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Facts and Concepts of Dyspnea

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Print :: Close FAST FACTS AND CONCEPTS #27 (PDF)Author(s): David E Weissman MDIntroduction Dyspnea is defined as a subjective sensation of difficulty breathing. This Fast Fact reviews keyelements in the assessment and treatment of dyspnea near the end-of-life.Etiology The causes of dyspnea include a wide spectrum of serious lung or heart conditions, anemia, anxiety,chest wall pathology, electrolyte disturbances or even urinary retention or constipation.Assessment Looking for simple problems is always warranted: is the Oxygen turned on? Is the tubing kinked? Isthere fluid overload from IV fluids or TPN? Is dyspnea part of an acute anxiety episode, severe pain, constipationor urinary retention? Is there a new pneumothorax or worsening pleural effusion? Understanding 1) wherepatients are at in the dying trajectory, and 2) their identified goals of care, is essential to guide the extent ofworkup to discover reversible causes. If the patient is clearly dying (see Fast Fact #3), and the goals of care arecomfort, then pulse oximetry, arterial blood gases, EKG, or imaging are not indicated.TreatmentGeneral measures Positioning (sitting up), increasing air movement via a fan or open window, and use ofbedside relaxation techniques are all helpful. In the imminently dying patient, discontinuing parenteral fluidsis appropriate.Treatment with opioids Opioids are the drugs of choice for dyspnea. In the opioid naïve patient, low doses oforal (10-15 mg) or parenteral morphine (2-5 mg), will provide relief for most patients; higher doses will beneeded for patients on chronic opioids. When dyspnea is acute and severe, parenteral is the route of choice:2-5 mg IV every 5-10 minutes until relief. In the inpatient setting, a continuous opioid infusion, with a PCAdose that patients, nurses or families can administer, will provide the timeliest relief (see Fast Facts #28,54). Nebulized morphine has been reported to provide benefit in uncontrolled case reports. Controlled trialshave not demonstrated any benefit compared to placebo, confirming the low bioavailability of nebulizedopioidsTreatment with oxygen Oxygen is often, but not universally, helpful. When in doubt, a therapeutic trial,based on symptom relief, not pulse oximetry, is indicated. Patients generally prefer nasal cannulaadministration than a mask, especially in setting of imminent death when agitation from the mask iscommonly seen. There is little reason to go beyond 4-6 L/min of oxygen via nasal cannula in the activelydying patient. Request a face-tent for patients who are claustrophobic from a mask.Treatment with other drugs Anti-tussives can help with cough (see Fast Fact #200), anit-cholinergics (e.g.scopolamine) will help reduce secretions, anxiolytics (e.g. lorazepam) can reduce the anxiety component ofdyspnea. Other agents that may have specific disease modifying effects include diuretics, bronchodilators,and corticosteroids.Family/Team Discussions While there is no evidence that proper symptom management for terminal dyspneahastens death, the course and management of terminal dyspnea, especially when opioids are used, should be fullydiscussed with family members, nurses and others participating in care to avoid confusion about symptom reliefvs.fears of euthanasia or assisted suicide (see Fast Fact #8).ReferencesBruera E, Sweeny C, and Ripamonti C. Dyspnea in patients with advanced cancer. In: Berger A, Portenoy Rand Weissman DE, eds. Principles and Practice of Palliative Care and Supportive Oncology. 2nd Ed. New York,1.# 027 Dyspnea at End of Life, 2nd ed http://www.mcw.edu/EPERC/FastFactsIndex/Documents/27DyspneaatEn...1 of 2 8/31/2009 10:16 AMNY: Lippincott-Raven; 2002.Chan KS et al. Palliative Medicine in malignant respiratory diseases. In: Doyle D, Hanks G, Cherney N, andCalman N, eds. Oxford Textbook of Palliative Medicine. 3rd Ed. New York, NY: Oxford University Press; 2005.2.Viola R et al. The management of dyspnea in cancer patients: a systematic review. Supp Care Cancer. 2008;16:329-337.3.Navigante AH, et al. Midazolam as adjunct therapy to morphine in the alleviation of severe dyspneaperception in patients with advanced cancer. J Pain Sympt Manage. 2006; 31:38-47.4.Fohr SA. The double effect of pain medication: separating myth from reality. J Pall Med. 1998; 1:315-328.5.Fast Facts and Concepts are edited by Drew A. Rosielle MD, Palliative Care Center, Medical College ofWisconsin. For more information write to: [email protected]. More information, as well as the complete set ofFast Facts, are available at EPERC: www.eperc.mcw.edu.Version History: This Fast Fact was originally edited by David E Weissman MD. 2nd Edition published July 2005.Current version re-copy-edited March 2009; new references were added.Copyright/Referencing Information: Users are free to download and distribute Fast Facts for educationalpurposes only. Weissman DE. Dyspnea at End-of-Life, 2nd Edition. Fast Facts and Concepts. July 2005; 27.Available at: http://www.eperc.mcw.edu/fastfact/ff_027.htm.Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice.Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of aproduct in a dosage, for an indication, or in a manner other than that recommended in the product labeling.Accordingly, the official prescribing information should be consulted before any such product is used.ACGME Competencies: Medical Knowledge, Patient CareKeyword(s): Non-Pain Symptoms and Syndromes© 2008 Medical College of WisconsinMedical College of Wisconsin8701 Watertown Plank Road, Milwaukee, WI 53226www.mcw.edu | 414.456.8296Print :: Close # 027 Dyspnea at End of Life, 2nd ed http://www.mcw.edu/EPERC/FastFactsIndex/Documents/27DyspneaatEn...2 of 2 8/31/2009 10:16


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