晚期癌症的呼吸困难和咳嗽.ppt.ppt

晚期癌症的呼吸困难和咳嗽Dyspnea&Cough:Advance Cancer,2,晚期癌症呼吸困难Dyspnea:Advance Cancer,呼吸困难：定义，发病率 Dyspnea:definition,prevalence呼吸困难的原因 Causes of dyspnea评估 Assessment症状治疗 Symptomatic therapy阿片类药物的作用 Role of opioids,3,呼吸困难：定义Dyspnea:Definition,呼吸困难的感知 Perception of difficulty breathing主观体验 Subjective experience无以下客观指征 Cannot be defined by躯体异常，客观体征 Physical abnormality,objective sign实验室诊断依据 Diagnostic test症状的严重程度与可测定的异常之间并无联系 No correlation between symptom severity and measurable abnormality,4,呼吸困难的变异性Dyspnea Variability,广泛的变异 Wide variation:疾病间的变异 Variation between diseases个体间的变异 Variation between individuals由先前的体验形成 Shaped by previous experience多因素调节感知的性质和强度 Many factors modulate quality and intensity of perceptionDudgeon et al.J Pain Symptom Management.1998;11(4):212-219.,5,呼吸困难的要素Components of Dyspnea,社会的Social,宗教的SpirituaL,情感的Emotional,躯体的Physical,“若认识不到这些要素分别是怎样引起呼吸困难的全部痛苦，那么对其处理将很难成功。”“without recognizing how each of these contribute to the total suffering of dyspnea,management is unlikely to be successful.”Zeppetella.Am J Hospice Pall Care.1998;322.,6,呼吸困难：全国姑息关怀调查Dyspnea:National Hospice Study,全国范围内的预期数据收集 National prospective data collection effort40家姑息关怀中心和14家非姑息关怀病房 40 hospices and 14 non-hospice care settings1754名预后小于6个月的癌症患者 1754 cancer patients with prognosis 6 months对症状进行两周一次的检查 Biweekly interview on symptoms70%的患者在生命的最后6周里有呼吸困难 70%had dyspnea during the last 6 weeks of lifeReuben et al.Chest.1986;89:234-236.,7,呼吸困难：全国姑息关怀中心调查Dyspnea:National Hospice Study,其发病率仅次于疼痛和吞咽困难 Prevalence exceeded only by pain and eating difficulties随着病人临近死亡呼吸困难的发病率增加 Prevalence rates increased as patients approached death呼吸困难最重要的预测指征 Most important predictor of dyspnea1754名癌症患者中有39%具有肺部和胸膜的癌性浸润 39%of the 1754 cancer patients had lung or pleural involvement of cancerReuben et al.Chest.1986;89:234-236.,8,呼吸困难：全国姑息关怀中心调查Dyspnea:National Hospice Study,与肿瘤无关的呼吸困难 Dyspnea not related to tumor心脏疾病占34%Cardiac disease 34%慢性肺部疾患占 24%Chronic pulmonary disease 24%24%的患者的呼吸困难可仅由衰竭引起 24%had dyspnea attributable to debility alone全身性肌无力 Generalized muscle weakness功能状态欠佳 Poor performance statusReuben et al.Chest.1986;89:234-236.,9,呼吸困难：存活的预测指征Dyspnea:Predictor of Survival,常见症状与幸存的相关性 Correlation of common symptoms with survival全国姑息关怀机构调查数据的再分析 Re-analysis of National Hospice Study data呼吸困难 Dyspnea幸存的独立预测指征 Independent predictor of survival仅次于功能状态和“进食问题”Second only to performance status and“eating problems”疼痛，精神错乱和恶心不影响预后 Pain,confusion and nausea did not affect prognosisReuben et al.Archives Internal Medicine.1988;148:1586-1591.,10,呼吸困难：与癌症的相关Dyspnea:Cancer