConstipation causes:MedicatiOpioids do Two things:Block Bowel (opioid receptors in mesenteric plexus and bowel wall)Decrease propulsionIncrease sphincter toneIncrease bowel toneBlock pain/discomfort with packed bowelOpioids do Two things:Block BoManagementof constipationGenera

27、l measuresestablish what is “normal”regular toiletinggastrocolic reflexCheck impaction 98% in rectal vault hard packed in stool to large to evacuateDiet hi fiber (greens, fruits, bran), fluids, additive fibers (avoid with opioids at EOL)Specific measuresstimulantsosmoticsdetergentslubricantslarge vo

28、lume enemasManagementof constipationGeneStimulant laxativesPrune juice Senna (Senokot)Casanthranol (Pericolace)Bisacodyl (Dulcolax)* Good preventatives with opioid useStimulant laxativesPrune juiceOsmotic laxativesLactulose or sorbitol Milk of magnesia (other Mg salts) Magnesium citratePolyethylene

29、Glycol (Miralax)* Good add-ons if stimulants not enough with opioid induced constipationOsmotic laxativesLactulose or Detergent laxatives(stool softeners)Sodium docusateCalcium docusatePhosphosoda enema prnDetergent laxatives(stool sofProkinetic agentsMetoclopramide Cisapride Prokinetic agentsMetocl

30、opramidLubricant stimulantsGlycerin suppositoriesOilsmineralpeanutLubricant stimulantsGlycerin sLarge-volume enemasWarm waterSoap sudsLarge-volume enemasWarm waterMr. L 62 yo with Colon cancerMr. L has end-stage metastatic colon cancer, diagnosed 6 months ago, with liver mets, ascites, carcinomatosi

31、s. 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 it 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

32、vomit smells slightly fecal-like and is brown. He is miserable and wants to die now!Mr. L 62 yo with Colon canceMr. L exam, tests?PE In distress- Abdomen distended and tense, tympanitic- Bowel sounds hyper- Abdomen diffusely tender- No stool in vault on rectal, hemoccult negativeTests KUB and upright abd x-ray shows dilated loops of bowel and multiple air-fluid levelsMr. L exam, tests?PE In dObstructionVomiting 90+%, Pain