Managing Palliative Symptoms of Advanced Cancer 2023-2024 PDF

8/31/2023 2023 PAIN AND SYMPTOM MANAGEMENT WITH ADVANCED CANCER – PARTS 3+4 DYSPNEA, ACS, MUCOSITIS , AND XEROSTOMIA 1 -subjective.. can't measure it Dyspnea: “common severe symptom in last days of life…” • “An uncomfortable awareness/sensation of breathing”- a subjective sensation that does no...

8/31/2023 2023 PAIN AND SYMPTOM MANAGEMENT WITH ADVANCED CANCER – PARTS 3+4 DYSPNEA, ACS, MUCOSITIS , AND XEROSTOMIA 1 -subjective.. can't measure it Dyspnea: “common severe symptom in last days of life…” • “An uncomfortable awareness/sensation of breathing”- a subjective sensation that does not correlate well with functional & physiologic parameters.” (Dudgeon & Rosenthal in Dr. Christine Jones, Palliative Care Medical Intensive Course, Victoria Hospice, Nov 2011) pps 40 s less- going to die within next month 2 • intensity may not correlate with pulse oximetry, ABG, CXR, Pulmonary Function Tests (PFT) • “breathlessness”, “air hunger”, “heavy breathing”, “suffocation” • Dyspnea ≠ tachypnea • Tachypnea = excessive rate of breathing marked by quick, shallow breathing. • 70% incidence in advanced cancer pts in last 6 wks of life. 50% severe/very severe dyspnea in last week of life with < ½ offered effective treatment. (Davis (1994), Therapeutics of dyspnea cancer survey, vol 21, p.85-98) • Seen in severe COPD, advanced Heart Disease, Renal Disease, AIDS, Dementia, ALS etc • Total experience affects all domains of life – Total Dyspnea 2 Dyspnea: doesnt correlate with O2 sats, need opiods 1st line drugs to control dyspnea • Multidimensional symptom – emotional + physical ss correlation • Higher reported prevalence in those with depression or anxiety. ( • Perception that the respiratory muscle response is inadequate or unsustainable. • Perception arises from sensory cortex from stimulation of various receptors: ise drugs on all 3 examples: 3 Brennan, & Mazanec, 2011, Dyspnea management across the palliative care continuum. Jhpn, 13(3), pp. 131) • Peripheral & central chemoreceptors • Mechanoreceptors (arising from large airways, lung parenchyma, chest wall) • Respiratory motor centres ( medulla & motor cortex) • (Dudgeon, D., Shadd, J. (2014) Assessment and management of dyspnea in palliative care, UpToDate.) 3 1 8/31/2023 HF exacerbeautions- dyspnea, or pleural effusion to go to icu- is dyspnea, Dyspnea Assessment: 4 uncomfortable awarness of breathing, • Dyspnea is not a single sensation – changes in quality of subjective, doesnt' correlate with functional and physiological paarameters dyspnea may prompt pt to go to ER. • Refractory Dyspnea can't say like when pt in pain = dyspnea that persists even when all identified reversible causes have been treated. (Johnson, Abernathy, & Currow, 2012, p.619) can't observe it by O2sats.. =subjective!!!!!!!!!1 = dyspnea that persists at rest or with minimal activity despite optimal therapy of underlying condition. dyspnea is not tachypnea!! • Chronic refractory dyspnea – can lead to feelings of helplessness, anxiety, depression, social isolation refractory- dany sss when doesnt responds to any TXT pharm or non • Dyspnea Crisis – sustained and severe resting breathing discomfort that occurs in patients with advanced, often lifelimiting illness and overwhelms the patient and caregivers’ сĚĞƉĞŶĚƐŽŶďĂĐŬĨŐƌŽƵŶŐŝĨƉůĞƵƌĂůĞĨĨƵƐŝŽŶͲƚŚĞŶĚƌĂŝŶŝƚ ability to achieve symptom relief. (Dudgeon, UpToDate, 2019) • Incident Dyspnea – acute episodic breathlessness. Dyspnea that comes on as a result of an action or activity. (Incident dyspnea/pain protocol –prev. lecture, Dr. Mike Harlos) ͲĐŽŵĞƐǁŝƚŚĂĐƚŝǀŝƚŝĞƐͬĨĂƐƚŽŶƐĞƚ͗ŐŝǀĞ͗ĨĞŶƚĂŶLJůŽƌƐƵůĨĞŶƚĂŶLJůсŝŶƚƌĂŶĂƐĂĂů pharm 4 dyd͗ϭ^dKW/K͕^KEEK PTS SUBJECTIVE REPORTED DYSPNEA RELIABLE- IS NOT TRUE BC YOU ARE TAKING TOOLS TO GET INFO FROM