Page 41 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 12 of 26 Guideline

ß PJP: Ethics. The decision to admit to the intensive care of choice for dyspnoea in the context of end-of-life care.
unit (ICU) and to ventilate usually rests with the ICU These can be given safely, that is, without the risk of
clinician or resident pulmonologist; however, this respiratory depression, if titrated carefully with attention to
38
action may be futile, that is, it does not guarantee dose and response. In addition, the careful use of
success or survival. The palliative care team must benzodiazepines may relieve anxiety associated with
make itself familiar with this scenario in order to breathlessness and asphyxiation. 38
provide wise support (insight and understanding) to
patients and colleagues and, where possible the death Specific end-of-life therapies include the following:
of a patient in the ICU and on a ventilator should be • Morphine: 5 mg po– 10 mg po every 30 min as needed
avoided. This is a source of great suffering for patients until the patient is comfortable, or IV 2 mg – 4 mg every
and their loved ones, although it is best managed 30 min to 1 h as needed until the patient is comfortable.
through discussion with the patient, family and • Oxygen: Adjust to achieve satisfactory saturation and
friends before the urgent need of ICU admission and subjective relief of dyspnoea.
ventilation arises. • Non-pharmacologic measures: Support, relaxation and
breathing exercises, et cetera.
Causes of dyspnoea and cough include the following: 47
• Acute infection: Trachea-bronchitis, pneumonia (viral Dry mouth
and bacterial).
• Chronic infection: Bronchiectasis, chronic lung infection Causes of dry mouth include:
(bacterial, e.g., TB, MAC, lung abscess), fungi (PJP, • Poor oral immunity: Often a sign of advanced HIV and
cryptococci, histoplasmosis), protozoa (toxoplasmosis) AIDS with or without HIV-associated dementia (HAD);
and rarely helminths. poorly controlled diabetes mellitus, gingivitis
• Airway diseases: Asthma, chronic bronchitis, postnasal • Infection: Chronic parotitis, salivary duct obstruction
drip. (stones, tumour), extensive oral candidiasis
• Diseases of the parenchyma and vessels of the lung: • Autoimmune: Sjögrens syndrome
Chronic interstitial lung disease, emphysema, sarcoidosis, • Drugs: Anticholinergics, alpha- and beta-blockers,
pulmonary vascular disease, namely, embolic, vasculitis, diuretics, calcium channel blockers
pulmonary hypertension. • Post-irradiation, for example, cancer of the head and neck.
• Tumour: Primary and secondary tumours of the lung and
chest cavity. (Note: Bold indicates conditions that are frequent among the
• Cardiovascular disease: Left ventricular failure, right- HIV-infected patients.)
sided endocarditis.
• Anaemia: Severe dyspnoea, Hb < 8 g/dL. Management: Address the cause, clean the mouth regularly,
• GIT: Acid reflux, aspiration pneumonia (cough often at maintain hydration – oral fluids if able to swallow, chewing
night). gum and mildly acidic sweets (lemon drops), stop offending
• Metabolic acidosis: Diabetic ketoacidosis, lactic acidosis drugs (above), artificial saliva.
(NRTIs: zidovudine, stavudine), renal tubular acidosis
(tenofovir disoproxil fumarate): Tachypnoea and Nausea and vomiting (N&V)
dyspnoea but with normal oxygenation (p0 ), chest
2
auscultation normal, CXR clear. Nausea is defined as the subjective feeling associated with
• Drugs: Angiotensin-converting enzyme (ACE) inhibitors the action of vomiting. Identify and treat the cause, including
(cough). the common associations mentioned below:
• Abdominal conditions: Gastroenteritis, intestinal diseases
(Note: Bold indicates conditions that are frequent among the (inflammatory, obstructive)
HIV-infected patients.) • General causes: Middle ear and CNS disease, for
example, meningitis and raised intracranial pressure
Management: Many of the conditions that present with (RICP); Anxiety and fear; cardiac, for example, acute
cough and dyspnoea in the HIV-infected patient are myocardial infarction; endocrine, for example, pregnancy,
treatable. However, some conditions, such as non- diabetic ketoacidosis; pancreatitis; end-organ failure, for
responsive PJP or end-stage (destroyed) lung disease example, renal (uraemia), liver disease, adrenal failure
whether from previous TB or from COPD, may not be (Addison’s disease)
reversible and will require palliation. Blood gas • Drugs: ARVs (e.g. zidovudine, lopinavir/ritonavir);
measurements, blood transfusion, intubation and antimicrobials (e.g. macrolides, beta-lactams, TB drugs);
ventilation are likely to be inappropriate when death is chemotherapy (oncology); digoxin; opioids; alcohol-
imminent. Supportive care such as oxygen, bronchodilators, intoxication, et cetera.
steroids and antimicrobials may be prescribed if indicated
and diuretics may be needed to treat pulmonary oedema (Note: Bold indicates conditions that are frequent among the
and fluid overload. Opioids are regarded as the treatment HIV-infected patients.)

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