9 Management of respiratory and gastrointestinal symptoms

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Contents

• Objectives
• Signs and symptoms
• General approach to symptom management in children
• Managing shortness of breath
• Managing excessive respiratory secretions
• Managing nausea and vomiting
• Managing constipation
• Case study

Objectives

When you have completed this chapter, you should be able to:

1. Describe the difference between a sign and a symptom.
2. Describe the general approach to symptom management.
3. Manage shortness of breath.
4. Manage excessive respiratory secretions.
5. Manage nausea and vomiting.
6. Manage constipation.

Signs and symptoms

9-1 What is a sign?

A sign is a clinical observation that suggests the presence of an abnormality, illness or disease (e.g. abdominal mass, tachycardia or hypotension) and can be detected by someone other than the patient themselves. A sign is objective and sometimes can be observed by both the patient and others. Signs are usually found on clinical examination of the patient.

9-2 What is a symptom?

A symptom is any sensation or feeling that is only experienced by a patient for example, loss of appetite, nausea from chemotherapy or anxiety. A symptom is subjective and is what a patient complains of. Infants therefore have signs but not symptoms as they cannot describe what they are feeling.

Symptoms are experienced only by a patient while signs can be observed by someone else.

9-3 Why are symptoms important?

Children with life-threatening or life-limiting conditions or serious illnesses will experience a range of symptoms that cause distress and suffering, impacting on the quality of life of the child and their family. Assessing and managing the child’s symptoms are equally as important as assessing and treating their clinical signs.

9-4 How do we group symptoms?

Symptoms can be grouped according to particular body systems, i.e. respiratory, gastrointestinal, neurological, constitutional (general), dermatological and haematological symptoms.

Children with serious illness may experience distressing symptoms affecting any part of the body.

9-5 What are some of the most common symptoms found in children who require palliative care?

Common symptoms include:

• Respiratory symptoms: Shortness of breath and excessive secretions
• Gastrointestinal symptoms: Nausea, vomiting and constipation
• Neurological symptoms: Anxiety and depression
• Constitutional symptoms: Fatigue and anorexia
• Skin symptoms (dermatological): Pruritus, pressure sores or wound.

General approach to symptom management in children

9-6 What are the principles of symptom management?

The principles of symptom management are:

1. Thorough assessment and treatment of the underlying cause if possible.
2. Non-pharmacological management should always be considered, depending on the symptom e.g. dietary changes, positioning, distraction with art or music.
3. Pharmacological management directed at the symptom, e.g. an anti-emetic for nausea and vomiting.
4. Good explanation and reassurance to the child and family.

Managing symptoms includes assessment, non-pharmacological and pharmacological interventions and good explanation and reassurance.

9-7 What are the four golden rules to remember when managing a child with distressing symptoms?

These are:

• Do not panic!
• Thorough clinical assessment
• Hope for the best, prepare for the worst
• Treat what you can treat

Always remember to use a team approach when managing any symptom.

Managing shortness of breath

9-8 What is shortness of breath?

A common symptom in children’s palliative care is shortness of breath (dyspnoea), which is difficulty in breathing or a sense of breathlessness. It is a frightening and exhausting, tiring and draining experience for both the child and the parents and therefore requires simple, effective management.

Shortness of breath is a common symptom in children who need palliative care.

9-9 What are the common causes of shortness of breath?

There are many underlying conditions or causes for shortness of breath which will require specific management or treatment. It is therefore important to assess the child to determine the possible cause. Common causes in children’s palliative care are related to advanced cancer, AIDS, anaemia, chest infections, heart conditions, neuromuscular diseases, stress, anxiety and treatments such as post radiation fibrosis.

There may be many underlying causes of shortness of breath so it is important to assess the child to determine the correct treatment.

9-10 Does anxiety affect shortness of breath?