THE PT Dyspnea Assessment: Currow, Dyspnea in Advanced Cancer: Dying Long Before Death, Nov. 29, 2017, Medscape) 5 • *****Patient’s subjective report of their dyspnea is the most reliable****** • Ask about dyspnea in relation to activity, “How troubling is the dyspnea? What have you given up to avoid feeling breathless” Pt often limit their activity to ↓ experiencing dyspnea. (Dr. David • Use visual analogue scale, Edmonton Symptom Assessment Scale(ESAS-r), MRC Dyspnea Scale • No single “gold standard” tool that thoroughly measures the severity of dyspnea. (Dudgeon et USE TOOLS THAT FITS PT'S AGE S EASY TO GET INFO TO ASSESS SSS YOU CAN'T MEASURE: bp S HR GOES UP , PHYSIO THINGS GOES UP al, 2014) z^WE^>͕ 5 Dyspnea Assessment: • Thorough physical assessment advanced COPD. (Gift & colleagues study, Oxford Textbook, 2010, pp. 306; 2015, pp.249-250). Studied physiological factors R/T dyspnea in subjects with COPD. 6 • Accessory muscle use may reflect intensity of dyspnea in 6 2 7 8/31/2023 7 = takes dyspnea grade 0 to 5 pt stops many times to catch breath - cant get out of bed/ even if given assistance (severe) 8 in palliative care - pts are in grade 3 and 4. advanced COPD,CA, HF- don't eat well, bc trying to grasp air Impact of dyspnea: • Estimated as most important variable influencing the will to live among terminally ill cancer patients. give meds before they eat. 2nd most common reason to initiate palliative sedation. (Dudgeon et al, 9 UpToDate, 2018) • Social Isolation: ↓activity to manage dyspnea • “Social death” before dying a physical death – (social isolation) friends aren’t coming around because dyspnea is difficult to watch. (Dr. David Currow, Dyspnea in Advanced Cancer: Dying Long Before Death, Nov. 29, 2017, Medscape) • Anxiety & fear: acute attacks accompanied by anxiety, fear, panic of impending death. • FEAR OF WAKING IN THE MIDDLE OF THE NIGHT WITH INTENSE AIR HUNGER. • FEAR OF DYING DURING EPISODES. • FOR FAMILY FEAR OF HELPLESSLY WATCHING SOMEONE DIE WITH ACUTE BREATHLESSNESS. -prevent dyspnea from happening, then will isolate activities to avoid dyspnea 9 ex: HF- wake up in middle night from dyspnea assess sss... s txt underlying cause.. 3 8/31/2023 Treatment/management: 10 • 1. Treat underlying reversible causes. • 2. Oxygen therapy – Only if hypoxic (BC Cancer) (UpToDate, 2019) • trial of 02 therapy if hypoxemic at rest of with minimal exertion (UpToDate, 2019) • In patients who are not hypoxemic, supplemental oxygen has not been shown to improve dyspnea when compared with room air (UpToDate, 2019) • Pt’s report of dyspnea that guides interventions not O2 saturation in palliative care. (Medical Care of the Dying, 2006) • Oxygen should never be the only therapy in mod-severe dyspnea. 1st line medications should always be used. (Medical Care of the Dying, 2006) ****** 1 st opiods, 2nd benzo • Palliative Care Drug Access Program (PCDAP) • 02 therapy - few data to support use for non-hypoxic pt. Mixed data re preference for O2 over inhaled air. 10 Treatment/management: • 3. Position – Upright -semi-high fowlers. Leaning / high fowlers/ side lying/ forward leaning forward with arms supported. Avoids compression of chest or 11 diaphragm. • 4. Breathing techniques – pursed lip breathing, diaphragmatic breathing. • 5. Air flow - fan, open window ↓ anxiety & feelings of purse s diaphgramatic breathing with COPD, use fans, open window. to decrease bretheless suffocation. Cool air blowing on face triggers reflexes in trigeminal nerve (V2 branch) creating a central inhibitory effect on dyspnea. (EPEC-0) • 6. Environment – cool, smoke-free, dust-free room with low humidity. (Indelicato, R.A. (2006). The advance practice nurse’s role in palliative care and the management of dsypnea. Topics in Advanced Practice Nursing ejournal, 6(4), 1-15.) • 7. Energy conservation – Use of assistive devices – walking aids, bathroom modifications. OT for energy conservation, PT for breath control. Teach pacing & planning of activities. 