Clinical approaches begin with accurate assessment, as delineated in part one of this two-part series. Kamal AH, Maguire JM, Wheeler JL, Currow DC, Abernethy AP. Table 4. Treatment goals for dyspnea center on identifying reversible anatomic and physiologic causes, intervening upon those, and in parallel, implementing global therapies for dyspnea management (Fig. Clinicians may choose between scopolamine and glycopyrrolate depending on whether sedation is preferred (e.g., scopolamine 0.4 mg subcutaneously every 4 h as needed [sedating]; glycopyrrolate 0.4 mg subcutaneously every 4 h as needed [not sedating]). Palliative Medicine in malignant respiratory diseases. Clemens KE. and transmitted securely. Long-term oxygen therapy improves health-related quality of life. People experiencing dyspnea often describe it as shortness of breath, tightness in their chest, fighting for air, or feeling smothered; or they might simply say, "I can't breathe.". Two landmark trials from almost 30 years ago demonstrate a clear survival advantage with continuous or nocturnal oxygen in hypoxemic COPD patients whose PaO2 assessments were 55mm Hg or <60mm Hg in the setting of cor pulmonale or other evidence of end-organ damage due to hypoxia.37,38 A recent study observed that, with ambulatory oxygen therapy in patients without resting hypoxemia but with oxygen desaturation during activity, 68% of COPD patients reported improved health-related quality of life and 35% reported less dyspnea.39. Curr Oncol. Am J Respir Crit Care Med. List best practices for end-of-life care. 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. Sedation was the most reported opioid-related adverse effect. At least 50% of both patient groups had dyspnea alleviated during the 2-hour titrating phase, with no significant difference between agents. Kor AC. The three-fold increase in endogenous opioids from rest to end-exercise suggests a mechanism by which exogenous opioids may also benefit the patient experiencing dyspnea. Opioids are the mainstay for managing dyspnea at the end of life It is suggested that physicians start with opioids,3 which do not impair respiratory status or hasten death when used appropriately with a symp-tom focus (e.g., hydromorphone 0.5 mg subcutaneously every 4 h, and 0.5 mg subcutaneously every 30 min, as needed).4 The dosage should be PMC Kaplan RM. Efficacy of nutritional supplementation therapy in depleted patients with chronic obstructive pulmonary disease. Bruera E, Sweeny C, and Ripamonti C. Dyspnea in patients with advanced cancer. Effect of nebulized furosemide in terminally ill cancer patients with dyspnea. Furosemide has been postulated to reduce dyspnea because of its inhibitory effect on the cough reflex, preventive effect on bronchoconstriction in asthma, and possible indirect actions on sensory nerve endings in the airway epithelium. Potential opioid-sparing effect of regular benzodiazepines in dyspnea: Longer duration of studies needed. A benzodiazepine is also sometimes added, particularly near the end of life. This clinical and research tool is in wide clinical use in more than 50 US sites and 11 countries and has been translated into Dutch, French, Chinese, Italian, Greek, and Tamil (India). Karen Blackstone , MD, George Washington University; Joanne Lynn , MD, MA, MS, Altarum Institute Last review/revision Oct 2021 | Modified Sep 2022 View Patient Education Pain Dyspnea Anorexia Nausea and Vomiting Constipation Pressure Injuries Delirium and Confusion Depression and Suicide Stress and Grief Global management of dyspnea is appropriate both as complementary to disease-targeted treatments that target the underlying etiology, and as the sole focus when the symptom has become intractable, disease is maximally treated, and goals of care shift to comfort and quality of life. Viola R. Kiteley C. Lloyd NS. It is suggested that physicians start with opioids, 3 which do not impair respiratory status or hasten death when used appropriately with a symptom focus (e.g., hydromorphone 0.5 mg subcutaneously every 4 h, and 0.5 mg subcutaneously every 30 min, as needed). Bruera E, et al. Jennings AL. Heliox in the treatment of airflow obstruction: A critical review of the literature. Methotrimeprazine is favoured because of its sedative properties (e.g., methotrimeprazine 6.25 mg subcutaneously every 6 h as needed [the dose can be increased if needed]). Abernethy AP. Mouth swabs can be helpful for mouth dryness. Episodes of breathlessness: types and patterns - a qualitative study exploring experiences of patients with advanced diseases. Benditt JO. Because the goal of palliative care and hospice for terminally ill patients is to provide comfort, you most likely should not call 911. Abernethy AP, et al. Effects of clorazepate on breathlessness and exercise tolerance in patients with chronic airflow obstruction. Oral transmucosal fentanyl citrate for dyspnea in terminally ill patients: An observational case series. Samsa GP. In a prospective study of 45 people with lung cancer, most with resectable disease and good performance status, a program of aerobic exercise for 30 minutes per day significantly decreased dyspnea and coughing