肺和胃肠道症状在生命的尽头的普通物理症状

CommonPhysicalSymptomsattheEndofLife PulmonaryandGISymptoms MikeMarschke MD Mr M ChronicSmoker Mr M 78YO isalifetimesmoker Dyspneabegan5yearsago intubatedtwiceinthepastyear Sincelastadmission2mosagoalwaysneeds2 3l minnasalcannulaoxygen evenatrest Hehaslost15lbs hasapersistentcough withgrayphlegmHeisonsteroidsandnebulizers WhatisDyspnea Subjectivesensethatyouneedtobreath thatyou hungerair MechanismRespiratoryCenterofMedullaChemoreceptorssensinglowO2 hiCO2Mechanoreceptors Jreceptors inlung respiratorymuscles anddiaphragmVascularcongestion CHFCerebralCortex Measurements pO2 pCO2 O2satsPeakflowsPulmonaryfunctiontestsmeasuringlungvolumesandflowPrognosis50 Dr arrives Mr Kissittinginarecliningchair Feels breathless withminimalexertion Breathingis heavyandsuffocating Noapparentprecipitatinginfectionetc Evaluation Physicalexam distantbreathsounds coarsecracklesatbasesbilaterally RR 32atrest takesbreathesinmid sentence tachycardicat100 minRecentWeightlossof15lbs in6months 2 edemabilaterallowerextremities TheBargainer Hasnowishtobe brutalized Heknowshisemphysemawillkillhimsomeday HehasexecutedaDNRHewantstofeelbetterbutdoesnotwanttogobackintothehospital WhataboutCXR labs Assesscause Completeassessment mayleadtotreatablecondition PleuraleffusionPneumothoraxAnemiaPECHFPneumonia CXRFindings MassoccludingRbronchusPostobstructionatelectasisTreatmentoptionsBronchoscopyRadiationSupportiveWeighrisk benefitsandpatientwishes Oxygen Pulseoximetrynothelpful goonsymptomsPotentsymbolofmedicalcareExpensive noisy hot uncomfortableforsomeFanmaydojustaswell Opioids ReliefnotrelatedtorespiratoryrateNoethicalorprofessionalbarriersSmalldosesCentralandperipheralactionInhaledmorphineworksperipherallybutmayinducebronchospasm Anxiolytics Safeincombinationwithopioidslorazepam0 5 2mgpoq1hprnuntilsettledthendoseroutinelyq4 6htokeepsettled Nonpharmacologicinterventions Reassure worktomanageanxietyBehavioralapproaches eg relaxation distraction hypnosisOtherCAM aromatherapies Eucalyptus Bergomot massage healingtouchLimitthenumberofpeopleintheroomOpenwindow Nonpharmacologicinterventions EliminateenvironmentalirritantsKeeplineofsightcleartooutsideReducetheroomtemperatureAvoidexcessivetemperatures Nonpharmacologicinterventions IntroducehumidityRepositionelevatetheheadofthebedmovepatienttoonesideorotherEducate supportthefamily 4WeeksLaterinHospice Moredyspneicandsemi comatoseLotsofupperairwaynoisewithwheezesmoreprevalentGetsagitatedattimes cyanoticDifficultswallowingpillsAttimeswhensleepingfamilyfeelsheischokingtodeath Finalhoursofcare Educatethefamily nosurprisesDoubleeffect Oralsecretionscanbelessenedbykeepingpatientdry scopalaminepatch levsin anti cholenergics Useopioids benzodiazepamsasneededSuctioningdifficultforpatientandlikelynottobeabletogetdeepenough GastrointestinalSx EOL Anorexia60 80 Xerostomia55 70 Nausea15 30 Vomiting15 25 Constipation50 Diarrhea 10 Anorexia CorticosteroidsMegestrolacetateDronabinolOthercauses gastritis PUD PPIs earlysatiety reflux Reglan oralthrush anti fungals RealizepatientusuallyVERYcomfortablewiththis DryMouth HyposalivationMouthcareandgum candy popsiclesArtificialsalivaOralswabs washclothPilocarpine5mgtidMucositisDiphenhydramine dexamethasone lidocaine andnystatinswishandswallow Nausea vomiting Anxiety fear anticipatory psychologicfactors increasedintra cranialpressureDopaminergic narcotic inducedandmanyothers Serotinergic chemoinduced Histamine labrynthitis meds Vagallymediated ulcers masses irritations Reflux gastritis regurgitation masses ulcers gastricoutletobstructionSmallbowelobstruction impactionRenal pyelonephritis stones liver hepatitis cirrhosis gallbladder uterine AMechanisticApproach Central Increasedpressures tumor swelling hydrocephalus steroids RT surgeryAnxiety fear anticipatory