11 opiods dyspnea dose is smallers.. in comparison to pain Treatment/Management: 12 • 8. Where dyspnea is not severe & where there is a significant anxiety - Relaxation therapy – music, distraction, progressive muscle relaxation, guided imagery, therapeutic touch. • 9. Calm presence – provide information to pt & family. HCP models behavior. Moving purposefully without agitation. • 10. When stabilized & able - Exercise to maintain muscle mass and prevent deconditioning. Pace activities. • 11. Medications: (UpToDate, 2017) • systemic opioids (1st line)- (Morphine, Hydromorphine) • Short acting + regular low dose sustained release • dyspnea accompanied by anxiety – Benzodiazepines(2nd line, • There is no role for benzodiazepines as a routine management strategy for dyspnea in the absence of anxiety (Dudgeon, UpToDate, 2019) • Select clinical conditions – Bronchodilators, Glucocorticoids, Diuretics 12 q4 h intervals.. cant sleep +end stage renal/HF= give low dose sustained release HM at night.. no mechanoreceptors) , only opiods work on this) incident dyspnea- fentanyl, sulfentanyl 4 8/31/2023 Meds to manage: Questions: anxiolytics is benzo 13 • True or False: F 1. Anxiolytics are 1st line therapy. -2nd line • ____ • ____2. T Opioids such as Morphine & Hydromorphone can be safely used to decrease dyspnea in advanced disease. • ____3. F Opioids are only effective if given by nebulization. • ____4. T Fentanyl and Sufentanil are effective in relieving Incident Dyspnea. 13 ACS (ANOREXIA AND CACHEXIA SYNDROME) 14 BC Cancer Agency-Definitions Anorexia: involuntary loss of appetite or desire to eat that results in reduced caloric intake and often weight loss. • Cachexia: a complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with or without loss of fat mass • Anorexia-Cachexia Syndrome: is a complex syndrome which is often defined in terms of its primary or secondary causes. Primary causes of ACS are related to metabolic and neuroendocrine changes directly associated with underlying disease and an ongoing inflammatory state. ie. Cytokine production → stimulates chronic inflammation and resulting catabolism. • Body gets energy by breaking down its own muscle /fat rather than using food nutrients. • Secondary causes of ACS are aggravating factors (e.g. fatigue, pain, dyspnea, dysphagia, infection, etc.) that contribute to weight loss. (Source: BC Cancer Agency-Symptom management guidelines 2010) lose appetite, slow transic time, se of meds s medical conditions, advanced cancer complex metabolic vs underlying conditions like copd s HF, loss muscles with or without fat masses, *** 15 Primary: causes inflammatory response in body, like tumor secretes mediators s grow into bones, s cause pain, mediators signal body to start breaking down protein and fatas source of fuel. chronic inflammation is resulting in catabolic state , body gets energy by breaking own muscles s fats is number 1 reason in palliative care -can be resolved secondary: like fatique, pain, neurological ALS s myasthesia gravis that inhibits swallowing reflexive, can't get enough calories, contribute to weight loss. can reverse it through by passing if can't swallow bc of dysphagia via gastrostomy tube 5 8/31/2023 cancer to inflammatory mediators like cytokines and tumor necrosis factor being secreted by cancer cells start process of catabolism, known as protein lysis and when it breaks down muscles and lipolysis where it breaks down fat for energy s have anorexia, s decrease foot intake 16 Anorexia/Cachexia: Definitions: • Anorexia: loss of appetite that persists over time. - Leads to decreased caloric intake. • Cachexia: