Physical Symptom Management

The main aim of palliative care is to improve quality of life for the patient with the help of symptomatic treatment and relief of suffering.
The following symptoms occur often in progressive tuberculosis: cough and shortness of breath, hemoptysis and bleeding, anorexia and cachexia, pain, night sweats, anxiety and depression.
People with Drug Resistant TB may have more intensity of disease and adverse effects to the medications.

1. Cough
Among people with pulmonary tuberculosis, including M/XDR-TB, cough is persistent. Nevertheless, cough may be caused by other reasons such as non-specific pulmonary infections, Influenza, COPD and Bronchiectasis, pulmonary tumor (Kaposi’s sarcoma, non-Hodgkin lymphoma in HIV-positive patients with tuberculosis), aspiration, and sinusitis following treatment with nasal drops, gastro-esophageal reflux, and spontaneous pneumothorax.

Management of Cough:
For cough caused by mucus hyper-production, use steam inhalations. If the volume of sputum exceeds 30 ml per day, forced expiration technique with postural drainage should be applied.
For people with mild cough, a trial of nonpharmacologic therapies may be attempted as a first step8. Options include use of linctus such as honey, breathing exercises, cough suppression techniques, and patient counseling. If these are ineffective, we then suggest a peripherally acting antitussive (eg, Benzonatate13100 mg TDS). Other peripherally acting antitussives include levodropropizine and levocloperastine available as cough syrup9,10

For cough with serous sputum use any of the following:

● Antihistamines, e.g., Levocetrizine, 5mg, once at night time after food
● Hyoscine 10 mg in every 8 hours. Hyoscinebutyl bromide: 20 - 120 mg in oral doses taken at certain intervals, or via continuous subcutaneous infusion
● Scopolamine transdermal patch: 1.5 mg; 1 - 3 patches applied every 72 hours
For cough caused by bronchial spasm, use any of the following:
● Oral bronchodilators, eg.,Acebrophylline 100mg twice a day after food
● Inhaled bronchodilators e.g. nebulization with levosalbutamol 0.63mg every 6th hourly till symptoms resolve.
● Oral corticosteroids eg., Prednisolone 0.5-1 mg per kg given in two divided doses
For cough caused by gastric reflux, use;
● Proton-pump inhibitors eg.,Pantoprazole 40 mg morning and night before food
For dry, non-productive cough, use:
● Dextromethorphan11 - 25 mg TDS; morphine – starting from 2.5 mg every 4 hours or
● Lidocaine inhalation12 3-5 ml 2% solution 3-4 times a day
For productive cough in patients who cannot cough effectively, use:
● Inhalations with 3 % Hypertonic saline solution – 5 ml every 4th hourly
● Mucolytics – Acetylcysteine, Bromhexine.
For productive cough in physically weak patients, use any of the following:
● Codeine 10- 20mg every 4 hours, not more than 60 mg a day
● Morphine 2.5mg-5mg every 4 hours
● Dextromethorphan 25-50 mg 3-4 times a day

For drug induced cough
● Stop drugs like ACE inhibitors and sitagliptin which can cause cough
For moderate to severe cough, use
● Morphine 2.5mg-5mg every 4 hour or
● Gabapentin14 300mg OD or Pregabalin 75mg OD

2. Shortness of Breath

The most effective drugs for treatment of shortness of breath are opioid analgesics such as Morphine (2.5mg-5mg) every 4 hours. Additional Oxygen may be especially useful for patients with hypoxia. The air is supplied by a fan or an open window, which can reduce shortness of breath by stimulating sensory receptors on the face and in the epipharynx.

3. Hemoptysis

Hemoptysis is blood coughed up from a pulmonary source. Hemoptysis must be differentiated from pseudo hemoptysis (expectoration of blood originating in the nasopharynx or oropharynx) and hematemesis (vomiting of blood).
Hemoptysis is usually caused by TB; however, it can be as well related to bronchiectasis, aspergilloma, bronchitis, thromboembolism, or tumor.

The use of red towels, dark sheets and blood collection containers can calm the patients with severe hemoptysis.
People with life-threatening hemoptysis should be immediately placed into a position in which the presumed bleeding lung is in the dependent position.

Antifibrinolytic agents like Tranexamic acid15,16 (500mg BD) acts by blocking the breakdown of blood clots, which in turn prevents bleeding. If hemoptysis is overwhelming and/or accompanied by hemodynamic instability and the goals of care do not support attempts at diagnosis or intervention, urgent sedation (midazolam at 0.2 mg/kg IV/SC) may be required.

4. Fatigue and Extreme Emaciation

This is one of the most frequent problems among people with TB. A comprehensive history and physical examination are indicated to identify potentially reversible etiologies such as depression or hypothyroidism. A review of all medications, both prescription and over the counter, is particularly important to identify side effects and potential drug-drug interactions that may be contributing to fatigue. Simply altering the dose or dosing interval may substantially improve fatigue. Other considerations for managing fatigue and extreme emaciations are:

● Psycho-stimulants (Modafinil 200 mg OD) and antidepressants may be useful in managing subjective symptoms of fatigue.
● Patients with severe anemia may be helped with blood transfusion18
● Prednisolone 5-15mg a day, up to 6 weeks, can be useful in the event of severe anorexia and asthenia19;
● Vitamin B1 should be administered daily since it plays a core role in production of energy from carbohydrates and is involved in RNA and DNA production;
● In the event of nausea and vomiting, prescribe antiemetic agents
● Provide information on coping strategies that conserve energy and information on good sleep hygiene
● Complementary medicine and nonpharmacologic approaches are available and may include ginseng, exercise, yoga, and cognitive-behavioral therapy, including mindfulness-based stress reduction
● Offer small but frequent portions of favorite food to the patient; do not force the patient to eat. Food should be taken in small portions until appetite revives.

5. Night Sweats
Night sweats are a common non-specific symptom that accompanies TB and M/XDR-TB. Treatment of fever with paracetamol, drinking plenty of water and frequent change of bed sheets and clothes may be advised.

6. Pain

Pain may have various origins in patients with TB and M/XDR-TB, i.e. they can be associated with the organ affected by tuberculosis, as well as for other reasons. It is essential to identify the source of the pain and to manage it properly
The causes of pain in the event of tuberculosis or M/XDR-TB may be as follows:
● Pulmonary or pleural inflammatory infiltration, or other internal organs;
● Muscle tension due to severe cough;
● Bone pain due to TB infiltration in the vertebral column or bones;
●Pain caused by arthralgia or septic arthritis

Management of Pain

Mild pain: Acetaminophen 500mg every 4-6 hours (not to exceed 4g/day); (59)
Moderate pain: Codeine phosphate 30-60mg every 4 hours;
Severe pain: Morphine sulphate 5-10mg every 4 hours, titrated to comfort;
Bone pain: Ibuprofen 200-400mg every 8 hours with antiulcer coverage;
Neuropathic pain: Vitamin B6 (pyridoxine) 100mg and tricyclic antidepressants (Amitriptyline 25mg before bed)