Related,气道阻塞 Airway obstruction直接浸入肺实质 Direct extension into lung parenchyma胸膜疾病 Pleural disease间皮瘤 Mesothelioma恶性心包渗出 Malignant pericardial effusion,上腔静脉综合症 SVC syndrome肌无力 Muscle fatigue恶病质综合症 Cachexia syndrome 横隔膜移位 Diaphragmatic excursion肝肿大 Hepatomegaly腹水 Ascitis胸壁疾病/疼痛 Chest wall disease/pain,11,呼吸困难：与治疗相关的Dyspnea:Treatment Related,化疗和放疗 Chemotherapy and radiation急性肺炎 Acute pneumonitis肺部纤维化 Pulmonary fibrosis外科 Surgery肺切除术 Pneumonectomy肺叶切除术 Lobectomy,12,呼吸困难：非癌性原因Dyspnea:Non-cancer Causes,感染 Infections支气管炎 Bronchitis肺炎 Pneumonia慢性阻塞性肺部疾患/哮喘 COPD/asthma气胸 Pneumothorax血栓性疾病Thromboembolic disease,心脏疾病 Heart disease缺血性心脏病 Ischemic heart disease心衰 Heart failure心律失常 Arrhythmias贫血 Anemia心理因素 Psychological factors,13,呼吸困难的原因：晚期癌症Causes of Dyspnea:Advance Cancer,与呼吸困难相关的前瞻性评估 Prospective assessment of factors associated with dyspnea100例在姑息关怀科住院的呼吸困难患者 100 patients admitted to palliative care unit with dyspnea49%肺癌 49%lung cancer28%非恶性呼吸道疾病 28%non-malignant respiratory disease21%缺血性心脏病 21%had ischemic heart diseaseDudgeon et al.J Pain Symptom Management.1998;16(4):212-219.,14,呼吸困难的原因：晚期癌症Causes of Dyspnea:Advance Cancer,呼吸困难的潜在可逆转原因 Potentially reversible contributors to dyspnea40%低氧血症：氧饱和度90%Hypoxemia 40%:O2 saturation 90%20%贫血：血色素10 Anemia 20%:Hemoglobin 10支气管痉挛 Bronchospasm 47%的在PFT有阻塞性因素 47%had obstructive component on PFTs88%的在PFT有狭窄的因素 88%had restrictive component on PFTsDudgeon et al.J Pain Symptom Management.1998;16(4):212-219.,15,呼吸困难：评估Dyspnea:Assessment,评估的目的 Aim of assessment找出可能的原因 Determine likely cause重点放在确定可逆转的原因 Emphasis on identifying reversible causes监控处理 Monitor management详细的病史和体征 Detailed history and physical,16,呼吸困难：评估Dyspnea:Assessment,评估引起症状的原因 Evaluate for contributing symptoms焦虑 Anxiety抑郁 Depression对生活方式的影响 Impact on lifestyle呼吸困难对病人的意义 Meaning of breathlessness to the patient尚无统一的测定方法 No widely agreed upon measurement toolVAS视觉量表 VAS Visual Analog Scale数字量表(0 10/10)Numeric(0 10/10)Scale,17,呼吸困难：评估 处理Dyspnea:Assessment Management,酌情考虑 Consider.病人的全身状况/功能状态 General condition of patient/functional status个人目标 Individual goals预测生存期 Expected survival姑息关怀的地点 Place of care有可能批准未经研究的治疗性验证 Therapeutic trial without investigation may be warranted治疗的目标：病人对症状缓解的陈述或表达 Target of treatment:patients report or expression of relief,18,疾病的特殊疗法Disease Specific Therapy,放疗 Radiation外照射 External Beam短距离放疗Brachytherapy化疗 Chemotherapy气管内疗法 Endobronchial therapy冷冻疗法 Cryotherapy激光疗法 Laser therapy斯坦特支架 Stents,抗生素 Antibiotics利尿剂 Diuretics支气管扩张剂 Bronchodilators输血 