hypercatabolic state with accelerated loss of skeletal et al, UpToDate, 2017) =not starvation!!! • involuntary weight loss of > 10% pre-morbid wt (*explain).before got • Frequency underestimated in obesity or where weight gain is due to edema or growing tumour mass. • associated with loss of muscle, visceral protein, bone mineral content ± fat – fatigue (asthenia) • In adults presents as wt. loss. In children = growth failure. (UpToDate, 2019) • A wasting syndrome – body is unable to process nutrients from food. 17 muscle in the context of a chronic inflammatory response. (Bruera sick, ex: pt is 150 pounds before sick s lost 15 pound or more after sick=enter cachexia state extra fluid causes issues s cant see lost weight, if kids =growth failure if HIV wasting syndrome, COPD= 17 Anorexia/Cachexia: see in cancer pt's=within months , chronic kidney disease, AIDS, COPD, liver failure • can be reversed with appropriate feeding and caloric intake. • Weight loss mainly adipose tissue. • leads to energy conservation (↓ resting energy expenditure) 18 • Cachexia ≠ starvation. • Starvation = caloric deficiency • Cachexia = profound weight loss • cannot be entirely attributed to poor caloric intake • In advanced cancer cachexia is not reversed by supplementation of calories. • Correlated with ↓ QOL & ↓ survival in all disease populations (Cancer, HF, COPD, CKD, ESLD, AIDS, Dementia) =quick weight loss • (Bruera et al, 2019, UptoDate) 18 6 8/31/2023 Cachexia vs Starvation: Cachexia Appetite Late suppression Early BMI Not predictive of mortality Predictive of mortality Albumin Low in late phase Low in late phase Cholesterol May remain normal Low Total lymphocyte count Low, responds to refeeding Low, no response to refeeding Cytokines Little data Elevated Inflammation Usually absent Present With re-feeding Reversible Resistant last 4 important 19 Starvation *********** *****************8 ************** *********** Thomas, D. (2002). Distinguishing starvation from cachexia. Clinics in Geriatric Medicine, 18, 883-891. cytokines- break protein s fats in body inflamm=chronic inflamm syndrome with advance cancer 19 catabolic state-cant process nutritional intake they actually eat re feeding is not reversible in Cachexia anorexia -doenst count for magnitube of weight loss • Anorexia does not account for the magnitude of weight loss seen in advanced cancer. • Inability of the body to process the nutrients in food. • In severe illness body gets energy by breaking downs its own muscle & fat rather than making use of the nutrients in food. 20 Anorexia/Cachexia Syndrome: • (Advanced Cancer Patient Information, CancerCare Manitoba) • Nutritional supplementation does not restore the lean body you can only get more infection from TPN when cancer stage 4.. doen't mass of cancer ACS. **************************************** (Oxford textbook, 2019, p. 140) reverese cachexic state, GI stasis s bowel distension/// happens also in COPD, HIV, advanced AIDS.... • Grave prognostic sign. aspiration pneumonia s causes pts to die- when they lose ability to swallow 20 re direct families - to do massages, or listen to music together ACS in other Chronic Diseases 21 21 7 8/31/2023 tools: Assessment: ESAS revised • 1. Assess Symbolic representation of food - pt/family’s meaning of giving, taking, refusing food: • Food= sustenance to fight against disease. • Belief that food is effective in counteracting weight loss & the weight loss is due to ↓ appetite alone. • Giving of food = caring. Equated with Love. “Feeding is caring” • Food preparation, provision & eating – place where families engage with the patient to fight against disease • Eating = part of who you are – your identity. • Good appetite = sign of good health • Not eating + wt loss = signals the irreversible decline – a frequent