Breathlessness is increasingly recognised as a common, disabling symptom of many advanced diseases and one that is very difficult to treat. There is now an understanding that a multi-disciplinary approach to management can make a significant impact on the severity of the symptom improving both the patient’s and their carers’ quality of life. Breathlessness is one of the most difficult conditions that palliative care (and other clinicians who care for patients with advanced disease) have to treat. With the improvements in pain control, it is possibly now the most difficult symptom for clinicians to manage: many feel frustrated at not being able to give their patients better care.  Many patients and families are enduring terrible suffering. There has been little progress in improving the symptom, in spite of an increase in the amount of research and interest in it over the last twenty years. The Cambridge Breathlessness Intervention Service (CBIS) has been established since 2004 and is a research-based service which has being evaluated since its inception: its model of caring has been shaped by the patients and families who use it and the clinicians who refer to it. CBIS has firm evidence of its effectiveness with patients with breathlessness with both malignant and non-malignant disease. This book will help others to manage breathlessness in their day-to-day clinical practice and, if so desired, set up their own breathlessness service. There is a well-established website which can be used in conjunction with the book. The book is written to give practical help in the clinical management of breathlessness and written so that the information is easy to access in clinic, ward or home.

scihub/10.1007/978-1-4471-4754-1.pdf

zlib/no-category/Booth, Sara; Burkin, Julie; Moffat, Catherine; Spathis, Anna/Managing Breathlessness in Clinical Practice ||_55257867.pdf

Booth, Sara; Burkin, Julie; Moffat, Catherine; Spathis, Anna

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Springer London, Limited

United Kingdom and Ireland, United Kingdom

Springer Nature, London, 2014

2014, 2013

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producers:
Adobe PDF Library 10.0.1