scores over a 4-week period.50 Similarly, most studies of exercise for dyspnea in cancer patients demonstrate benefits in patients who are either awaiting or recovering from lung resection. Castro MA. Organ support for conditions associated with dyspnea includes interventions with various levels of invasiveness (noninvasive ventilation, mechanical ventilation via endotracheal tube or . McDonald C. Oaten S. Kenny B. Allcroft P. Frith P. Briffa M. Johnson MJ. Jobst K. Chen JH. Accordingly, the official prescribing information should be consulted before any such product is used. The most common symptoms and comorbidities among patients with end-stage heart failure include dyspnea, pain, depression, fatigue, and edema. Opioids are the most effective and widely studied agents available for palliation of dyspnea in this population, while adjuvant therapies such as oxygen, noninvasive positive pressure ventilation, and hand-held fans may also be used. Inhaled furosemide has been studied in patients with cancer27,28 and COPD,29 as well as in normal participants.30 In placebo-controlled studies in COPD patients, Ong et al.29 and Jensen et al.31 both showed a significant improvement in dyspnea scores with exercise; the latter study also showed a benefit in exercise endurance time. Because some patients who might benefit from oxygen therapy may not want to receive it42 and because the data on dyspneic patients' treatment preferences are not conclusive, palliative oxygen should be delivered only with careful consideration of the intervention's potential benefit versus patient burden and costs43; this conversation should include the patient and caregiver, whenever possible. 1 Benzodiazepines treat a variety of symptoms in palliative care, including anxiety, delirium associated with alcohol withdrawal, seizures, and when symptoms are refra. Dyspnea review for the palliative care professional: assessment, burdens, and etiologies. 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. Shannon VR. Coyne P. French W. Ramakrishnan V. Corrigan P. Failure to accrue to a study of nebulized fentanyl for dyspnea: Lessons learned. McHugh A. Bui C. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. Long term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. 3Department of Palliative and Supportive Services, Division of Medicine, Flinders University, Bedford Park, South Australia, Australia. McGraw-Hill Publishing, 2002. Bethesda, MD 20894, Web Policies FOIA Abernethy AP. Opioids are the mainstay for managing dyspnea at the end of life. NCCN Clinical Guideline Palliative Care 2015 Pal 11-12. Try a relaxation technique, such as playing relaxing music, applying massage, or some other relaxing touch of the patient's choosing. Fazekas B. Abernethy AP. Treatment options for dyspnea, defined as difficult, painful breathing or shortness of breath, include opioids, nasal cannula oxygen, fans, raising the head of the bed, noninvasive ventilation, and adjunctive agents. National Emphysema Treatment Trial Research Group: Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial Research Group. 8600 Rockville Pike This question is for testing whether or not you are a human visitor and to prevent automated spam submissions. 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. One trial24 compared three arms: morphine alone, midazolam alone, and morphine plus midazolam; the study showed a modest benefit with the addition of the benzodiazepine to morphine leading to reduction in dyspnea intensity and decreased breakthrough dyspnea. Nutritional support for individuals with COPD: a meta-analysis. Respiratory acidosis. Dyspnea: Nonpharmacologic: Elevate head of bed, fluid restriction, suctioning, bedside fan, flowing air: Morphine: . Sternberg AL. Supplemental nutrition has been studied to counteract the muscle wasting and weight loss that are common in patients with COPD. Ferreira IM. Explore the Fast Facts on your mobile device. Dyspnea in Patients with Advanced Stage Cancer: A Nurses Guide to Assessment and Treatment. Creutzberg EC. Part one of this two-part series on dyspnea for the palliative care professional describes the burden and measurement of dyspnea.1 Because of its complex biopsychosocial etiology and manifestations, dyspnea presents a particularly challenging symptom to manageyet it is one which, nonetheless, requires an evidence-based symptom management approach. She is widely published on the topics of dyspnea assessment and treatment. Anticholinergics are the medication of choice to reduce secretions. There are many causes of dyspnea in end-of-life situations. Sullivan DR, Iyer AS, Enguidanos S, Cox CE, Farquhar M, Janssen DJA, Lindell KO, Mularski RA, Smallwood N, Turnbull AE, Wilkinson AM, Courtright KR, Maddocks M, McPherson ML, Thornton JD, Campbell ML, Fasolino TK, Fogelman PM, Gershon L, Gershon T, Hartog C, Luther J, Meier DE, Nelson JE, Rabinowitz E, Rushton CH, Sloan DH, Kross EK, Reinke LF. Klaschik E. Effect of hydromorphone on ventilation in palliative care patients with dyspnea. Filshie J. Penn K. Ashley S. Davis CL. There is little reason to go beyond 4-6 L/min of oxygen via nasal cannula in the actively dying patient. Hoover JM. A randomized continuous sequential clinical trial. INTRODUCTION. Bulk download StatPearls data from FTP. Begin with relaxing neck and shoulders, Close your mouth and inhale slowly through your nose. Physicians should be prepared to escalate the dose rapidly if necessary. (See "Assessment and management of dyspnea in palliative care".). 