reminder that the patient will die. 22 • ACS has devastating effect on family life. • Too often the family member attaches a huge significance to nutritional intake & exerts pressure on the pt to ↑intake. • Patient may be less troubled than the family calculation pre morbid weight no daily weight benefit only if in community s PPS more than 50 inflamm mediators cause C reactive protein go up s albumin go down like advanced liver s heart disease.. BIGGEST_educate families that eating wont improve cachexis state, change to massage.. (Medical Care of the Dying, 2006) 22 • 2. Appetite - Numerical rating scale (ESAS-r) • 3. Body weight – BMI + amount of wt. loss + level of disease. Any benefit to daily wts? • 4. Dietary intake – prospective 3 day log more reliable than retrospective • 5. Albumin (↓), C-Reactive Protein (↑ CRP) • 6. Assess for potentially reversible causes of wt loss – mucositis, N&V, constipation, early satiety, gastroparesis, malabsorption, pain, depression, hypogonadism (males with Ca), social/economic/psychological factors. • 7. Failure to respond to nutritional trial. • 8. Goals of Care (GOC) • 9. Functional Status – PPS 23 Assessment: 23 Management: every bite counts: high protein s high calories • 1. Education: ACS will not necessarily improve with more nutrition. Reframe condition from “starving to death” or “wasting syndrome” to “a natural process 24 that occurs at end of life”. (Bruera, 2014) • Very difficult for all involved. (helplessness & guilt on part of caregivers) (UpToDate, 2019) • 2. Support pt/family: family members felt that not enough education & psychosocial support was provided regarding hydration & nutrition at EOL (UpToDate, 2017) • Help family to identify other ways in caring for pt – mouth care, massage, music, reading & telling stories • Reinforce - “Rejection of food is not a rejection of you” (Cancer Care Manitoba) 24 8 8/31/2023 Management: - Being mindful that aggressive nutritional intervention does not reverse anorexia/cachexia syndrome. - Dietary consult – mixed data re overall benefit 25 • 3. Manage potentially correctable problems that cause↓ intake – consider GOC • 4. Nutritional Support to ↑ intake or maximize nutritional content may be helpful in early stage of disease process or in specific disease states. (UpToDate, 2019) - Useful for education & recommendation of appropriate interventions. (Wholihan, 2015, Oxford Textbook) 25 Nutritional Interventions: (Oxford Textbook of Palliative Nursing, 2019, pp. 143-144) • 1.Evaluate nutritional quality of intake & modify to improve. Emphasize pleasure of tasting food over caloric intake. • 2. Encourage culturally appropriate or favoured foods. Preserve cultural & social traditions around meals. 26 Provide nutrient dense foods. High protein, high calorie (if possible). Make every bite count. • (ie. glass of wine with meal if allowed). Provide opportunities for families to eat together. • Assess for cultural beliefs. Illnesses classified as “cold” by some southeast Asians & Latinos are thought to be harmed by food or drink that is cold. • 3. Try foods with various tastes, textures, seasonings, colors. Try flavouring foods with orange, lemon, fruit juices, sweet or sour relishes. • 4. Small, frequent meals on pt’s schedule according to tastes/whens of pt. 26 Nutritional Interventions: constant parade of foods to try. 6.Try different liquids – cold, clear liquids usually well tolerated. • ↑calorie + protein liquids (smoothies, soups, boost). • Avoid filling fluids without nutritional value at mealtime. (ie. Carbonated soda) • Limit fluids to 30 minutes prior to meals to avoid early fullness.- increase saiety.. • 7. Timing – early satiety – take most nutritious part of the meal first. 