benzodiazipines psychotherapyChemo triggerReceptorZone narcotics othermeds manyGIcauses Anti dopaminergics prochlorperazine compazine haloperidol droperidol trimethobenzamide Tigan metoclopramide Reglan promethazine phenergan CanbegivenPO suppository someIM IV someeveninapasteform AMechanisticApproach NauseaCenter chemotherapyinduced Anti serotinergics ondansetron Zofran granisetron Kytril dolasetron palonosetronIV PO andexpensiveVestibular ocularreflex withvertigo Anti histamines Benedryl Antivert AtaraxAnti cholinergics ScopolamineOro pharyngealvagal lidocaineswishandswallow treatthelesion AMechanisticApproach Gastro esophageal Reflux regurg prokineticagentslikemetoclopramide reglan H2blockers ProtonpumpinhibitorsGastritis ulcers H2blockers PPIsDelayedgastricemptying narcotics DM metoclopramideGastricoutletobstruction NGsuction surgery AMechanisticApproach IntestinalObstruction NGsuction surgery NPOwithOctreotide Sandostatin Impaction remembertocheckrectalexam mayneedmanualdis impaction enemasOtherorgans trytotreatunderlyingcauseifpossible mayalsorespondtomedseffectingCRZ Otheragentsfornausea CAM aromas peppermint ginger herbs ginger cola mind focusing meditation acupunctureDronabinol marijuana Combinationsuppositories gelsBDR Benadryl Decadron Reglan Canaddativan Tigan compazineandothers Constipation Defined hard infrequentstools needingtostrainfor10minutesUncomfortablefeelingIncidence USnutrition Male8 Fem 21 Hospice80 Hospiceonnarcotics90 Hospital66 Home22 Physiology Mealpassesoutofstomachintosmallintestine withtheadditionofgastric pancreatic andbiliarysecretionsTransittimeis1 2hrsthruthesmallintestine wheredigestionandabsorptiontakesplaceLargeboweltransittimeis1 3days wherebulkofwaterisremovedandstoolisformedFinalBM whenrectalampulafills increaseabdomenalpressure relaxanalsphincterand thebrownriverflows Constipation causes Medicationsopioidscalcium channelblockersanticholinergicDecreasedmotilityIleusMechanicalobstructionDiet lofiber himeatandstarch Metabolicabnormalities hiCa SpinalcordcompressionDehydrationAutonomicdysfunction DM Malignancy OpioidsdoTwothings BlockBowel opioidreceptorsinmesentericplexusandbowelwall DecreasepropulsionIncreasesphinctertoneIncreaseboweltoneBlockpain discomfortwithpackedbowel Managementofconstipation Generalmeasuresestablishwhatis normal regulartoiletinggastrocolicreflexCheckimpaction 98 inrectalvault hardpackedinstooltolargetoevacuate Diet hifiber greens fruits bran fluids additivefibers avoidwithopioidsatEOL Specificmeasuresstimulantsosmoticsdetergentslubricantslargevolumeenemas Stimulantlaxatives PrunejuiceSenna Senokot Casanthranol Pericolace Bisacodyl Dulcolax Goodpreventativeswithopioiduse Osmoticlaxatives LactuloseorsorbitolMilkofmagnesia otherMgsalts MagnesiumcitratePolyethyleneGlycol Miralax Goodadd onsifstimulantsnotenoughwithopioidinducedconstipation Detergentlaxatives stoolsofteners SodiumdocusateCalciumdocusatePhosphosodaenemaprn Prokineticagents MetoclopramideCisapride Lubricantstimulants GlycerinsuppositoriesOilsmineralpeanut Large volumeenemas WarmwaterSoapsuds Mr L 62yowithColoncancer Mr Lhasend stagemetastaticcoloncancer diagnosed6monthsago withlivermets ascites carcinomatosis Hefailedchemo nowinhospicefor2wks Over2dayshehashadpersistentvomiting unrelievedwithcompazine steroids ativan withreglanmakingitworse Overthistimehisabdomenhasbecomeverydistended hehascrampyperi umbilicalpain andhehasnothadaBMin7days Lately hisvomitsmellsslightlyfecal likeandisbrown Heismiserableandwantstodienow Mr L exam tests PE Indistress Abdomendistendedandtense tympanitic Bowelsoundshyper Abdomendiffuselytender Nostoolinvaultonrectal hemoccultnegativeTests KUBanduprightabdx rayshowsdilatedloopsofbowelandmultipleair fluidlevels Obstruction Vomiting90 Pain75 Hyperparastalsis