Dorothy House Hospice Care

BREATHLESSNESS MANAGEMENT TOOLBOX Modified for Motor Neurone Disease Jeanne Burnett / Karen Tudge 30th April 2014

Breathlessness can be an interaction between physical, emotional and psychological factors, not just a symptom of disordered breathing Breathlessness in MND is slightly different and is a combination of reduced respiratory function due to: 1.Progressive 1 Progressive weakness of respiratory muscles 2.Anxiety related to general progression of the disease and possibly fear for the future Our aim is to teach some simple coping strategies at the earliest opportunity which can be patient or helper led opportunity,

Overview •

70% of patients having cancer experience breathlessness at some point due to disease or treatments but SOB either on exertion or at rest is common in many other conditions including progressive neurological conditions such as MND

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Patients with COPD or Heart Failure may become breathless periodically (episodic breathlessness) or have continuous g differently y breathlessness and each is managed

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Patients with MND can have both episodic breathlessness due to anxiety and continuous breathlessness due to disease progression

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Many people get chest infections which can cause breathing difficulties- this can be an additional and frequent occurrence in MND

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Breathlessness is often reported as the most distressing symptom after pain and for patients with MND ranks alongside the fear of choking

Tools to try: • • • • • • • • •

Comfort Zone Positioning Fan/moving air Breathing techniques Calming Hand technique Acupressure S b d Seabands Pacing activity Exercise

Comfort Zone

Sitting

Lying

Standing

Wheelchairs Positioning in a suitable wheelchair may improve respiratory function tilt in space wheelchairs can be positioned so as to functionmaximise head support and allow maximal costal expansiontherefore use of collars for neck support may not be necessary

Use of a fan

Breathing Techniques In general terms: • • • •

Aim to slow the rate of rapid shallow breathing Encourage a longer out breath: Try 3:5 - count to 3 on the in breath and 5 on the out breath ((smell the rose,, blow out the candle)) For patients with MND in later stages this may not be feasible

Clearing Chest Secretions Effective coughing and positioning can g drainage g of excessive or encourage infected secretions Acupuncture/acupressure/TENS may also help move secretions if applied to pertinent acupuncture p p points(St40, p ( Sp9) p )

Huffing and panting may loosen secretions before an attempt to cough Gentle pressure on the ribs or breast bone may help move secretions

Visualisation and Distraction Finding ways to aid relaxation may be helpful, e.g. listening to music/story tapes/radio or watching T.V. Enjoyable hobbies may also be beneficial e.g. painting, knitting and crafts if physical ability allows

The Calming Hand

Burnett and Blagbrough (2010) ‘The Calming Hand’ in Oxford Textbook of Palliative Medicine 4th Edition, Oxford: Oxford University Press

Acupressure Techniques to aid Respiratory Management All 361+ acupuncture points have specific actions • Manyy acupuncture p points can help p p with breathing g difficulties (references available but currently little research related specifically to MND) • Pressure on these points can be as effective as true acupuncture using needles • The Th mostt pertinent ti t points i t are on the th L Lung M Meridian idi and d Bladder Meridian but also on the Conception Vessel (midline with points on the sternum) • Uses: Acupressure can be used to relieve breathlessness and/or to clear secretions

Th Lung The L Channel Ch l (L (Lu))

The Bladder Channel (Bl)

The Conception Vessel (CV)

Acupressure •

‘Acupressure’ Acupressure means applying any form of pressure over an acupuncture point (e.g. finger pressure or use of ‘Seabands’)

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Pressure on relevant acupuncture points has been shown to help relieve symptoms of breathlessness and other respiratory symptoms e.g. cough (references are available)

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Acupressure can be self-administered or carried out by a helper h l and d as outlined tli d iin th the nextt ffew slides lid will ill nott interfere with any other treatments and can do no harm

Acupressure 2 There are many ways to apply acupressure, but the two easiest are: • •

Fingertip pressure over one point Stroking over a series of associated points (sometimes called a meridian, line or channel) The following slides show some examples of both techniques being used to help with breathlessness:

Stroking the Lung Meridian Using the palm of the hand hand, firmly stroke down the arm and off the thumb This is best done by a carer but can be a self help technique If the arm is also supported on a pillow this will be even more p effective

Acupressure to acupoint Lu5 may help to relieve a dry or productive cough: Lu 5 is in the centre of the cubital fossa lateral to the Biceps tendon

Thumb Hold Acupressure to acupoint Lu11 may relieve breathlessness Lu 11 is at the base of the thumb nail

This is an easy technique to use whilst active or struggling to catch breath e e.g. g when climbing stairs or to reduce symptoms of breathlessness associated with anxiety

Bladder Meridian

Conception Vessel

Acupressure p to acupoint p Bl13 may y relieve breathlessness Bl 13 is either side of T3 spinous process

Acupressure to acupoint CV17 may relieve the feeling g of a tight g chest CV 17 is in the centre of the sternum at the nipple line – use pressure with the side of the hand