27 5. Caution that family doesn’t overwhelm pt with explain as active phase dying-i ts gut shutdown, gut doesnt have motility s no absorption s content in gut is same s feel bloated , anorexia s nausea, only give antiemetic to move content along but they wont eat more give antiemetics 30 minutes before 27 9 8/31/2023 Nutritional interventions: 28 • 8. Limit procedures, psychological distress prior to meals. Relaxation 30-60 mins ac. • 9. Sit upright 30-60 mins after eating to promote digestion. 10.Team approach – OT for independent feeding options. advanced CA+chemotherapy= stomatitis (mouth sores s painful) afect ability to eat s drink • 11. Manage oral pain (stomatitis). • 12. Artificial Nutrition – assessed on individual basis. Consider pt goals of care. Will this benefit the pt? 28 dont do TPN bc need to monitor BG regularly Artificial Nutrition: Enteral (NG, PEG, Jejunostomy), Parenteral Nutrition (TPN): gastrostomy tubes/jejustomy only if head s neck cancer or dysphagia(ALS, myesthesia gravis)= only if secondary which is rarely 29 • No evidence to support that AN prolongs life or functional status in advanced cancer. • Sensitive communication. Decisions often emotionally based. Discuss when to start & when to stop. • May be useful for a small subset of pts: • Those with good functional status + relevant 2ndary (exogenous) component to ACS who may benefit from invasive nutritional interventions. (Oxford Text, 2019, p. 144) • Head & neck cancers - severe dysphagia undergoing radiation therapy. • Neuromuscular conditions – Dysphagia – ie. ALS (if consistent with GOC ) educate: gut shutdown s no desire to eat s can cause complications 29 At End of Life: 30 must be in upright position • Feeding did not support comfort at EOL, did not improve longevity. Caused ↑ complications ( N&V, abdominal discomfort). • Often @ EOL there is ↓ desire to eat – may not be hungry. • If hungry – comfort feeding - can often be satisfied with small amounts of PO feeding carefully by hand. (Dr. Duerksen, WRHA Palliative Care Rounds, Nov.2013) 30 10 8/31/2023 Enteral /Parenteral Nutrition: • TPN only if aligns with GOC, if good functional status, prognosis of at least 2-3 months, where enteral feeding is not possible. (Oxford Textbook, 2019, p, 144) • TPN considered in highly selective patients where prognosis is several months to years (UpToDate, 2017) • Enteral: Parenteral: - tube placement issues - needs special venous access - skin excoriation - tube site - ↑infection, blood clots - dumping syndrome - refeeding syndrome - risk for aspiration - frequent blood monitoring - exacerbate chronic nausea - stimulates tumor growth ? • Parenteral Nutrition (TPN) is Not part of the WRHA palliative care program. Requires monitoring, frequent blood work, expensive, can increase morbidity & complications. 31 31 Pharmacological Interventions: • 1. Megestrol Acetate (MA)– synthetic progesterone. – Hypothesis: acts on cytokines inhibiting TNF – ↑ appetite & overall weight but no effect on QOL or lean body mass in advanced cancer. =increase apetite s gain weight= expectancy weeks to months – Doesn’t reverse cachexia. – ↑appetite < 1wk but ↑ weight can take several wks. – S/E: edema, life threatening thromboembolic events. – Use if life expectancy is weeks to months. (Bruera et al, 2015) • 2. Corticosteroids – Dexamethasone, Methylprednisolone – ↑ appetite, nutritional intake, well-being. Effects last 34wks. dexmethasone is a choice= increase apetite,, useful if less than 2 months life expectancy – Possible modest weight gain but not improved survival or QOL. (UpToDate, 2017) dont worry about renal suppression it's a low dose – Most useful with life expectancy < 6 -8 wks. – S/E: adrenal suppression, hyperglycemia, peptic ulcers. 