1993;39. Krasna MJ. Whats the Difference Between Palliative Care and Hospice? Clipboard, Search History, and several other advanced features are temporarily unavailable. Further analysis suggested that patients with higher baseline dyspnea derived more benefit preferentially from palliative oxygen than did patients with lower baseline dyspnea, and that most benefit from the intervention occurred in the first 48 hours, with nearly all symptomatic and functional improvements manifesting in the first 3 days. Principles and Practice of Palliative Care and Supportive Oncology. Pulmonary rehabilitation may be beneficial for patients with stage 3 or 4 COPD by GOLD (Global Initiative for Chronic Obstructive Lung Disease) criteria or for patients with severe dyspnea out of proportion to the severity of the disease.48 The most common model for pulmonary rehabilitation in the United States is a multidisciplinary, hospital-based, outpatient program, but the service may also be provided in home-based, community-based, or inpatient settings. A recent double-blind study of 15 patients (primarily lung cancer) randomized participants to receive either nebulized furosemide 40mg, nebulizer 0.9% saline, or no treatment in random order over 3 consecutive days. Benzodiazepines may also be helpful in select patients. Treatment with opioids Opioids are the drugs of choice for dyspnea at the end-of-life as well as dyspnea refractory to the treatment of the underlying cause. Curr Opin Support Palliat Care. Benzodiazepines can be helpful, particularly if the patient has associated anxiety (e.g., lorazepam 0.5 mg subcutaneously every 2 h, as needed [the dose can be increased if necessary]). Schols AM. Midazolam. Normal breathing and the exchange of oxygen for carbon dioxide is a combination of the rate of breathing (breaths per minute) and the volume of air per breath (tidal volume). This recent report is the first to show efficacy of a benzodiazepine in an outpatient setting, with reasonable reported safety profiles. Quednau I. Klaschik E. Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: A prospective study. Goss CH. Hoffman EA. Selecky PA. Harrod CG. Washko GR. Costs of pulmonary rehabilitation and predictors of adherence in the National Emphysema Treatment Trial. Although oxygen is called upon often to alleviate dyspnea, its use should not be considered automatic and certainly should not be continued if patients do not experience clinically relevant relief in a brief time period with its use. National Library of Medicine Broadley KE. Frith P. Fazekas BS. Constipation. Fan VS. Giardino ND. McCue JD. A more recent placebo-controlled study of 36 patients, mostly with COPD, found a significant improvement in VAS scores, observed in both acupuncture and placebo (mock transcutaneous electrical nerve stimulator) groups with no significant between-group difference.65 A prospective study of 20 patients with cancer-related dyspnea at rest treated with acupuncture reported that 70% of participants experienced significant dyspnea improvement; benefit peaked at 90 minutes and lasted up to 6 hours.66 Although more recent studies are now being reported demonstrating mixed results on its effect on dyspnea, the latest systematic review5 and Cochrane Database review53 found inadequate evidence to recommend acupuncture as a routine intervention for dyspnea control in cancer patients. National Emphysema Treatment Trial Research Group: Changes in arterial oxygenation and self-reported oxygen use after lung volume reduction surgery. In: Berger A, Portenoy R and Weissman DE, eds. National Emphysema Treatment Trial Research Group: The effect of lung volume reduction surgery on chronic obstructive pulmonary disease exacerbations. Cranston JM. Symptomatic pleural effusions can be addressed by many surgical/procedural approaches including mechanical and chemical pleurodesis, pleural tunneled catheter placement, and open or video-assisted thoroscopic surgery (VATS) pleurectomy. Martinez FJ. Neder JA. INTRODUCTION Dyspnea, or breathing discomfort, is a subjective experience described as air hunger, increased effort of breathing, chest tightness, rapid breathing, incomplete exhalation, or a feeling of suffocation. J Palliat Med. Nebulized morphine has been reported to provide benefit in uncontrolled case reports, however a controlled trial demonstrated no greater efficacy or lower rate of side effects compared to subcutaneous morphine. 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). In this article we focus on restorative and global interventions for dyspnea management, which are intended to be used parallel to any ongoing or new disease-modifying therapies or as stand-alone therapies when modification of the underlying disease is no longer possible.

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