Shortness of breath has a strong emotional component and therefore it can be made much worse by anxiety. This can cause a vicious cycle of shortness of breath which leads to anxiety, that in turn causes worsening shortness of breath. This cycle needs to be broken by using non-pharmacological approaches that will reduce the child’s anxiety.

Anxiety and shortness of breath make each other worse.

Figure 9-1: The relation of shortness of breath and anxiety to each other

9-11 How can you manage shortness of breath?

Complete a thorough assessment and treat any underlying cause or reversible factors if possible. Specific management will depend on the stage of the disease, how actively the child is still being managed and the available resources.

9-12 What non-pharmacological strategies can you use to treat shortness of breath?

Effective non-pharmacological management includes:

• Explanation of the probable causes and constant reassurance to both the child and family
• Sitting the child up into a position where they can lean forward and support themselves on their forearms or raising the head of the bed
• Opening the windows or using an electric or hand-held fan to ensure a flow of air across the room and towards the child’s face
• Placing a cool cloth on the child’s forehead
• Using age appropriate distraction techniques including play, music therapy and breathing exercises
• In older children, exploring any psychological reasons for shortness of breath and providing reassurance and supportive counselling when appropriate
• Maintaining oral hygiene while keeping the child’s mouth and lips moist as mouth breathing can cause uncomfortable dryness
• If the shortness of breath is anxiety related and reoccurring, consider referring to other members of the team who could assist with counselling e.g. a social worker, counsellor or psychologist.

Non-pharmacological management of shortness of breath includes mouth care, positioning, cool air onto the face, distraction and reassurance.

9-13 What is the pharmacological management for shortness of breath?

Pharmacological management will be determined by the underlying cause and how actively the child is to be managed:

• Antibiotics may be used to treat pneumonia if in line with the goals of care and stage of the disease.
• Bronchodilators and oxygen therapy may be helpful if there are signs of bronchospasm.
• Saline nebulisers can be helpful to loosen secretions and to moisten the airways.
• If there is an upper airway obstruction or stridor, consider nebulisation with adrenaline or give high dose intravenous dexamethasone over two minutes.
• Diuretics may be beneficial in children with fluid retention and shortness of breath associated with pulmonary oedema or congestive heart failure.
• Anxiolytics (benzodiazepines), e.g. diazepam (Valium) or lorazepam (Ativan) can help assist when there is an associated anxiety component to the shortness of breath.
• Use morphine if the shortness of breath is severe as this helps reduce anxiety and pain. If the child is not already on an opioid, give morphine at a third of the normal starting dose. If the child is already on morphine, increase the dose by a half.
• If a child is short of breath but not hypoxic, oxygen therapy is not likely to relieve the shortness of breath. However, it may provide reassurance to the parents and some comfort to the child as long as the child is not distressed by the nasal cannula or an oxygen mask.
• Sudden and severe shortness of breath in terminal care must be managed quickly with a combination of morphine and midazolam which can be given buccally (by mouth) or rectally. Likely causes are a pneumothorax or pleural effusion. Treat any specific cause if appropriate.

If shortness of breath is severe, giving morphine and a benzodiazepine can reduce anxiety and pain.

Managing excessive respiratory secretions

9-14 What are the causes of excessive secretions?

There are a number of causes for an accumulation of secretions:

• The illness or condition itself, e.g. cystic fibrosis or bronchiectasis
• Pulmonary oedema resulting from congestive heart failure or kidney failure
• Neuro-muscular diseases (e.g. myopathies or cerebral palsy) in children unable to swallow secretions leading to drooling
• Excessive secretions at the end-of-life which are caused by a reduced level of consciousness and the child’s inability to cough or swallow secretions

Excessive secretions in terminally ill children are usually due to reduced level of consciousness and poor swallowing.

9-15 How can you manage excessive secretions?

