,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,*,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 perception,Dudgeon 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 effort,40,家姑息关怀中心和,14,家非姑息关怀病房,40 hospices and 14 non-hospice care settings,1754,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 symptoms,70%,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 life,Reuben 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 dyspnea,1754,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 cancer,Reuben 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 status,Reuben 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 prognosis,Reuben 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 dyspnea,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%lung cancer,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,Dudgeon 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 dyspnea,40%,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 PFTs,88%,的在,PFT,有狭窄的因素,88%,had restrictive component on PFTs,Dudgeon 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 tool,VAS,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 tr