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Modules:

  • Introduction
  • 1. Advance Care Planning
  • 2. Communicating Bad News
  • 3. Whole Patient Assessment
  • 4. Pain Management
  • 5. Assisted Suicide Debate
  • 6. Anxiety, Delirium
  • 7. Goals of Care
  • 8. Sudden Illness
  • 9. Medical Futility
  • 10. Common Symptoms
  • 11. Withholding Treatment
  • 12. Last Hours of Living
  • 13. Cultural Issues
  • 14. Religion, Spirituality
  • 15. Legal Issues
  • 16. Social and Psychological
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    Back to Module 10: Common Physical Symptoms
    Specific Symptoms

      Breathlessness (Dyspnea) Nausea and Vomiting
    Constipation
    Diarrhea
    Anorexia/Cachexia
    Fatigue/Weakness
    Fluid Balance/Edema
    Skin
    Odors
    Insomnia

    Breathlessness (Dyspnea)

    Case Example

    MS is a 67 year-old accountant with advanced pulmonary fibrosis. She experiences severe breathlessness with minimal activity around the house. She experiences little benefit from bronchodilators. She would like to be able to do things for herself

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    Definition/Description

    • One of the most frightening and distressing symptoms for patients, families, and caregivers
      • Shortness of breath
      • Smothering feeling
      • Inability to get enough air
      • Suffocation
      • Sense of drowning
    • Prevalence in the life-threateningly ill: 12%–74%, depending on the diagnosis and the stage of illness
    • Fortunately, for the majority of patients, relief can be relatively straightforward
    • Yet lack of understanding of breathlessness and the medications to manage it, and the fear of adverse effects, frequently lead to inadequate relief and unnecessary suffering for the patient, family, and caregivers
    • Respiratory rate, pO2, blood gas determinations DO NOT correlate with the feeling of breathlessness
    • The only reliable measure is patient self-report
      • Some patients may not report breathlessness

      • However, when asked about walking, they may indicate that breathlessness prevents them from walking at their usual pace or distance
    • Families and caregivers need to be aware that what they see may be very different from the patient’s experience
    • Time spent to understand the patient’s wishes for symptom control, and to communicate management strategies to the patient, family, and caregivers, will minimize misunderstanding and onlookers’ distress

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    Causes

    • Anxiety
    • Airway obstruction
    • Bronchospasm
    • Hypoxemia
    • Pleural effusion
    • Pneumonia
    • Pulmonary edema
    • Pulmonary embolism
    • Thick secretions
    • Anemia
    • Metabolic disorders
    • Family/financial/legal/spiritual/practical issues

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    Management

    • Treat the underlying cause
    • However, when patients report air hunger, it is frequently not possible to identify and/or correct the underlying etiology
    • In patients with advanced disease, the burden of investigations and disease-modifying interventions may outweigh any potential benefit
    • Symptomatic management (focus of this module)

    Oxygen

    • As breathlessness is frequently perceived to be a lack of air, it would seem to be quite reasonable to suppose that the administration of supplemental oxygen would relieve a patient’s sense of air hunger
    • Yet, research has shown that the majority of patients who report breathlessness are not hypoxemic
      • Measures of hypoxemia (pulse oximetry, blood gas determination) do not correlate with the patient’s self-report

      • Thus, do not follow pulse oximetry or blood gases to assess relief

      • These tests do not reliably reflect breathlessness or its relief

      • They may be uncomfortable and/or expensive, and divert the focus away from the symptom

      • It does not help symptom management to know that the oxygen saturation is 86% if the patient feels fine

      • If a patient is breathless, a therapeutic trial of supplemental oxygen may be beneficial

        • Goal is to make the patient feel better

        • However, clinicians should be aware that there is likely a placebo effect in non-hypoxemic patients

        • Supplemental oxygen is frequently viewed as a potent symbol of contemporary medical care

        • In addition, it is important to know that cool air moving across the patient’s face (e.g., from compressed air or from a fan) may relieve the sense of breathlessness

        • This is likely due to the physiological effect of stimulating the V2 branch of the fifth cranial nerve that has a centrally inhibitory effect on the sensation of breathlessness

        • Portable oxygen is expensive and is not reimbursed by all insurance payers

        • Nevertheless, if the patient reports relief, use supplemental oxygen if it can be afforded

