Skip to main content

Potpourri from clinical work IX: BiPaP, Movantik, and Lord Grantham





by: Alex Smith, @alexsmithMD


This is the ninth iteration in the potpourri from clinical work series, where I basically raise issues that were interesting from recent time on the palliative care service.  For prior iterations just enter the word "potpourri" into the search box on the right side of the screen.


1. BiPaP for patients who are DNI.  This came up for a hospitalized patient with a severe pulmonary infection and effusion (fluid around the lung).  The idea was BiPaP, a tight fitting mask hooked up to a mini-ventilator, might be used as a bridge until a needle could remove some of the fluid around his lung.  It worked.  Though his oxygenation improved, he died without ever regaining consciousness.  BiPaP is in a grey zone.  One useful question I sometime use in code status discussions  (learned from Gail Gazelle) is to ask people, "How do you feel about living on machines?"  People who don't want to live on machines are generally DNI.  The problem is that BiPaP is a machine.  There isn't the tube down the throat, but in many other respects it resembles intubation and ventilation.  I've had patients with severe dyspnea try it and find relief, only to say the next day, "Get this mask off! It's too tight."  These non-invasive devices are only going to get smaller and more comfortable for people.  It will be harder and harder to figure out where these machines fit into our understanding of the patients goals and preferences.  Incremental small decisions to try this or try that can lead one down a path that eventually strays far from the patient's goals and values.


2. Walking the halls.  I love that we have transformed the culture of our hospital.  When I was a medical student here around 15 years ago, the patients stayed in their beds.  All the time.  Now our older adult patients are up and about, often with nurses or nurses aids walking with them or trailing behind.  The emphasis on mobility is awesome.  One unintended side effect is that it's harder and harder for our clinical team to round and talk about patients in the hallway.  Patients keep wandering into our conversations.  We had one wonderful older hospitalized gentleman who would come and stand in our rounds, with his hands behind his back, nodding as if he was a team member.  We'd slide over, and he'd slide with us.  We'd go into a patient room, and he'd start to wander after us, only to be pulled back by his nurse.  We loved it.


3.  Movantik (naloxegal).  OK, I live a sheltered life.  I had not heard of this medication.  When I was showing the residents and fellows on service our GeriPal opioid dysmotility dance video,  they said, "Have you seen the commercial for this new opioid constipation medication?"  I hadn't seen it (you see how little TV we watch these days).  So what's up with this new medication?  It looks like it costs almost $300/month, or $10/day.  I gather it's a peripheral opioid antagonist, kind of like an oral version of methylaltrexone. The commercial presents it as a first line treatment (misleading).  Does anyone have experience and want to comment?  Is this actually an awesome medication that we should anxiously await going generic?  How is the evidence?


4.  Lord Grantham.  On the latest episode of Downton (spoiler alert) (OK, I watch some TV, but no Movantik commercials!) Lord Grantham has what looks like a convulsive upper GI bleed.  Very dramatic.  The New York Times described it as "Downton meet Alien."  I've had two patients die in the last month with rather dramatic bleeds due to head and neck cancer eroding into blood vessels.  Same sort of blood pouring out of the mouth and nose.  Very disturbing to the patients and their families.  And that was with the best care and medications we can provide in a hospital setting.  Going over one of these patients in Morbidity and Mortality conference, I was asked how to manage these patients at home.  Though I'm an inpatient provider, I still felt at a loss.  Prepare the family. Dark towels.  Dark sheets.  As the Lord Grantham episode reminds - bleeds at home can be gruesome and overwhelming.  One of our outpatient docs said, sometimes you may have to call 911, even if they're on hospice.  Other suggestions?  Anyone tried tranexamic acid? 









Comments

Janice Reynolds said…
I also had never heard of Movantik, however listening to its side effects I was a bit perturbed (especially reversing pain. I was on the nursing board of methylnaltrexone and had followed it before it even came up for approval. As an injection it was/is perfect for those patients who get into trouble or can not any longer take oral. The biggest problem is constipation prevent needs to be addressed immediately on initiating an opioid as well as some other medications (such as tricyclics) which won't respond to medication for opioids induced constipation. It takes a little playing with to get what is right for each person. I have taken opioids and nortriptyline for almost 7 years. I take Miralax in the am (unless things are too soft) two senna, am & pm, two docusate am & pm, and 2 generic Fibercon in am. I have only needed to take a little extra twice. Of course when I am sick and have some diarrhea, it is the devil to get on schedule. Before I retired I had an older woman (80's) whom we started opioids on. As always I asked for an order for Pericolace (or standard hen). The doctor refused because she didn't want her to become addicted to the laxative! (one other anecdote, about 15 years ago) we were doing a set of PCA orders and the pharmacist didn't play well with others. She tried to push them through without the physician and myself having any input The committee read them and during discussion one of the physician's said; "hey there aren't any orders for Pericolace on here-Janice must not have worked on it and they were sent back.)
Alexia Torke said…
Thanks for the conversation on naloxegol. I am reading my JPSM and see an add for it with the header, "In adult patients with chronic non-cancer pain, How do you tread opioid-induced constipation?" That will be a lot more patients who need this expensive medication...
Meredith said…
Thank you for bringing up the bipap issue. In training, I watched dozens of COPDers rip off their bipap mask in the middle of the night, when their CO2 finally fell enough for them to be aware of what was going on. I assumed that mask must be incredibly uncomfortable. Recently, though, I've admitted the occasional patient with lung disease who was clear he/she didn't want intubation, but DID want a trial of bipap, which was successful (either in temporizing until the mask could be removed, or in giving a little more time for family to arrive). I can recall one woman making "fart" jokes with her mask to entertain me on rounds, she was grateful for the extra time the bipap afforded, although her lung disease never improved enough for her to leave the hospital. So now I'm a bit more cautious in dissuading people who ask my opinion, as I HAVE seen it help a small number of patients.
Andrew 1 said…
As of now, the American Association Of Physical Therapist requires at least a graduate degree in exercise based recuperation before you can begin a profession as a specialist, in concurrence with the tenets of the Commission on Accreditation in Physical Therapy Education. physics tuition

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Opening the Black Box of LTACs: Podcast with Anil Makam

What happens in Long Term Acute Care Hospitals, or LTACs (pronounced L-tacs)?  I've never been in one.  I've sent patients to them - usually patients with long ICU stays, chronically critically ill, with a gastric feeding tube and a trach for ventilator support.  For those patients, the goals (usually as articulated by the family) are based on a hope for recovery of function and a return home.

And yet we learn some surprising things from Anil Makam, Assistant Professor of Medicine at UCSF.  In his JAGS study of about 14,000 patients admitted to LTACHs, the average patient spent two thirds of his or her remaining life in an institutional settings (including hospitals, LTACs and skilled nursing facilities).  One third died in an LTAC, never returning home.

So you would think with this population of older people with serious illness and a shorter prognosis than many cancers, we would have robust geriatrics and palliative care in LTACs?  Right? Wrong.

3% were seen by a geriatrici…

Length of Stay in Nursing Homes at the End of Life

One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

 The length of stay data were striking:

the median length of stay in a nursing home before death was 5 months the average length of stay was l…