The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

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A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 6: Pulmonary SymptomsTable 6-3: Treatment of Respiratory Secretions26 picasGoal Medication Dose Frequency RoutePOPO4 to 6 hrs12 hrs100 – 400 mg600 – 1200 mgThin secretionsGuaifenesin liquid/syrupGuaifenesin LA tabsN-Acetylcysteine300 – 1200 mg12 hrsPOInhaled aerosolIntratracheal6 to 12 hrs1-4 hrs3-5 ml of 20% solution1-2 ml 20% solutionN-Acetylcysteine soln(e.g., Mucomyst)PO, IVAs toleratedFluidsTransdermal72 hrs1-3 patches (1.5 mg)ScopolamineReduce mucusproductionHyoscyamine sulfate0.125 – 0.5 mg4 to 6 hrsPO, SCAtropine0.4 – 0.8 mgPRN 4 to 6 hrsPO, SCDiphenhydramine25 – 50 mgPRN 4 to 6 hrsPO, IV, IM, PR144U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau
A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 6: Pulmonary SymptomsScopolamine transdermal patches (1.5 mg, with 1 to 3 applied at a time, replaced every 3 days),hyoscyamine sulfate (0.125 to 0.25 mg oral or subcutaneous every 4 hours), or atropine (0.4 to0.8 mg oral or subcutaneous) can be effective in reducing secretion production if given earlyenough.26Antihistaminespicassuch as diphenhydramine (25 to 50 mg every 4 to 6 hours) are effectivedrying agents occasionally used in the final hours of life to control secretions. The “death rattle”may partially respond to frequent repositioning of the patient, with a special effort to avoid flator supine positions that allow pooling of secretions in the pharynx or larynx.Treatment of DyspneaDyspnea is a general term that describes a subjective sensation, an “uncomfortable awarenessof breathing.” 11 Patients may use a variety of words or phrases to explain these distressingsymptoms, such as chest tightness, breathlessness, air hunger, unable to take a deep breath,feeling of suffocation or smothering, or unable to get enough air. 12 The symptoms usually worsenwith exertion and often limit the patient’s activity. Extensive research has not yet provided asimple, clear explanation of the physiological basis for the symptom of dyspnea. One reasonableexplanation is that the sensation of shortness of breath occurs when the air movement or “stretch”in the lungs is disproportional to the respiratory effort involved in breathing. This may be exacerbatedwhen a patient’s respiratory muscles are fatigued or have inadequate energy stores.Surveys of outpatients with HIV/AIDS indicate that shortness of breath or dyspnea was identifiedas a problem by between 11% and 48% of the patients. 13 The differential diagnosis of dyspneain AIDS patients includes pulmonary infections, pulmonary malignancies, pleural effusions, congestiveheart failure, marked anemia, and metabolic abnormalities. Malnutrition and weaknesscan lead to chronic respiratory muscle fatigue that also contributes to dyspnea. Anxiety and fearcan precipitate or worsen this symptom in combination with other etiologies.The sensation of dyspnea is not necessarily associated with low oxygen tension in the blood. Infact, the oxygen saturation of hemoglobin and oxygen partial pressure in blood are often normalin spite of very distressing symptoms. On the other hand, some patients with significant hypoxemiahave little or no feeling of dyspnea associated with their abnormal blood gases. In addition,the severity of dyspnea does not necessarily correlate with the severity of pulmonary disease orpulmonary function test values. While dyspnea is usually associated with pulmonary or cardiacdisease, it can occur with no detectable evidence of abnormalities in these organs. Even interminally ill cancer patients, 24% had no evidence of pulmonary or cardiac disease to explainsymptoms of dyspnea. 14 For patients with some exercise tolerance, the etiology of dyspnea canbe evaluated with a pulmonary exercise test that measures expired and arterial gases duringstrenuous exercise. However, this approach is seldom practical or useful in patients with terminalillnesses.VITreatment of Reversible Causes of DyspneaPalliative care aims to relieve the discomfort associated with feeling short of breath, regardlessof the origin of the symptom. The first step in treatment is to identify any reversible causes ofdyspnea and treat these with appropriate medications such as diuretics, bronchodilators, orsteroids (Table 6-4). Corticosteroids, in particular, are used generously in palliative medicine,not only for relief of bronchospasm but also to reduce symptoms associated with swelling aroundU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 145
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DedicationA Clinical Guide to Suppo
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Lynn A Jansen, RN, PhDAssistant Res
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TABLE OF CONTENTSPart IChapter 1Cha
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IChapter 1.26 picasHIV and Palliati
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IA Clinical Guide to Supportive and
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A Clinical Guide to Supportive and
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IIIChapter 3.Assessment of Physical
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Chapter 10.26 picasPsychiatric Prob
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Chapter 11.26 picas Substance Use P
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Chapter 14.26 picasCulture and Care
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Chapter 15.26 picasSpecial Populati
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Chapter 17.26 picasEthical IssuesLy
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Chapter 18.26 picasLegal and Financ
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Chapter 19.Palliative 26 picas Care
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DRUGS AND THERAPIES INDEXNOTES: Ent
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The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

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