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    Opioids

    • Research has demonstrated that opioids will relieve the distress of breathlessness in many patients without a measurable effect on their respiratory rate or blood gas concentrations
    • The precise mechanism by which opioids exert this effect is unclear
      • Both central and peripheral effects possible
    • In the opioid-naive patient, doses lower than those used to relieve pain may be effective
    • When an effective dose has been established, convert to an extended-release preparation to simplify dosing
    • Always anticipate adverse effects, particularly constipation
    • While nebulized opioids have been widely reported to be effective in anecdotal reports and phase II studies, in placebo-controlled studies, they have not yet been demonstrated to be superior to nebulized saline
    • When opioids are used to manage breathlessness, pharmacological tolerance is not a clinically significant problem
    • In some patients, the symptom relief may be associated with increase in exercise tolerance and mobility
    • If opioid dosing guidelines are followed (see Module 4: Pain Management), respiratory depression has not been demonstrated at the doses used to relieve breathlessness
    • Concerns that opioids used to manage symptoms will hasten death (i.e., double effect) or cause addiction are not relevant
    • When opioids are used appropriately to relieve a symptom, like the management of pain
      • Opioid treatment for dyspnea is consistent with good medical practice

      • Ethical when the intent is to relieve suffering, widely accepted dosing guidelines are followed

      • Very unlikely to be associated with abuse behaviors
    • Sample opioid prescriptions
      • Mild dyspnea in patients taking no opioid analgesics

        • Hydrocodone 5 mg tab q 4h with a breakthrough dose of 5 mg q 2h prn

        • Acetaminophen 325 mg with codeine 30 mg (1 tab) q 4h with a breakthrough dose of 30 mg q 2h prn

        • For children or elderly who may require lower doses:

          • Consider hydrocodone/acetaminophen syrup 1–3 ml q 4h with a breakthrough dose equivalent to the q 4h dose offered q 2h prn

      • Severe dyspnea in the opioid-naive patient

        • Morphine (as elixir or tablets) 5–15 mg q 4h and titrate
        • Oxycodone 5–10 mg q 4h and titrate
        • Hydromorphone 0.5–2 mg q 4h and titrate

      • Comments:

        • In patients receiving an opioid on a fixed schedule, an additional dose of a short-acting opioid (eg, morphine) equivalent to 30–50% of the amount of the baseline opioid taken over 4 hours can be tried q 1h, and titrated to effect

        • Opioids can be administered IV or SC for urgent situations or when the oral route is not available or advisable

        • Chlorpromazine and promethazine have both been reported improve breathlessness, particularly when combined with opioids

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    Anxiolytics

    • Breathlessness, particularly when it is acute or severe, may cause severe anxiety and panic
      • Opioid and non-drug therapies may relieve both breathlessness and resultant anxiety

      • Consequently, their use is recommended as first line pharmacological therapy for breathlessness

      • However, the opioids themselves, particularly with continued dosing, are not particularly anxiolytic
    • Some patients who are breathless and anxious may need treatment for their anxiety
    • Anxiolytics are safe in combination with opioids
      • Benzodiazepines are highly effective anxiolytic medications

      • Use formulations that have relatively longer half-lives to avoid pronounced peak and trough effects that may lead to rebound anxiety

      • Begin with low doses and titrate to effect

      • These medications may be combined safely with opioids
    • Suggested benzodiazepines include:
      • lorazepam 0.5–2.0 mg PO, SL, against the buccal mucosa, or IV q 1h prn until settled, then dose routinely q 4–6h to keep settled

      • diazepam 5–10 mg PO, IV q 1h until settled, then dose routinely q 6–8h prn

      • clonazepam 0.25–2.0 mg po q 12h

      • midazolam 0.5 mg IV q 15min until settled, then by continuous SC or IV infusion

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    Nonpharmacological Interventions

    • When possible, coordinate treatments with the family and other caregivers
      • Work closely with the patient and family to provide understanding and support

      • Explain the various interventions

      • Include other members of the interdisciplinary team to increase interaction, minimize loneliness, explore issues of meaning and value, and provide counseling for family, financial, legal, spiritual, or practical issues that may be adding to anxiety
    • Reassure and work to manage anxiety
    • Behavioral approaches, eg, relaxation, distraction, and hypnosis
    • Limit the number of people in the room
    • Open window
      • Keep line of sight clear between patient and outside
    • Eliminate environmental irritants (e.g., smoke)
    • Reduce the room temperature (without chilling the patient)
    • Introduce humidity
    • Reposition
      • Elevate the head of the bed
      • Move patient to one side or other
    • Educate and support the family
    • Nonpharmacological therapies may be effective without other medications
      • However, in the highly anxious patient, combination therapies are usually necessary

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    Family and Caregiver Reactions

    • Standing next to a person who is breathing at 36 breaths/min, with a pulse oximeter beeping and oxygen rushing through tubing, is anxiety-producing for almost anyone
    • Family members and caregivers frequently take on the anxiety of the patient
    • In turn, their anxiety may make the patient’s breathlessness worse
    • When managing breathlessness, it is important to distinguish between the patient’s distress and that of family members and caregivers
    • Minimize the number of machines and sounds
    • Titrate medications to relieve the patient’s report of distress, not someone else’s perception of it
    • As patients approach the last hours of their lives, be sure to educate family members and caregivers about the breathing patterns they may witness
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