32 check BG= once a week, to protecct to gut = periate, ameprazole 32 Pharmacological Interventions: not an appetite stimulant • 3. Metoclopramide – to treat early satiety in gastroparesis. antiemetic prokinetic • ↑ gastric emptying & ↓ nausea. • Prokinetic agent. • Is not an appetite stimulant • Domperidone work indirectly by relieving gastroporesis, cause content of stomach to move contents move to lumen of bowels, by moving along it decreases early satiety( feeling of fullness to stop eating) 33 33 11 8/31/2023 Cannot Recommend: • 4. Cannabinoids – Nabilone, Dronabinol – ↑ appetite ↓ nausea but without evidence of weight gain. No evidence to recommend in advanced cancer. (UpToDate, 2019) little evidence that deals with neuropathic pain • CNS S/E limit use: somnolence, confusion, dysphoria especially in elderly. (Oxford Text, 2019, p.145) dont work SE outweight the benefit – Comparing Dronabinol to Megestrol Acetate (MA) in study of 469 adults with advanced Cancer & weight loss: (National Cancer Institute) • in MA group: Appetite ↑ 75% + weight ↑ 11% • In Dronabinol group: appetite ↑ 49% + weight ↑ 3% 34 34 MUCOSITIS/STOMATITIS: csuses chemotherapy, radiation/ advanced CA= destroyed fast growing cells = has mouth sores/pain/bleeding/affects ability to drink/difficult to swalllow • Oral cavity is often the 1st site of manifestation or treatment related S/E in terminally ill pts. (UpToDate, 2017) stomatitis goes to back of the throat • Mucositis or Stomatitis: inflammation, infection or ulceration of the mouth and throat leading to pain & sometimes bleeding. – (Pallium Pocketbook, 2008, 8-47) • Common Sx: redness, pain, swelling, ulcers, burning, difficulty swallowing, sensitivity to heat/cold, salty, spicy foods & beverages. • (Head & neck cancer patient guide, CancerCare Manitoba, 2013) ******* • Incidence: ~ 40% in pts receiving standard dose chemo (EPEC-0) – All receiving radiation therapy to head/neck will get mouth & throat side effects. Usually appears 2 wks after initiation of radiation therapy. (CancerCare Manitoba, 2013) 35 35 Impact of oral conditions: Pain Taste alterations - ↓ appetite Dental caries + difficulty with dentures Difficulty with chewing & swallowing – impaired nutrition → anorexia/cachexia Difficulty with speech, halitosis– social isolation Dignity & respect Interrupted sleep - Dry mouth sensation is worse at night (diurnal saliva production) Oral complications can impact QOL, contribute to functional decline & failure to thrive. (UpToDate, 2019) 36 • • • • stomatitis= inside of lips/tongue/guns=thrush= give statin =swish s swallow • • • • 36 12 8/31/2023 Stomatitis: Varying types of lesions: Oral candida - thrush 37 stomatitis 37 Management: (BC Cancer, oral mucositis) • After brushing, rinse minimum of four times daily with 1 tablespoon (15 ml) oral rinse, swish for 30 sec, then spit out. Prepare rinse solution daily to avoid risk of contamination. • Bland Oral Rinses: Normal Saline: NS/Sodium Sodium Bicarbonate: Bicarbonate Mixture: ½ tsp (2.5 ml) salt in 8 oz (240 ml) water ¼ tsp (1.25 ml) salt + ¼ to ½ tsp baking ¼ tsp (1.25ml) baking soda in 8 oz (240 ml) soda in 8 oz (240 ml) water water • Multi-agent rinses – “ Magic Mouthwash” may be prescribed to help palliate pain - limited evidence to suggest superior over bland rinses (BC Cancer Agency, Oral Mucositis) • (Tache Pharmacy, CD Whyte Ridge Pharmacy, Shopper Drug Mart 777 Sherbrook St. or Manitoba Clinic, The Compounding Pharmacy of Manitoba) 38 anesthetic med=pink colour=relieve pain from sores of mouth NS = sodium bicarb= tell to rinse 4x times a day after meals.. ex: magic mouth wash or biotin helps to hydrate mouth chek mouth daily for sores 38 Causes & Management: • Causes: chemotherapy, radiation therapy, xerostomia, q1-2h after eating malnutrition, infections • Assessment: Mouth Care Assessment Flow Sheet – Check mouth daily for infection, sores, changes remove dentures if lots of