Complete a thorough assessment and treat any underlying causes where possible:

• If these secretions are due to pulmonary oedema, they will need to be treated with a diuretic such as furosemide.
• If the child is distressed or short of breath this may need to be treated accordingly.
• If the child has difficulty swallowing, positioning may help and if distressing, airway suction and medication to dry up the secretions can be used such as atropine or hyoscine butylbromide (Buscopan).

9-16 What name is given to excessive secretions at the end-of-life?

Excessive respiratory secretions are commonly referred to as ‘noisy secretions’ or the ‘death rattle’. These sounds that are often produced at the end of life are a result of fluids such as saliva and bronchial secretions that accumulate in the throat and upper chest.

9-17 Are these noisy secretions distressing?

As the child’s level of consciousness is decreasing prior to death, the child is not aware that these secretions are accumulating and therefore it is not distressing to the child. However, these noisy secretions or ‘death rattle’ can be very distressing to the family as they may think that their child is drowning or choking on their secretions.

9-18 How do you manage noisy secretions at the end of life?

• The most important part of management is to ensure that the family understands the reason for these noisy secretions.
• Reposition the child by sitting them up or lie them on their side so that the secretions can drain from the side of the mouth.
• Good mouth care is important as a dry mouth is uncomfortable.
• Only consider gentle suctioning if there is thick mucus or blood in the mouth. Deep suctioning is not necessary and may trigger the gag reflex and cause more distress than the accumulated secretions.
• Consider using the following treatment:
  • Hyoscine butylbromide (Buscopan) to reduce the production of secretions as a single dose subcutaneously (single doses given over 10 minutes 4 hourly may be required or via a subcutaneous infusion).
  • Atropine 1 to 2 drops sublingually 6 hourly. Start with 1 drop in small children and increase to 2 drops if necessary. For older children start with 2 drops.
  • Glycopyrronium can be given as a single dose subcutaneously. If effective, continue using 4 hourly. It is not recommended that it be combined with other medications in a subcutaneous infusion.

Note

Hyoscine butylbromide is not very effective unless started as soon as possible after the onset of noisy breathing.

If the child is positioned with the head lower than the body it allows excessive secretions to drain from the mouth.

Managing nausea and vomiting

9-19 Why is the management of nausea and vomiting important?

Nausea and vomiting are commonly experienced by children with serious illnesses. Nausea is not always accompanied by vomiting and children who vomit are not always necessarily nauseous. Understanding the underlying cause or trigger factor may help in choosing the correct anti-emetic (anti-vomiting) drugs.

9-20 What causes nausea and vomiting?

There are many physical causes of nausea and vomiting which act via direct (central) or indirect (peripheral receptor) mechanisms that can stimulate the vomiting centre in the brain. Psychological causes of nausea and vomiting include anxiety, fear and pain. Children also have a sensitive gag reflex and any irritation in the back of the throat may trigger vomiting. It is therefore important to assess the child fully to identify the underlying causes and mechanisms before treating the child.

Note

There are multiple central and peripheral receptors with neurotransmitter pathways that stimulate the vomiting centre in the medulla oblongata of the brain stem. Vomiting is usually triggered by the stimulation of either the vagal afferent receptors in the gut, the vestibular apparatus in the inner ear or direct stimulation of the vomiting centre in the medulla.

9-21 What are the different mechanisms that trigger vomiting?

There are generally four mechanisms that cause nausea and vomiting:

