Facts and Concepts of Dyspnea (2 pages)

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Facts and Concepts of Dyspnea



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027 Dyspnea at End of Life 2nd ed 1 of 2 http www mcw edu EPERC FastFactsIndex Documents 27DyspneaatEn Print Close FAST FACTS AND CONCEPTS 27 PDF Author s David E Weissman MD Introduction Dyspnea is defined as a subjective sensation of difficulty breathing This Fast Fact reviews key elements 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 Is there fluid overload from IV fluids or TPN Is dyspnea part of an acute anxiety episode severe pain constipation or urinary retention Is there a new pneumothorax or worsening pleural effusion Understanding 1 where patients are at in the dying trajectory and 2 their identified goals of care is essential to guide the extent of workup to discover reversible causes If the patient is clearly dying see Fast Fact 3 and the goals of care are comfort then pulse oximetry arterial blood gases EKG or imaging are not indicated Treatment General measures Positioning sitting up increasing air movement via a fan or open window and use of bedside relaxation techniques are all helpful In the imminently dying patient discontinuing parenteral fluids is appropriate Treatment with opioids Opioids are the drugs of choice for dyspnea In the opioid na ve patient low doses of oral 10 15 mg or parenteral morphine 2 5 mg will provide relief for most patients higher doses will be needed 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 PCA dose 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 trials have not demonstrated any benefit compared to placebo confirming the low bioavailability of nebulized opioids Treatment 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 cannula administration than a mask especially in setting of imminent death when agitation from the mask is commonly seen There is little reason to go beyond 4 6 L min of oxygen via nasal cannula in the actively dying 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 of dyspnea 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 dyspnea hastens death the course and management of terminal dyspnea especially when opioids are used should be fully discussed with family members nurses and others participating in care to avoid confusion about symptom relief vs fears of euthanasia or assisted suicide see Fast Fact 8 References 1 Bruera E Sweeny C and Ripamonti C Dyspnea in patients with advanced cancer In Berger A Portenoy R and Weissman DE eds Principles and Practice of Palliative Care and Supportive Oncology 2nd Ed New York 8 31 2009 10 16 AM 027 Dyspnea at End of Life 2nd ed 2 of 2 http www mcw edu EPERC FastFactsIndex Documents 27DyspneaatEn NY Lippincott Raven 2002 2 Chan KS et al Palliative Medicine in malignant respiratory diseases In Doyle D Hanks G Cherney N and Calman N eds Oxford Textbook of Palliative Medicine 3rd Ed New York NY Oxford University Press 2005 3 Viola R et al The management of dyspnea in cancer patients a systematic review Supp Care Cancer 2008 16 329 337 4 Navigante AH et al Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer J Pain Sympt Manage 2006 31 38 47 5 Fohr SA The double effect of pain medication separating myth from reality J Pall Med 1998 1 315 328 Fast Facts and Concepts are edited by Drew A Rosielle MD Palliative Care Center Medical College of Wisconsin For more information write to drosiell mcw edu More information as well as the complete set of Fast 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 educational purposes 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 a product 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 Care Keyword s Non Pain Symptoms and Syndromes 2008 Medical College of Wisconsin Medical College of Wisconsin 8701 Watertown Plank Road Milwaukee WI 53226 www mcw edu 414 456 8296 Print Close 8 31 2009 10 16 AM


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