Foreword 8
Acknowledgements 10
Contents 12
Part I: Introduction 19
Chapter 1: Breathlessness; the Experience for the Patient, an Approach for the Clinician 20
Features of Chronic Breathlessness 21
Understanding Chronic Intractable Breathlessness 23
Can Breathlessness Be Palliated? 25
Summary of BIS Approach 26
Summary 30
Further Reading 32
Chapter 2: The Genesis and Assessment of Breathlessness 34
Introduction 34
Models for Understanding the Genesis of Breathlessness 35
Pathophysiological Model (Parshall et al. 2012) 35
Breathing, Thinking, Functioning (BTF) Perpetuation Model 38
Assessment of Breathlessness 41
The First Assessment: Practical Tips 45
References 47
Part II: Non-pharmacological Interventions – Breathing 48
Chapter 3: Fan and Oxygen Therapy 49
Introduction 49
Oxygen Therapy 50
Evidence Base 50
Potential Mechanisms 52
Clinical Guideline for Use of Non-emergency Supplemental Oxygen 53
Burdens of Oxygen Therapy 55
Fan Therapy 57
Evidence Base 57
Potential Mechanisms 58
Clinical Guideline for Use of a Handheld Fan 59
References 62
Chapter 4: Positions to Ease Breathlessness 64
Introduction 64
Forward Lean 65
Leaning vs Bending from the Waist 66
Fixation of the Shoulder Girdle 67
Combining Forward Lean with Upper Limb Bracing 71
Upper Limb Activity 73
Walking Aids 73
Positions for Breathlessness at Rest 75
Supported Forward Lean in Sitting 75
Supported Sitting 76
High Side Lying 77
Summary 78
Unique positions of ease adopted by patients 79
References 80
Chapter 5: Breathing Techniques for Breathlessness 81
Introduction 81
Breathing Control vs Diaphragmatic Breathing 81
Breathing Control: Efficient Breathing 83
Introducing Breathing Control 84
The Diaphragm 85
Breathing Accessory Muscles 85
The Breathing Action of the Diaphragm 86
Demonstrating the Movement of the Diaphragm 88
When to Use Breathing Control 89
Teaching Breathing Control 90
Step 1 92
Step 2 92
Step 3 92
Step 4 93
Breathing Control vs Breathing Pattern Re-education 93
Patients Who Find Breathing Control Difficult 95
Position and Posture 96
Abdominal Weight 97
Increased Tidal Volumes 97
Two Hands: Upper Chest and Tummy 97
Two Hands: Tummy Only 98
Deflate the Upper Chest 98
‘Not Doing’ 99
Relaxation Techniques 99
No Observers 100
Fear or Anxiety 100
Observe Other Mammals 101
Keep It Simple 101
Musculoskeletal 101
Pain 101
Alternatives to Breathing Control or Relaxation Techniques 102
Severely Hyperinflated Lungs 102
Visual Aids to Memory 104
The 3 R’s 105
Waves 105
Breathing Rectangle 106
Dynamic Hyperinflation 109
Pursed-Lips Breathing 111
Research Evidence 112
Instinctive PLB 112
Can PLB Be Taught? 113
Teaching PLB 114
Recovery Breathing: The 3 F’s 114
When to Use Recovery Breathing 117
A Patient Unfamiliar with Breathing Control 117
Patients with Severely Hyperinflated Lungs 117
Extreme Breathlessness and Panic 117
Modifying Recovery Breathing 118
“Blow as You Go!” 119
Paced Breathing 119
Nose vs Mouth Breathing 121
Flash Cards 122
Summary 123
References 125
Part III: Non-pharmacological Interventions – Thinking 127
Chapter 6: Anxiety Management 128
Introduction 129
Identifying the Triggers for Anxiety 132
Cognitive Behavioural Therapy 133
Exploring and Dispelling Misperceptions 134
Having a Plan of Action 135
Challenging Unhelpful Thoughts 135
Relaxation 136
Mindfulness 138
Distraction 138
Summary 139
References 140
Chapter 7: Energy Conservation 141
Introduction 142
All or Nothing 144
Activity Participation Habits 144
Adapting Activities 145
Activity Pacing 146
Prioritising 147
Realistic Goal Setting 148
Planning 148
Posture 148
Sleep 149
Effective Rest 150
Summary 150
References 151
Part IV: Non-pharmacological Interventions – Functioning 153
Chapter 8: Exercise and Activity Promotion 154
Introduction 154
The Clinician’s Role in Exercise and Activity Promotion 156
A Stepwise Approach to Exercise and Activity Promotion 157
Step 1: Deconditioning Cycle 158
Step 2: Overcoming Common Barriers to Exercise 160
Barriers Created by Carers 160
Step 3: Goal Setting 163
Long Term Goal 164
Short Term Goals 164
Step 4: Managing Breathlessness on Exertion 164
Step 5: Engage the Patient in a Suitable Exercise Programme or Regime 166
Recording Exercise and Activity 169
Inspiratory Muscle Training 171
Pedometer (Step Counter) Walking Programme 175
Step 6: Ongoing Motivation 178
Summary 179
References 180
Further Information & Resources 182
Exercise and COPD 182
Asthma and Exercise 182
Physical Activity and Cardiac Disease 182
Exercise and Activity for People Living with and Beyond Cancer 183
Self Management of Long Term Conditions 183
Chapter 9: Supporting Carers 184
Introduction 185
Breathing 187
Thinking 187
Negative Emotions 187
Frustration 187
Anger 188
Anxiety and Worry 188
Distress 189
Guilt 189
Positive Emotions 189
Pride 189
Self-Efficacy 190
Functioning 190
Strategies to Support Carers 191
Breathing 191
Thinking 191
Functioning 191
Action Plans / Ritual for Crises 192
Recognition and Acknowledgement 192
Respecting Autonomy 192
Support 193
Respite 193
Differing Priorities 193
Summary 194
References 196
Part V: An Integrated Strategy 198
Chapter 10: Pharmacological Management of Breathlessness 199
Slowly Progressive or Rapidly Progressive Breathlessness 200
Individual Drugs 202
Opioids e.g. Morphine, Fentanyl, Hydromorphone, Buprenorphine, Diamorphine 202
Possible Mechanisms of Action 202
Indications 203
Using Opioids to Palliate Breathlessness 203
Patients Breathless on Exertion 203
Patients Breathless on Minimal Exertion 204
An Alternative View 206
Patients Breathless at Rest 207
Patients Entering or Line the End of Life Phase 207
Cautions 208
Route of Administration 209
Adverse Effects 209
Chronic Non-malignant Versus Malignant Disease 211
Benzodiazepines 211
What Are the Problems with Benzodiazepines? 212
Drug Portraits 212
Mirtazapine 212
Indications 213
Other Psychoactive Drugs 214
References 216
Further Reading 216
Chapter 11: Care Towards the End of Life for the Breathless Patient 217
Introduction 218
Open Communication 220
Barriers 222
Practical Tips 223
Symptom Control 226
Practical Tips to Manage Breathlessness and Anxiety 227
Practical Tips to Manage Other Symptoms 228
Carer Support 229
References 231
Chapter 12: An Approach to the Breathless Patient 233
Using the Research Evidence 234
First Steps in Assessment – Taking a History of the Patient’s Breathlessness 237
Selecting an Intervention 239
Box 12.1: ‘Some examples of ‘Do no harm, likely to do good’ interventions’ 240
Pro-central, Non-pharmacological Interventions 241
Summary of ‘the Complex Intervention, Breathlessness Service’ Approach 242
Deciding When Drug Therapy is Needed for Palliation of Breathlessness 243
Other Symptoms: Making a Full Assessment of the Breathless Patient 247
General Treatment Strategies for People with Chronic Conditions 248
Use Your Common Sense 256
Reviewing the Evidence 256
Example – The Hand-Held Fan 256
Breathlessness Services 257
Principles of Setting Up a Breathlessness Service 258
Who to Call and When 260
What can you do in Your Setting to Help Breathless Patients? 261
Summary of Current Best Practice in Managing Breathlessness (Johnson and Booth 2010, Ahmedzai et al. 2012) 261
Disseminating Your Practice 262
References 264
Further Reading 265
Index 266

Breathlessness Management in Clinical Practice presents evidence-based practical techniques for helping the breathless patient with advanced disease of any aetiology used in the Cambridge Breathlessness Intervention Service (CBIS). This book will help individuals in the multidisciplinary team both manage breathlessness in their current clinical setting and describe the breathlessness service model which can be adapted for use in any situation. It uses a model of care based on interventions for breathing, thinking and functioning. Breathlessness Management in Clinical Practice is an invaluable resource for those working in the respiratory medicine, oncology and cardiology and other specialties where breathlessness is commonly managed although less recognised like nephrology and neurology. It will be of help to occupational therapists, physiotherapists and specialist nurses as well as physicians. It will also be of interest to anyone who wishes to increase their knowledge of the advances in evidence that now enable clinicians to offer much improved care for those suffering with frightening symptom of breathlessness

2015-07-15