1. A mechanical mechanism which is caused by effects on the gut (gastrointestinal tract):
   • Oesophageal causes such as compression, mucosal inflammation due to reflux, or infections due to Candida or Herpes simplex
   • Incomplete stomach emptying (gastric flow obstruction), e.g. partial or complete bowel obstruction, tumours, masses or constipation
   • Any cause of slow stomach emptying (gastric stasis or poor gut motility)
   • Inflammation of the stomach mucosa from drugs, e.g. non-steroids anti-inflammatory drugs (NSAIDs), steroids, antibiotics, and untreated anxiety
   • Stimulation of receptors (vagal stimulation) in the gut which stimulate the vomiting centre in the brain
   • Ascites or a large abdominal mass causing intra-abdominal pressure.
2. A ‘toxic’ mechanism which stimulates receptors in the gut to send messages via the chemoreceptor trigger zone (CTZ) to the vomiting centre in the brain:
   • Drugs, e.g. opioids, antibiotics, chemotherapy, TB medication and antiretroviral drugs
   • Biochemical, e.g. hypercalcaemia, uraemia and liver failure
   • Toxins from tumour breakdown or infections.
3. Direct effects on the vomiting centre in the brain:
   • Raised intracranial pressure
   • Brain metastases or primary brain tumours
   • Radiotherapy to the brain
   • Pain, fear, memories and anxiety can be major triggers of nausea and vomiting in children.
4. Vestibular (inner ear) effects:
   • Motion sickness
   • Cerebellar tumour.

Nausea and vomiting can be triggered via various receptors in the gut, brain and vestibular apparatus of the inner ear.

Figure 9-2: Causes of nausea and vomiting, and pathways to the vomiting centre in the brain.

9-22 How do you assess the nausea and vomiting?

The three steps in finding a cause for nausea and vomiting are:

1. Take a full history, including all medication that the child is receiving.
2. Complete a clinical examination focusing particularly on the neurological and gastrointestinal systems.
3. Identify the possible effects of the vomiting e.g. dehydration.

9-23 What questions should you ask when taking a history of the nausea and vomiting?

To obtain a full history you would question the child, if they are old enough to give a history, as well as the caregiver (nursing staff and parents) about:

• Whether they feel nauseous or not
• The timing, frequency, consistency and volume of the vomiting
• The stool habits, e.g. constipation or diarrhoea
• Any factors that may be contributing, e.g. certain food or medications
• Any factors that may help reduce vomiting e.g. eating before taking medication
• Any neurological problems that may be contributing e.g. swallowing problems
• Any gastrointestinal problems that may be contributing e.g. gastro-oesophageal reflux
• Any pain or anxiety that may be contributing to the nausea
• Any movement or positioning that may trigger nausea or vomiting
• Any history of allergies.

9-24 What symptoms, signs and underlying causes should you look for when doing a clinical examination?

Identify the possible underlying cause of vomiting with a thorough history and examination before treating.

9-25 How do you manage a child with nausea and vomiting?

To manage nausea and vomiting correctly, an understanding of the physiology and the receptors involved in triggering the vomiting are essential. This is because different anti-emetic (anti-nausea) drugs work at different receptor sites. Treat and correct any of the underlying causes or reversible factors such as pain, infection or constipation.

9-26 What non-pharmacological strategies can you use to manage nausea and vomiting?

Common strategies include:

• Explain and reassure the child and family about what the cause may be and how you will help manage it.
• Offer small meals frequently and keep them bland and dry e.g. toast.
• Avoid giving the child foods that may aggravate nausea and vomiting especially spicy, very sweet and fatty foods and remove any leftover food immediately.
• Avoid exposing the child to certain strong odours as these can aggravate nausea, e.g. strong perfumes, deodorants and cooking smells.
• Maintain hydration by giving frequent small amounts of liquid, including oral hydration solution if the child is already dehydrated. This may require cup and spoon or syringe feeding.
• If a very thirsty infant is feeding, try to avoid letting them drink too fast, as this may lead to them sucking in air which can cause more vomiting.
• Position the child upright or use feed thickeners if gastro-oesophageal reflux disease is a concern.
• Encourage the child to rinse out the mouth and brush teeth after vomiting.
• Review the medication list for dosages or possible side effects that may be triggering nausea and vomiting.
• Split medications dosages where possible if vomiting is associated with a certain medication.
• Address psychological issues like anxiety or fear.

9-27 How do you decide on what pharmacological treatment to use?

Consider the most likely stimulus of nausea and vomiting as this will guide the choice of an anti-emetic. If the first choice of anti-emetic is only partially successful after 24 hours, increase the dose or use a different anti-emetic.