Clearing secretions with acupressure • From a TCM perspective secretions are defined as ‘Damp’ or ‘Phlegm’ depending on duration of presence and origin • Both can be cleared effectively with acupuncture, acupressure or TENS • This can be useful for patients with MND who may not be ab able e to o coug cough e effectively ec e y a and d may ay not o tolerate oe ae drainage positioning • St 40, Sp9 p are two accessible p pertinent p points on the lower limbs

St 40 and Sp9 • St 40 is halfway between ankle kl and d kknee ttwo fifinger widths lateral to the crest of the tibia

• Sp 9 is under the medial  condyle of the tibia

Using ‘Seabands’ to apply acupressure  for Breathlessness Management

PC6 This is also known as the sea sickness or nausea point It is located three fingers width above the wrist crease on the palm side of the forearm Using Seabands for prolonged periods on this point can be very relaxing as well as reducing symptoms of nausea or breathlessness

Seabands should not be used on an arm at risk of lymphoedema

H7 This point is located in the hollow at the wrist crease on the h lilittle l fifinger side id off the h fforearm It is a very useful point to reduce anxiety and palpitations which may be apparent during an episode of breathlessness or during a panic attack, also used for insomnia

Acupressure or ‘Seabands’ can be used on this point Caution for patients with a history of heart problems- discuss with therapist

Lu9 This acupoint is on the wrist crease at the base of the thumb Finger acupressure here or ‘Seabands’ may be used to relieve breathing difficulties and cough.

Oxygen and Nebulisers Oxygen may be provided on medical advice Additional oxygen is not always necessary Use of a fan can be even more effective for some people

A nebulizer with saline may assist with secretion clearance

Pacing Activity •

Shortt episodes Sh i d off gentle tl activity ti it followed by short rest periods will allow greater achievement without becoming excessively breathless

Stairs- general advice: •

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Going upstairs - stop halfway up up, regain breathing control and then continue It mayy help p to have a chair on a halfway landing It may help to use the thumb hold technique or a hand held fan during this activity A stairlift may be more appropriate for patients with MND

Aids and Adaptations

Breathlessness which is exacerbated by particular activities may be relieved by the appropriate use of aids e.g. bath aids, perching stool stool, walking aids or small aids to assist with daily life

Exercise Evidence shows that the most important exercise to help with breathlessness generally is to maintain strength in the thighs e.g. Hip flexion/gentle marching, leg straightening sitting in the chair, or sit to stand With the physical limitations of MND this may not be possible in later stages

Assessment for Breathlessness • The new BMT includes a section for assessment of breathlessness • This includes a section to record triggers gg for SOB,, previous coping strategies, subjective problems relating to SOB and objective observations • It is useful to record which Toolbox techniques have been tried and if possible capture their perceived effectiveness ff ti att various i stages t off disease di progression i

Summary •   Being mildly breathless is not dangerous although it can be • • • •

frightening. Episodic and/or continuous breathlessness is more worrisome Have equipment readily available Practice when well - familiarity f will reassure Breathlessness does respond to non-pharmacological measures They are easy to learn learn, empower both patient and helper and are cost effective For patients with MND any or all of these techniques may be helpful if used d alongside l id the th advice d i and d equipment i t supplied li d b by th the neurorespiratory specialists and cannot cause harm

References •

Bausewein, B i C C., B Booth, th S S., G Gysels, l M M., Hi Higginson, i II. (2008) ‘N ‘Non-pharmacological h l i l interventions for breathlessness in advanced stages of malignant and non-malignant diseases.’ Cochrane Database of Systemic Reviews 2008, Issue 2 2. Art Art.No.:CD005623.DOI:10.1002/14651858.CD005623.pub2 No :CD005623 DOI:10 1002/14651858 CD005623 pub2

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Bausewein, C., Booth, S., Gysels, M., Kuhnbach, R., Higginson, I.J. (2010) ‘Effectiveness Effectiveness of a hand-held hand held fan for breathlessness: a randomised controlled phase II trial.’ BMC Palliative Care 19, (9) 22

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Burnett,, J.,, Blagbrough, g g , M.,, (2010) ( ) ‘The Calming g Hand and Breathlessness Management Toolbox.’ in Oxford Textbook of Palliative Medicine. 4 th Edition. Oxford: Oxford University Press 229–230

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Deadman, P., Al‐Khafaji, M., Baker, K. (2007) A Manual of Acupuncture. Hove:  Journal of Chinese Medicine Publications 

Medical Management Of Dyspnoea Medical Management Of Dyspnoea •Teamwork •Trusting relationships •Address fears •Plan ahead, anticipate problems, preparation •Drugs: Dr gs -Opioids -Benzodiazepines - Night sedation

Medical Management Of Secretions Medical Management Of Secretions Reduced swallowing causing drooling is distressing:

• Anticholinergics: g - Atropine drops tds - Hyoscine (s/l, transdermal, s/cut) • Tricyclic antidepressants: Amitriptyline • Propranolol 10mg tds • Glycopyrronium (subcut) Salivaryy g glands: - Botulinum toxin - Radiotherapy