What can we do
to
Palliate Dyspnea?
Steve Dupuis DO
Faith Hospice
Associate Medical Director
Life is not measured by
the number of breaths we take,
but by the moments that take
our breath away....
Anonymous
Objectives


Review the common treatments that our colleagues
have already tried
Explore more creative modalities that our colleagues
expect of us

Share our expertise

Create an update for WMMD manual
Dyspnea is not....



Tachypnea which is rapid breathing
Hyperpnea which is increased ventilation in
proportion to metabolism
Hyperventilation which is ventilation in excess
of metabolic requirement

Comroe 1966
Dyspnea is instead….
….difficult, labored, uncomfortable
breathing; it is an unpleasant type of
breathing, though it is not painful in
the usual sense of the word.

Comroe 1966
Dyspnea

It is subjective, and like pain, it
involves both the perception of the
sensation by the patient and their
reaction to the sensation….

Comroe 1966
Prevalence
• Reported to occur in 21-70% of all terminally ill
patients
• National Hospice Study
• 25% patients experiencing breathlessness did not
have underlying pulmonary diseases
Management
Oxygen
Should be offered in any circumstance of dyspnea but no
studies that show it to be any more effective than….
Environmental changes:

Cool humidified air

Circulating fan

Fowler’s position

Pursed lip breathing
Reassurance

Calming, relaxation techniques

Breathing exercises

Music therapy

Aromatherapy

Social Work

Chaplain
Nebs

Duonebs q 3hrs & prn

Decadron
4mgs q 4hrs

For Pulmonary Edema

4 mls 50% Ethyl Alcohol/Vodka

3 treatments q 15 minutes & repeat 6-8 hrs
Nebulized Furosemide
• Bronchodilatory effects
• Inhibition of irritant-receptors of the lung
• Rocker, Horton 2010
• Inhibition of stretch receptors (vagal nerve)
• Shimoyama, JPSM 2002
• Anti-inflamatory effect
• Prandota, Am J Ther 2002
• 40 mgs IV soln dye free per neb prn
Corticosteroids


Dexamethasone

Start 4 mgs bid and titrate up

24 mgs to 96 mgs/day IVP
Solumedrol


IVP 550 mgs qid
Prednsone

Start 40 mgs/day and titrate up
Benzos
• Are they effective?
• Breaks Anxiety-Dyspnea Cycle….prevalence of
fear, anxiety, or panic?
• Short Acting preferred….Versed is the shortest
• No studies that show effectiveness in Advanced
Cancer or ES COPD
• Cause more drowsiness than Morphine
• Use 2nd line or in combination with Opiods
• Ativan Infusion 1-5 mg's/hr starts to accumulate
in 3 days and may have to cutback
Opiods
Nebulized Morphine does not work…studies too small
Oral opiods work but with the usual side effects
Lack of adverse effect on blood gasses
Jennings, Thorax 2002
Do decrease the perception of Air Hunger & ↓ventilatory
response to ↓ O2 & ↑CO2
Cause vasodilation of pulmonary vessels: ↓ preload to the
Heart
Improve Dyspnea without causing Respiratory Depression
Opiod Phobia
Opiod Responsive Dyspnea
• Parallels to opiod responsive and opiod non
responsive type of pain
• Dyspnea may have varying degrees of opiod
responsiveness dependent on several specific
factors
Opiod Delivery
Class
Preparation
Onset
Duration
Short
Acting
Morphine
Hydromorphone
Oxycodone
30-60
Minutes
3-4
hours
Long
Acting
Morphine SR
Hydromorphone SR
Oxycodone SR
3-4
Hours
8-12
hours
Rapid
Onset
Fentanyl
Oral Transmucosal
Buccal Tablet
Sublingual Tablet
Intranasal Spray
10-15
minutes
1-3
hours
Canadian Dyspnea Protocol
Steps
Medication
# mcgs SL
(50 mcg/ml)
1
Fentanyl
25
2
Fentanyl
50
3
Sufentanil
10
4
Sufentanil
15
Terminal Sectretions
Non- pharmacologic Interventions
– Reposition the patient first….basic Nursing Technique
– Suction is rarely useful
– Secretions re-accumulate rapidly & is overstimulating
Anticholinergic / Antimuscarinics
– 1% Atropine Opthalmic Gtts
4 gtts SL q 15mins X 4 then prn
– Transdermal Scopolamine Patches
– Robinol 0.2 mgs q 1 hr subQ/IVP
If secretions become wet/rattling but not foamy
-Atropine Aerosol 1mg with Albuterol 2.5 mgs q 4hrs prn