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1、晚期癌症的呼吸困难和咳嗽晚期癌症的呼吸困难和咳嗽Dyspnea&Cough:Advance Cancer2晚期癌症呼吸困难晚期癌症呼吸困难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 therapyl阿片类药物的作用 Role of opioids3呼吸困难：定义呼吸困难：定义Dyspnea:Definition呼吸困难的感知 Perception of difficulty breathingl主观主观体
2、验体验 Subjective experience无以下客观指征 Cannot be defined byl躯体异常，客观体征 Physical abnormality,objective signl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 abnormality4呼吸困难的变异性呼吸困难的变异性Dyspnea Variability广泛的变异广泛的变异 Wide variation:l疾病间的变异疾病间的变异 Variation betw
3、een diseasesl个体间的变异个体间的变异 Variation between individualsl由先前的体验形成由先前的体验形成 Shaped by previous experiencel多因素调节感知的性质和强度多因素调节感知的性质和强度 Many factors modulate quality and intensity of perceptionDudgeon et al.J Pain Symptom Management.1998;11(4):212-219.5呼吸困难的要素呼吸困难的要素Components of Dyspnea社会的Social宗教的Spirit
4、uaL情感的Emotional躯体的Physical“若认识不到这些要素若认识不到这些要素分别是怎样引起呼吸困难的分别是怎样引起呼吸困难的全部痛苦，那么对其处理将全部痛苦，那么对其处理将很难成功。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：全国姑息关怀调查呼吸困难：全国姑息关怀调查D
5、yspnea:National Hospice Study全国范围内的预期数据收集全国范围内的预期数据收集 National prospective data collection effortl4040家姑息关怀中心和家姑息关怀中心和1414家非姑息关怀病房家非姑息关怀病房 40 hospices and 14 non-hospice care settingsl17541754名预后小于名预后小于6 6个月的癌症患者个月的癌症患者 1754 cancer patients with prognosis 6 monthsl对症状进行两周一次的检查对症状进行两周一次的检查 Biweekly i
6、nterview on symptoms70%70%的患者在生命的最后的患者在生命的最后6 6周里有呼吸困难周里有呼吸困难 70%had dyspnea during the last 6 weeks of lifeReuben et al.Chest.1986;89:234-236.7呼吸困难：全国姑息关怀中心调查呼吸困难：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
7、难的发病率增加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呼吸困难最重要的预测指征 Most important predictor of dyspneal17541754名癌症患者中有名癌症患者中有39%39%具有肺部和胸膜的癌性浸润具有肺部和胸膜的癌性浸润 39%of the 1754 cancer patients had lung or pleural involvement of cancerReuben et al.Chest.1986;89:234-23
8、6.8呼吸困难：全国姑息关怀中心调查呼吸困难：全国姑息关怀中心调查Dyspnea:National Hospice Study与肿瘤无关的呼吸困难与肿瘤无关的呼吸困难 Dyspnea not related to tumorl心脏疾病占心脏疾病占34%34%Cardiac disease 34%l慢性肺部疾患占慢性肺部疾患占 24%24%Chronic pulmonary disease 24%24%24%的患者的呼吸困难可仅由衰竭引起的患者的呼吸困难可仅由衰竭引起 24%had dyspnea attributable to debility alonel全身性肌无力全身性肌无力 Gener
9、alized muscle weaknessl功能状态欠佳功能状态欠佳 Poor performance statusReuben et al.Chest.1986;89:234-236.9呼吸困难：存活的预测指征呼吸困难：存活的预测指征Dyspnea:Predictor of Survival常见症状与幸存的相关性常见症状与幸存的相关性 Correlation of common symptoms with survivall全国姑息关怀机构调查数据的再分析全国姑息关怀机构调查数据的再分析 Re-analysis of National Hospice Study datal呼吸困难呼吸困难
