Dyspnea: Advance Cancer
呼吸困难：定义，发病率
Dyspnea: definition, prevalence
呼吸困难的原因 评估
Assessment
Causes of dyspnea
症状治疗
Symptomatic opioids
2
Dudgeon et al. J Pain Symptom Management. 1998; 11(4): 212-219.
4
呼吸困难的要素
Components of Dyspnea
“……若认识不到这些要素 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， 全部痛苦，那么对其处理将 很难成功。” 很难成功。 “…without recognizing how each of these contribute to the total suffering of dyspnea, management is unlikely to be successful.”
与呼吸困难相关的前瞻性评估 Prospective assessment of factors associated with dyspnea 100例在姑息关怀科住院的呼吸困难患者 100例在姑息关怀科住院的呼吸困难患者 100 patients admitted to palliative care unit with dyspnea 49%肺癌 49%肺癌 49% lung cancer 28%非恶性呼吸道疾病 28%非恶性呼吸道疾病 28% non-malignant respiratory disease 21%缺血性心脏病 21% had ischemic heart disease 21%缺血性心脏病
肺切除术 Pneumonectomy 肺叶切除术 Lobectomy
11
呼吸困难： 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/ 慢性阻塞性肺部疾患/哮喘 COPD/asthma 气胸 Pneumothorax 血栓性疾病Thromboembolic 血栓性疾病 disease
6
Reuben et al. Chest. 1986; 89: 234-236.
呼吸困难：全国姑息关怀中心调查 呼吸困难： 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 dyspnea 1754名癌症患者中有39%具有肺部和胸膜的癌性浸润 1754名癌症患者中有39%具有肺部和胸膜的癌性浸润 名癌症患者中有39% 39% of the 1754 cancer patients had lung or pleural involvement of cancer
呼吸困难： 呼吸困难：定义
Dyspnea: Definition
呼吸困难的感知 Perception of difficulty breathing 主观体验 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
晚期癌症的呼吸困难和咳嗽
Dyspnea & Cough:
Advance Cancer
Terence L. Gutgsell, MD Hospice of the Bluegrass Palliative Care Center of the Bluegrass October 2003
晚期癌症呼吸困难
3
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 perception
Reuben et al. Chest. 1986; 89: 234-236. 8
呼吸困难：存活的预测指征 呼吸困难：
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 仅次于功能状态和“进食问题” Second only to performance status and “eating problems” 疼痛， 疼痛，精神错乱和恶心不影响预后 Pain, confusion and nausea did not affect prognosis
Dudgeon et al. J Pain Symptom Management. 1998; 16(4): 212-219.
Anemia 20%: Hemoglobin < 10
14
呼吸困难： 呼吸困难：评估
Dyspnea: Assessment
评估的目的 Aim of assessment Determine likely cause 找出可能的原因
Reuben et al. Chest. 1986; 89: 234-236.
7
呼吸困难： 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% 心脏疾病占34% Cardiac disease 34% 24%Chronic 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%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 status
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
15
呼吸困难： 呼吸困难：评估
Dyspnea: Assessment
Dudgeon et al. J Pain Symptom Management. 1998; 16(4): 212-219. 13
呼吸困难的原因： 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 dyspnea 40%低氧血症：氧饱和度<90% 40%低氧血症：氧饱和度<90% Hypoxemia 40%: O2 saturation < 90% 低氧血症 20%贫血：血色素<10 20%贫血：血色素<10 贫血 支气管痉挛 Bronchospasm 47%的在PFT有阻塞性因素 47%的在PFT有阻塞性因素 的在PFT 47% had obstructive component on PFTs 88%的在PFT有狭窄的因素 88%的在PFT有狭窄的因素 的在PFT 88% had restrictive component on PFTs
9
呼吸困难： 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 上腔静脉综合症 SVC syndrome 肌无力 Muscle fatigue 恶病质综合症 Cachexia syndrome 胸膜疾病 间皮瘤 Pleural disease Mesothelioma 横隔膜移位 Diaphragmatic excursion 肝肿大 Hepatomegaly 腹水 Ascitis 胸壁疾病 / 疼痛
Zeppetella. Am J Hospice Pall Care. 1998; 322.
5
宗教的 SpirituaL 躯体的 Physical
社会的 Social
情感的 Emotional
呼吸困难：全国姑息关怀调查 呼吸困难： Dyspnea: National Hospice Study
全国范围内的预期数据收集 National prospective data collection effort 40家姑息关怀中心和14家非姑息关怀病房 40家姑息关怀中心和14家非姑息关怀病房 家姑息关怀中心和14 40 hospices and 14 non-hospice care settings 1754名预后小于6 1754名预后小于6个月的癌症患者 名预后小于 1754 cancer patients with prognosis < 6 months 对症状进行两周一次的检查 Biweekly interview on symptoms 70%的患者在生命的最后6 70%的患者在生命的最后6周里有呼吸困难 的患者在生命的最后 70% had dyspnea during the last 6 weeks of life