stomatitis s mucositis • Management: Mouth care q1-2h (awake) & after eating or ingesting meds & at hs. • May need to remove dentures until mucosa healed. Clean/soak dentures regularly. • Floss daily • Do not floss if:*** - Platelet count < 50, 000 mm3 or advised by MD (BC Cancer, Mucositis) • Avoid lemon glycerine swabs (drying). Avoid OTC mouthwashes with alcohol or phenol: ↑ pain =use biotin instead like B alladin s avoid vaseline • Super soft tooth brushes, picks (from dentist) • Use Biotene® if can’t tolerate regular fluoride toothpaste. • Apply water or lanolin-based moisturizer to lips – not Vaseline avoid highly acidic s spicy (petroleum based). Oil based lubricants ↑ risk of aspiration + occlusive nature ↑ growth of pathogens. 39 39 ex: magic mouth wash= like anaesthetic agent-lidocaine or Tantum 13 8/31/2023 Management: • Magic Mouthwash: prescription –many different formulas can contain topical analgesic-Lidocaine • Benzydamine Hydrochloride 0.15% (Tantum®) - antiinflammatory mouth rinse prevent/relieve pain & inflammation radiation therapy for head/neck cancer. (BC Cancer, Mucositis) • Antifungal (Nystatin) for thrush (swish & swallow), Fluconazole (po tab). Antiviral (Acyclovir) for herpes • Systemic opioids. • Avoid acidic, spicy foods, sharp foods (chips), caffeine, alcoholic beverages. Limit diet soft drinks – acid can weaken enamel. • Oral zinc sulfate lozenges may be effective (Bruera, 2014) 40 40 Xerostomia: • Definition: sensation of dry mouth. Sticky thick saliva. • Up to 78% of cancer patients. (UpToDate, 2017) • Causes: – Dry mucosa – mouth breathing, dehydration, N&V, cytotoxic agents, swallowing difficulties etc. – Infection – candidiasis, parotitis – ↓ salivation – drug therapy ie opioids, diuretics, anticholinergics, antidepressants (TCA), radiation to head & neck ↓es salivation by 60% • Assessment: 1. cracker biscuit test 2. tongue blade 3. Oral assessment – Mouth care assessment flow sheet excessive fluid doesn't take away dry mouth sensation • (Oxford Textbook of Palliative Care, 2019, p. 179) 41 41 Xerostomia: Management:  1. Treat underlying infection or disease Regular cleaning of teeth, tongue, gums – toothpaste with fluoride. Biotene toothpaste if regular toothpaste irritating.  3. Mouth care q1-2h. ** Avoid commercial mouthwashes that contain alcohol. See Bland Rinses. Rinse mouth ac & pc. use moisture sprays + other techniques  4. Mouth lubricant – Oral Balance by Biotene®  5. Artificial saliva: Saliment, Orex. Spray, gel, rinse.  6. Rehydration – sipping cold water, ice chips, H20 by dropper, syringe or spray. Especially at night to promote sleep.  2. 42 42 14 8/31/2023 Management Cont’d: 7. Sugarless chewing gum, mints or lemon drops 8. Room humidifier – especially at night. * caution 9. Dietary modifications – Add sauces, gravies, salad dressings. Take 2-3 sips of fluid with each bite of food to wash food. Avoid alcohol & spicy foods – may irritate mouth. non pharmacological 10. Acupuncture – weekly or regular intervals. (Oxford Text, 2019, p.181) 43 43 Symptom Management kit and recommended starting doses for Patients with severe coronavirus disease 2019 CMAJ – March 31, 2020 • The severe acute respiratory syndrome coronavirus 2 (SARSCoV-2) pandemic will likely strain our health care system beyond capacity, and palliative care services will be needed across many different care settings, including intensive care units, hospital wards, emergency departments and long-term care. • The SARS-CoV-2 pandemic has been tragic for many people worldwide. Failing to provide Canadians with effective palliative care would compound that tragedy. 44 44 Symptom Management kit and recommended starting doses for Patients with severe coronavirus disease 2019 CMAJ – March 31, 2020 =1st = Haloperidol for Nausea in smaller dose 45 45 15