9-28 Which are the commonly used anti-emetics for nausea and vomiting?

Commonly used anti-emetics are:

• Prokinetics that work by stimulating contractions in the gastrointestinal tract e.g. domperidone or metoclopramide for conditions such as gastritis, gastric stasis and partial bowel obstruction.
• Anti-emetics that work on the chemoreceptor trigger zone e.g. haloperidol or ondansetron. These are used for most of the chemical or metabolic causes of nausea and vomiting such as opioids, chemotherapy treatments, hypercalcaemia and renal failure.
• Anti-emetics that work on the vomiting centre in the brain e.g. cyclizine for raised intracranial pressure, and complete bowel obstruction.
• Anti-emetics that have antispasmodic (reduce contractions of the gastrointestinal tract) and anti-secretory effects e.g. hyoscine butylbromide for bowel colic or the need to reduce gastrointestinal secretions.

9-29 What are some important principles of using anti-emetics?

These include:

• A combination of anti-emetics working at different sites may achieve better control than a single drug alone.
• Cyclizine is possibly the best first line choice of anti-emetic if in doubt of the cause of nausea and vomiting.
• For raised intracranial pressure, dexamethasone can be added to either cyclizine or ondansetron.
• Do not combine metoclopramide (Maxolon) and cyclizine or hyoscine butylbromide as the prokinetic effect of the first is cancelled by the opposite effect of the other two drugs.

Cyclizine is usually the first line choice but using a combination of anti-emetics that work at different sites may achieve better results when treating nausea and vomiting.

Managing constipation

9-30 What is constipation?

Constipation is the infrequent or difficult passing of a stool that is usually hard. It is a common symptom and can be very distressing for both the child and the carer but can be managed effectively with a combination of diet and medication.

9-31 What are the causes of constipation?

Constipation in children is usually due to:

• Functional causes such as inactivity, dehydration, incorrect diet, and fear of pain when passing stools. Lack of privacy and embarrassment can also lead to functional constipation.
• Side effects of medication such as opioids, chemotherapy, iron and anti-depressants.
• Disease-related causes such as cystic fibrosis, cerebral palsy, abdominal tumours or masses.

Constipation is caused by either functional, drug or disease-related factors.

9-32 How can you assess constipation?

1. Take a full history by determining the following from the parents (and the child if they are old enough):
   • How long has constipation been a problem?
   • What are the size and consistency of the stools? Is there any leaking of liquid stool?
   • How often are stools passed – daily, weekly or sporadic?
   • Is there any anal pain or bleeding (fresh blood) when passing the stool?
   • How often does the child eat and what foodstuffs are included in the diet?
   • How mobile is the child?
   • What is the child’s daily fluid intake?
   • What medication is the child currently taking?
   • Are there any psychosocial issues like depression or anxiety?
   • Is the child vomiting and/or complaining of any abdominal pain?
2. Complete a physical examination of:
   • The abdomen, listening for bowel sounds, looking for distension and feeling for any tenderness or palpable masses
   • The anus and perineum to identify any fissures, abscesses or tears
   • General status looking for signs of dehydration, malnutrition, either underweight or overweight.

Always consider the history and complete a physical examination before deciding on the management of the constipation.

9-33 How should you manage constipation?

Treat and correct any underlying causes or reversible factors where possible. It is important to also explain to the child and the family that it might take a few days and different strategies to resolve any constipation issues. If the child is approaching end-of-life, focusing on comfort care, rather than aggressive management of the constipation, may be more appropriate.

9-34 What non-pharmacological strategies can you use to manage constipation?

