Dyspnea in Palliative and End-of-Life Care

Chapter: Dyspnea in Palliative and End-of-Life Care
Section Editor(s) in Interna Szczeklika: Ewa Niżankowska-Mogilnicka, Filip Mejza
McMaster Author(s): Mohamed Panju, Kajenny Srivaratharajah, Zahra Merali
Author(s) in Interna Szczeklika: Małgorzata Krajnik, Piotr Sobański
Additional Information

Also see Dyspnea: General Considerations.

Symptomatic TreatmentTop

1. Nonpharmacologic treatment involves establishing good trust-based communication with the patient (dyspnea is accompanied by anxiety and determined by the patient’s previous experiences), providing an optimal environment (appropriate room ventilation and humidity), education (teaching how to breathe and expectorate effectively), airway suctioning (in patients with ineffective evacuation of respiratory secretions), appropriate body positioning (eg, a sitting position in pulmonary edema; a lateral recumbent position to reduce agonal respirations), appropriate fluid intake (to dilute respiratory secretions), prevention of constipation (elevation of the diaphragm and increased abdominal pressure at defecation may precipitate dyspnea), psychological techniques (eg, relaxation), and occupational therapy (this may prevent the patient from dwelling on the threat of dyspnea).

2. Pharmacotherapy in palliative care (patients with advanced cancer or in the terminal, irreversible stage of chronic respiratory, cardiovascular, or neurologic disease):

1) Oxygen therapy: Used to relieve dyspnea in patients with hypoxemia. In patients without hypoxemia, the beneficial effects of oxygen are similar to administering air. Inducing air movement using a fan may provide comfort to the patient.

2) Opioids: Oral or parenteral agents may be used (Table 11.1-1).

3) Bronchodilators: Inhaled beta-agonists or anticholinergic agents improve dyspnea in most patients with chronic obstructive pulmonary disease (COPD) or obstructive airway disease.

4) Glucocorticoids: Used, among others, in lymphangitis carcinomatosis, superior vena cava syndrome, bronchospasm (in asthma or COPD), and radiation-induced pneumonitis.

5) Benzodiazepines: Used predominantly to stop the vicious circle of anxiety leading to dyspnea (eg, in a respiratory panic attack). Usually benzodiazepines are administered in combination with opioids. Principles of using benzodiazepines: Table 11.1-2.

Overuse of opioids and benzodiazepines can lead to somnolence and respiratory depression and therefore these drugs should be administered with caution. When administered in other than end-of-life care, their antagonists (naloxone and flumazenil, respectively) must be available for immediate use.

Special ConsiderationsTop

Special Clinical Considerations in Palliative Care

1. Respiratory panic attacks are attacks of dyspnea accompanied by fear of suffocating. If possible, encourage the patient to control hyperventilation by taking slow deep breaths. Try to eliminate any factors that exacerbate the dyspnea. Administer a short- or intermediate-acting benzodiazepine (midazolam or lorazepam: Table 11.1-2) to stop the attack.

Long-term management after a respiratory panic attack: Establish good trust-based communication with the patient and together try to identify the psychosocial factors behind the respiratory panic attacks. Evaluate the patient for any underlying causes of dyspnea and start appropriate treatment (targeted at both the underlying condition and symptoms). Depending on prognosis, antidepressant therapy may be used, usually in the form of a selective serotonin reuptake inhibitor, for 2 to 3 weeks and, while waiting for the full effect of the antidepressant to develop, an intermediate- or long-acting benzodiazepine (eg, lorazepam or clonazepam) may be added. Relaxation techniques may also be beneficial to the patient.

2. Agonal respirations are mostly a consequence of accumulation of saliva in the laryngopharynx in patients who are dying. When approaching a patient with agonal respirations, exclude pulmonary edema and other causes of pseudo-agonal breathing (below). Anticholinergic agents such as scopolamine or glycopyrrolate may be used. Scopolamine can be administered subcutaneously (0.4-0.6 mg every 4-8 hours as needed) or transdermally (1-mg patch applied every 72 hours for mild symptoms). Glycopyrrolate can be administered subcutaneously (0.2-0.4 mg every 4-8 hours as needed).

Agonal breathing can be distressing to family members or caregivers. It is important to explain that these are not likely to cause discomfort to an unconscious patient. Airway suctioning may be beneficial. Pseudo-agonal breathing is caused by the inability to expectorate excess airway secretions (eg, due to infection, pulmonary edema, airway hemorrhage) and is not necessarily an indicator of impending death. As pseudo-agonal breathing is less dependent on the secretion of saliva, anticholinergic drugs are less effective. Also see Last Days and Hours.

TablesTop

 

Table 11.1-1. Suggested dosage of morphine for symptomatic treatment of dyspnea in palliative and end-of-life care

Clinical setting

Dosagea

Opioid-naive patient with moderate to severe dyspnea at rest

PO morphine:

1) Test dose of immediate-release morphine 2.5-5 mg (or hydromorphone 0.5-1 mg). Patient must be monitored for 60 min after the first dose. If ≥2 doses are required for dyspnea within 24 h, regular morphine is usually started and dose titrated depending on effect, duration, and adverse effects.