10、 Dyspneal幸存的独立预测指征幸存的独立预测指征 Independent predictor of survivall仅次于功能状态和仅次于功能状态和“进食问题进食问题”l Second only to performance status and“eating problems”l疼痛，精神错乱和恶心不影响预后疼痛，精神错乱和恶心不影响预后 Pain,confusion and nausea did not affect prognosisReuben et al.Archives Internal Medicine.1988;148:1586-1591.10呼吸困难：与癌症的相关呼吸
11、困难：与癌症的相关Dyspnea:Cancer Relatedl气道阻塞气道阻塞 Airway obstructionl直接浸入肺实质直接浸入肺实质 Direct extension into lung parenchymal胸膜疾病胸膜疾病 Pleural diseasel间皮瘤间皮瘤 Mesotheliomal恶性心包渗出恶性心包渗出 Malignant pericardial effusionl上腔静脉综合症上腔静脉综合症 SVC syndromel肌无力肌无力 Muscle fatiguel恶病质综合症恶病质综合症 Cachexia syndromel 横隔膜移位横隔膜移位 Diaph
12、ragmatic excursionl肝肿大肝肿大 Hepatomegalyl腹水腹水 Ascitisl胸壁疾病胸壁疾病 /疼痛疼痛 Chest wall disease/pain11呼吸困难：与治疗相关的呼吸困难：与治疗相关的Dyspnea:Treatment Related化疗和放疗 Chemotherapy and radiationl急性肺炎 Acute pneumonitisl肺部纤维化 Pulmonary fibrosis外科 Surgeryl肺切除术 Pneumonectomyl肺叶切除术 Lobectomy12呼吸困难：非癌性原因呼吸困难：非癌性原因Dyspnea:Non-ca
13、ncer Causes感染感染 Infectionsl支气管炎支气管炎 Bronchitisl肺炎肺炎 Pneumonia慢性阻塞性肺部疾患慢性阻塞性肺部疾患/哮喘哮喘 COPD/asthma气胸气胸 Pneumothorax血栓性疾病血栓性疾病Thromboembolic disease心脏疾病心脏疾病 Heart diseasel缺血性心脏病缺血性心脏病 Ischemic heart diseasel心衰心衰 Heart failurel心律失常心律失常 Arrhythmias贫血贫血 Anemia心理因素心理因素 Psychological factors13呼吸困难的原因：晚期癌症呼吸
14、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与呼吸困难相关的前瞻性评估 Prospective assessment of factors associated with dyspnea100100例在姑息关怀科住院的呼吸困难患者例在姑息关怀科住院的呼吸困难患者 100 patients admitted to palliative care unit with dyspneal49%49%肺癌肺癌 49%lung cancerl28%28%非恶性呼吸道疾病非恶性呼吸道疾病 28%non-malignant respirator
15、y diseasel21%21%缺血性心脏病缺血性心脏病 21%had ischemic heart diseaseDudgeon et al.J Pain Symptom Management.1998;16(4):212-219.14呼吸困难的原因：晚期癌症呼吸困难的原因：晚期癌症Causes of Dyspnea:Advance Cancer呼吸困难的潜在可逆转原因呼吸困难的潜在可逆转原因 Potentially reversible contributors to dyspneal40%40%低氧血症：氧饱和度低氧血症：氧饱和度90%90%Hypoxemia 40%:O2 satura
16、tion 90%l20%20%贫血：血色素贫血：血色素1010 Anemia 20%:Hemoglobin 10l支气管痉挛支气管痉挛 Bronchospasm l47%47%的在的在PFTPFT有阻塞性因素有阻塞性因素 47%had obstructive component on PFTsl88%88%的在的在PFTPFT有狭窄的因素有狭窄的因素 88%had restrictive component on PFTsDudgeon et al.J Pain Symptom Management.1998;16(4):212-219.15呼吸困难：评估呼吸困难：评估Dyspnea:Assessment评估的目的评估的目的 Aim of assessmentl找出可能的原因找出可能的原因 Determine likely causel重点放在确定可逆转的原因重点放在确定可逆转的原因 Emphasis on identifying reversible causesl监控处理监控处理 Monitor management详细的病史和体征详细的病史和体征 Detailed history