Common non-pharmacological strategies include:

• Parents or caregivers should be encouraged to maintain a positive and supportive attitude throughout treatment and expect gradual improvement.
• The child’s diet may need to be adjusted by including more fibre and ensuring adequate hydration. This is usually the first step in managing constipation.
• If appropriate, encourage regular physical exercise and activities.
• Encourage regular daily bowel routines e.g. try and get the child to pass a stool every morning after breakfast.
• Create an environment where the child feels relaxed and comfortable, i.e. private and quiet.
• Ensure the toilet seat is at the right height so the child is sitting upright.
• If using a bedpan, warm it up first and position the child so that they are not lying flat on the pan.
• Where necessary assist, support and provide comfort during bowel movement.
• Where this has become a painful experience, try lubricating the anus with KY Gel or Vaseline, distracting the child with different measures and offering encouragement through the process.
• Use abdominal massage or heating pads if the child is experiencing discomfort and pain.
• If the child has fissures or tears, consider oral paracetamol and lubricate the area before the child passes a stool.
• Try natural remedies e.g. 1 to 5 teaspoons of crushed dried paw-paw seeds given at night or prune juice.

Encouraging regular daily bowel routines and adjusting the diet to include fibre and adequate hydration are usually the first steps to prevent constipation.

9-35 What laxatives can you use for constipation?

As different laxatives have different methods of action, a decision should be made as to which type of laxative to use. Children that are on long term opioids should routinely be placed on a laxative.

9-36 What is a general regime to treat constipation?

A general regime to treat constipation is as follows:

1. Start with a laxative that absorbs fluid from the bowel to soften the stool (an osmotic laxative) such as lactulose. If needed, increase the dose over a week.
2. If there is no improvement, add a laxative that stimulates bowel movement such as oral senna or bisacodyl (Dulcolax).
3. If the rectum is full and there is:
   • Hard stool – use glycerine suppositories, or olive oil/arachis oil or sunflower oil retention enema
   • Soft stool – use bisacodyl suppositories
   • If there are no results, give a sodium phosphate enema or sorbitol micro–enema.

It is often necessary to use a combination of laxatives if the constipation is an ongoing or severe problem.

See Appendix H for formulary and the correct doses.

Always consider preventing morphine induced constipation with a laxative such as lactulose.

Case study

Cindy, a 14-year-old with an abdominal tumour, has presented with symptoms and signs indicating a partial bowel obstruction. She is very nauseous and has been vomiting for a couple of days, especially after eating. She is currently on morphine and says her bowels last worked 7 days ago.

1. What mechanism is most likely triggering Cindy’s nausea and vomiting?

Any large abdominal mass may stimulate the pressure receptors in the gastro-intestinal tract which will send a message to the vomiting centre in the brain. This is therefore a mechanical mechanism triggering her nausea and vomiting.

2. What could another underlying cause of the nausea and vomiting be other than the tumour?

Cindy says she has not had a bowel movement for seven days. If she is severely constipated this could be the cause of the partial bowel obstruction and the trigger for the nausea and vomiting. It is important to check if she is on a daily prophylactic dose of a laxative to treat this side effect of the morphine.

3. What is the correct management for nausea and vomiting caused by a partial bowel obstruction?

Metoclopramide (Maxolon) is the drug of choice for a partial bowel obstruction.

4. What advice would you give the parents with regard to managing Cindy’s nausea and vomiting at home?

• Offer small meals frequently and keep them bland and dry e.g. toast
• Avoid foods that may aggravate the nausea and vomiting especially spicy, very sweet and fatty foods and remove any leftover food immediately
• Avoid exposing her to certain strong odours as these can aggravate nausea, e.g. strong perfumes and deodorants, cooking smells
• Maintain hydration by giving small amounts of liquid, including oral hydration solution if she is already dehydrated

5. How would you manage Cindy’s constipation?

She should have a regular dose of a laxative such as lactulose to manage her constipation which is a common side effect of morphine. Increase the dose over a few days if needed.

If she remains constipated another laxative such as bisacodyl (Dulcolax) or senna can be added. These laxatives stimulate bowel movement so will improve the action of lactulose which softens the stool.