Transfusions胸腔穿刺术，胸膜固定术Thoracentesis,pleurodesis心包穿刺术，心包开窗Pericardiocentesis,pericardial window穿刺术 Paracentesis,19,呼吸困难：症状治疗Dyspnea:Symptomatic Therapy,患病后已用尽特殊的干预措施 After disease specific interventions have been exhausted与不可逆转因素相关的呼吸困难 Dyspnea associated with irreversible causes目的是减轻痛苦感而不是根治疾病 Aim is to reduce sensation rather than cure disease最好由多学科团队联合治疗 Best delivered by interdisciplinary team,20,呼吸困难：症状治疗Dyspnea:Symptomatic Therapy,氧气疗法 Oxygen阿片类药物 Opioids抗焦虑药物 Anxiolytics非药物性干预措施 Non-pharmacological interventions,21,末期呼吸困难Terminal Dyspnea,不应该让病人死于痛苦的呼吸困难 No person should die in distressing breathlessness为了使病人更加舒适，值得让病人冒进行性增加的嗜睡的风险 Patients weigh risk of increasing drowsiness in order to be more comfortable目的是使病人舒服 Aim is to keep patients comfortable症状控制 Symptom control维持尊严 Maintain dignity提供支持 Provide support,22,末期呼吸困难Terminal Dyspnea,药物治疗是治疗的主体 Pharmacological treatment is mainstay of therapy阿片类药物 Opioids苯二氮卓类或氯丙嗪 Benzodiazepines or chlorpromazine用抗胆碱能药物治疗过量的气道分泌 Anticholinergics for excessive airway secretions可通过皮下，舌下或直肠给予药物 Medications can be given subcutaneous,sublingual or rectal,23,晚期癌症呼吸困难的标准的姑息疗法Palliation of DyspneaStandard of Care in Advance cancer,恰当时治疗潜在的原因 Treatment of the underlying cause when appropriate若低氧血症则给予氧气疗法 Oxygen if a patient is hypoxemic一些特殊情况下使用抗焦虑药和皮质类固醇药物 Anxiolytics and corticosteroids in select situations必要时给予恰当剂量的吗啡以缓解痛苦 Morphine given in dosage required to relieve distressLegrand et al.Current Opinion Oncology.1999;11:250-254.,24,咳嗽的发病率Prevalence of Cough,59%的病人在生命的最后一年主述咳嗽 59%complain of cough in last year of life.46%病人明显地感觉不适 46%are significantly distressed.52%的病人在生命的最后一周主述咳嗽 52%complain of cough in the last week of life.Edmonds,Palliative Medicine,15,287-95,25,咳嗽的非恶性原因Non-malignant causes of cough,急性/慢性感染Acute/chronic infection气道疾病 Airways disease心血管性 Cardiovascular器质性疾病 Parenchymal disease,反复发生的吸入Recurrent aspiration药源性 Drug induced胸膜疾病 Pleural disease声带疾病 Vocal cord disease刺激物 Irritant,26,治疗 Treatment,若可能，治疗潜在的原因 When possible,treat the underlying cause祛痰治疗（有效的缓解咳嗽）Protussive treatment(improve effectiveness of cough)适当的水化（输液）Adequate hydration胸部理疗 Chest physiotherapy咽部吸痰 Pharyngeal suctioning高渗盐水雾化吸入 Aerosolized hypertonic salineBeta-激动剂，N-乙酰半膀氨酸 Beta-agonists,N-acetylcysteine,27,治 疗 Treatment,止咳治疗 Anti-tussive treatment阿片类药物 Opioids口腔局部麻醉剂 Oral local anesthetics安息香酸盐 Benzoate局部麻醉剂雾化吸入（利多卡因）Nebulized local anesthetic(lidocaine)支气管扩张剂（Beta-激动剂）Bronchodilators(Beta-agonists)抗炎药物（类固醇，色甘酸盐）Anti-inflammatory agents(steroids,cromoglycate)抗毒蕈碱（异丙阿托品，氢溴酸东莨菪碱，胃长宁）Anti-muscarinics(ipatropium,hyocyine hydrobromide,glycopyrrolate),