What can we do

to

Palliate Dyspnea?

Steve Dupuis DOFaith 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

CorticosteroidsDexamethasone

Start 4 mgs bid and titrate up24 mgs to 96 mgs/day IVP

SolumedrolIVP 550 mgs qid

PrednsoneStart 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

MorphineHydromorphoneOxycodone

30-60Minutes

3-4 hours

Long Acting

Morphine SRHydromorphone SROxycodone SR

3-4Hours

8-12hours

Rapid Onset

Fentanyl

Oral Transmucosal Buccal TabletSublingual TabletIntranasal Spray

10-15minutes

1-3hours

Canadian Dyspnea Protocol

Steps Medication # mcgs SL(50 mcg/ml)

1 Fentanyl 25

2 Fentanyl 50

3 Sufentanil 10

4 Sufentanil 15

Terminal SectretionsNon- 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