Respiratory symptoms

Respiratory symptoms may be related to a cancer or due to concur­rent illness such as asthma or chronic obstructive airways disease. In the palliative situation, in-depth investigations of the aetiology are often not appropriate or available.

It is important to look at all symptoms holistically, in the current context before instituting treatment.

Key questions are:

1. What is the most likely diagnosis?

2. What investigations are needed and what is the risk of these investigations?

3. What treatment is needed and what is the risk?

4. What is the prognosis?

5. How frail is the patient?

6. Will treatment improve quality of life or prolong suffering?

Solutions must constantly balance and re-evaluate risks and bene­fits and involve the patient and family in decision-making.

Thromboembolic disease with pulmonary emboli is a par­ticular example of the importance of balancing risks and benefits. Anticoagulation will improve symptoms and prevent recurrence but at what cost? They increase the risk of bleeding, especially where wounds are present. Regular monitoring might be inconvenient or impossible and a drain on resources, especially in resource-poor communities. Low-molecular-weight heparin (Clexane) is more convenient but often unaffordable. Is treatment likely to prolong life or prolong suffering? Ventilation/perfusion or computed tom­ography pulmonary angiography scans for diagnosis of pulmonary emboli might not be available, or indicated.

Treatment

Treatment includes four elements: general management, treatment of reversible factors, disease-directed treatment (e.g. radiation), and management of symptoms.

General measures may be very effective and should not be under­estimated. They include reassurance, building trust, a fan, sitting up­right, open windows, and ‘calm, positive approach... adjustments to patient's life style and expectations' (27).

Reversible factors and specific treatment measures are listed in Table 69.1.

Cough

Cough is often the most distressing symptom for patients, causing exhaustion and insomnia, and adding to the pain. While the first response may be to suppress cough, the underlying cause should sought first—if it is secondary to aspiration or reflux, simple ele­vation of the head of the bed and perhaps the addition of a proton pump inhibitor or a H2 receptor antagonist may resolve the problem. Drugs such as an angiotensin-converting enzyme inhibitor may add to the symptoms and need to be stopped. Underlying asthma may need bronchodilators. Finally, cough due to failure to clear ac­cumulating secretions might benefit from expectorants (guaifen­esin, acetylcysteine) to make the cough more effective in clearing airways. If there is no treatable source underlying the cough, then management with cough suppression (codeine, dextromethorphan) is warranted.