Use of Anesthetic-Based and Interventional Pain Management Techniques for Intractable Pain in Pediatric Cancer Patients (524)

Abstract

Objectives 1. Identify common barriers and challenges in assessing dyspnea. 2. Critique available diagnostic and therapeutic options for malignant pleural effusions. 3. Review the available evidence for medical management of dyspnea. Dyspnea is a highly prevalent and distressing symptom for many patients with advanced illness. Without careful assessment, dyspnea may go unrecognized and untreated even in patients at the end-of-life. Thorough assessment of dyspnea includes attention to the impact of dyspnea on daily activities. We will review several validated scales for assessing dyspnea and their relative strengths and weaknesses in assessing dyspnea for clinical or research purposes. We will highlight some of the challenges of assessing dyspnea, including lack of objective measures and the numerous contributing factors. Pleural effusions are an especially common cause of dyspnea in a palliative care population and often recur despite initial treatment. We will highlight the available interventional options for treating pleural effusions, including thoracentesis, pleurodesis, and indwelling pleural catheters. The appropriate indications, the potential risks, and the benefits of each modality will be discussed in detail. The available evidence for the medical management of dyspnea will be reviewed, focusing on the use of oxygen, anxiolytics, and opioids. We will analyze the literature on the use of supplemental oxygen in COPD as well as comparative data on oxygen and medical air. The limited data supporting the use of anxiolytics, such as phenothiazines and benzodiazepines, will be critiqued and distilled. We will appraise the value of newer, less established, or potentially promising treatment modalities, such as nebulized opioids, steroids, nutrition, exercise, pulmonary rehabilitation, behavioral interventions, and complementary therapies (eg, massage). The evidence basis for the use of opioids in the management of dyspnea will also be reviewed with an emphasis on trials that help dispel common myths about the dangers of using opioids for alleviating shortness of breath. Finally a step-by-step strategy for assessing and managing dyspnea will be proposed.