2) Immediately start regular morphine (2.5-5 mg every 4 h) or hydromorphone (0.5-1 mg every 4 h) using immediate-release formulation and consider rescue dosesb (eg, morphine 1-1.5 mg or hydromorphone 0.25-0.5 mg every 1-2 h). Patient must be monitored for 60 min after the first dose. If necessary, titrate the dose further.

Use caution to avoid excessive sedation.

Patient receiving PO morphine every 4 h for dyspnea after establishing dose requirements

Switching to controlled-release formulation + rescue dosesb may be considered.

Patient treated with PO or SC morphine for pain who develops further dyspnea

Additional dose of immediate-release morphine depending on the severity of dyspnea (eg, in mild to moderate dyspnea add 25%-50% of regular analgesic dose every 4 h):

1) If response is good, use only if dyspnea worsens (and continue regular analgesic doses).

2) After assessing the initial dose, the current analgesic dose of morphine used every 4 h may be increased (eg, by 25%) and further titrated.

Patient treated with PO morphine for dyspnea who needs to be switched to parenteral route (eg, dysphagia, vomiting)

Converting PO opioid to SC opioid: see Pain Management: Basic Principles

Usually SC morphine = 1/3 to 1/2 of PO morphine

Usually SC hydromorphone = 1/3 to 1/2 of PO hydromorphone

 

Patient with increasing dyspnea at rest and anxiety (most often end-of-life; usually oral intake no longer possible)

1. Morphine or hydromorphone used regularly and in case of dyspnea: Switch from PO to SC (reduce daily dose 3 times, sometimes 2 times) and titrate the dose. If anxiety and dyspnea persist, consider adding benzodiazepine; eg, if patient receives morphine, add midazolam, starting from low doses (eg, 1-2.5 mg SC if needed).c

2. Opioid-naive patients: Use initial dose of SC morphine (eg, 1.25-2.5 mg) or hydromorphone (0.5-1 mg); use SC every 4 h and make sure rescue doses are available. Consider adding benzodiazepine (see above).c Continue morphine titration.

Acute dyspnea (eg, dying patient)

No universal dosage regimens exist. Individual approach and close monitoring are necessary. Morphine/hydromorphone is the mainstay of treatment. Adding midazolam is often necessary (most frequently in continuous infusion with parenteral rescue doses).c

Rapid titration with low doses of morphine is also possible (in-hospital and under close monitoring):

1) Administer morphine/hydromorphone in low dosesd (0.5-1 mg) IV every 10-15 min or SC every 20-30 min until dyspnea begins to resolve or adverse effects (somnolence) appear. There may be delayed increase in drug concentration in CNS (slow penetration of blood-brain barrier).

2) Usually benzodiazepine is recommended, eg, parenteral midazolam (eg, 0.5 mg IV or 1-2 mg SC)e; repeated dosing may be needed.

Comments:

1) If parenteral morphine/hydromorphone and midazolam are used (especially IV), make sure their antagonists are available if clinical situation warrants reversal.

2) In patients with compromised peripheral perfusion (eg, dehydration, shock, hypothermia), absorption of drugs used in SC boluses during rapid titration and their effects on dyspnea may be delayed. If peripheral perfusion improves (rehydration, reversal of subcutaneous vasoconstriction, warming up), the drug may undergo rapid absorption from subcutaneous tissue.

a No universal dosage regimen exists. Dosage is individual and requires close monitoring. Doses are at discretion of the physician caring for the patient.

b Rescue doses of immediate-release morphine (PO or SC) must also be titrated. When the daily morphine requirement is stabilized, rescue doses are usually 10% of the total daily use. There are no recommendations on dosing frequency. Based on morphine pharmacokinetics and physician expertise in the management of breakthrough pain, the recommended dosing interval of subsequent doses is ≥60 to 90 minutes for PO morphine and 60 minutes for SC morphine.

c Consult the manufacturer’s prescribing information to establish whether a particular formulation of midazolam may be mixed in one syringe with morphine or if it should be administered separately.

d One of many available regimens; the choice is made on an individual basis and requires close monitoring. Elderly patients, patients with cachexia, with COPD, and those treated with benzodiazepines are more susceptible to opioids. Dosage should be adjusted on a case-by-case basis.

e Because response to the drug varies from patient to patient, it must be administered very slowly and with caution. This is only one of many available regimens. Elderly patients, patients with cachexia, with COPD, and those treated with opioids are more susceptible to benzodiazepines.

CNS, central nervous system; COPD, chronic obstructive pulmonary disease; PO, oral; SC, subcutaneous.

Table 11.1-2. Principles of using benzodiazepines in dyspnea accompanied by anxiety in patients receiving palliative care

Clinical setting

Dosagea

Outpatient with dyspnea attacks accompanied by anxiety

Oral lorazepam starting from 0.5 mgb

Patient at end of life treated with oral morphine for constant dyspnea with anxiety

Oral lorazepam (starting from single dose 0.5 mg)b administered on regular basis and/or in case of dyspnea and anxiety (eg, 0.5-1 mg, if necessary up to 3 times/d); further titration may be required

a No strict dosage regimens exist. Dosage is determined on an individual basis and needs close monitoring. Consider dose reduction in elderly patients, patients with cachexia, frail patients, and in patients with severe pulmonary comorbidities (eg, COPD).

b In patients with coexistent COPD some authors recommend titration of the rescue dose starting from 0.25 mg.

COPD, chronic obstructive pulmonary disease

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