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Dyspnea 

Dyspnea
Chapter:
Dyspnea
Author(s):

Meaghann S. Weaver

DOI:
10.1093/med/9780190066529.003.0005
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date: 08 April 2020

Definition

Dyspnea or breathlessness is the subjective experience of breathing discomfort. Dyspnea is a common end-of-life symptom for adults and for children, warranting palliative care attentiveness to the suffering associated with a sense of air hunger or a feeling of suffocation.

Measurement

A patient with normal blood gas, normal respiratory rate, and normal oxygen saturation level may still be experiencing dyspnea. Given the subjective nature of dyspnea, dyspnea is measured by patient report. Dyspnea can be measured using tools (such as the Edmonton Symptom Assessment Scale, Dalhousie Dyspnea Scale, Cancer Dyspnea Scale, or standard numerical scales) sequentially. For patients who are not able to self-report their extent of dyspnea, owing to developmental status or inability to express, close monitoring of nonverbal signs or distress observation scales can be considered.

Treatment

Consider interventions to target the underlying medical condition that may be causing the dyspnea if these are within the goals of care. Examples include use of bronchodilators or inhaled steroids for chronic obstructive pulmonary disease (COPD), use of transfusions for anemia, use of diuretics or angiotensin-converting enzyme (ACE) inhibitors or inotropes in congestive heart failure (CHF), use of cancer-directed therapies for lung tumor, use of antibiotics for pneumonia, and use of a tunneled drainage catheter for pleural effusion.

Steps and considerations in treating dyspnea include the following:

  • Reposition the patient to positions of comfort; consider elevating the chest with pillow support.

  • Circulate air via open windows or blowing fans with the goal of keeping air flowing.

  • Teach pursed-lip meditation breathing: inhale peacefulness and calm slowly via the nose; exhale stress and fear via pursed lips.

  • Consider supplemental oxygen for comfort.

  • Avoid smoke exposure and avoid wearing strong fragrances.

  • Reduce secretions with pharmaceuticals such as atropine drops under the tongue or scheduled anticholinergics, offer gentle suctioning, and avoid overly thickening secretions.

  • Foster a calm environment, as anxiety symptoms worsen breathlessness, and the sense of air hunger worsens anxious feelings.

  • Noninvasive ventilator support may be considered in certain diagnoses according to the goals of care.

  • Honor family presence and relaxation for the family members and for the patient.

  • Consider gentle wind-instrument music as background noise in the room for the comfort of surrounding the senses with the reminder of a breezy, refreshing air.

Pharmaceuticals Interventions

Opioids are the preferred approach to symptomatically treating dyspnea (see Table 5.1).

Table 5.1. PCHC Dyspnea Algorithm

Step 1: Assess dyspnea on the basis of patient report or standardized scale.

Step 2: Treat underlying conditions when feasible and appropriate for goals of care.

Step 3: Implement nonpharmacological interventions.

  • Reposition patient to position of comfort, elevate chest.

  • Circulate air: open windows, use fans.

  • Consider supplemental oxygen for hypoxemic patients.

Step 4: Treat dyspnea with opioid analgesic.

  • MORPHINE

    • Route: PO/SL/PR/IV/SC

    • Adult Dose:

      • PO/SL/PR: 5–15 mg q4–6h

      • IV/SC: 2–5 mg q2–4h

        • Decrease dose by 50% if patient is elderly or renal disease is present.

    • Pediatric Dose:

      • PO/SL/PR: 0.15–0.3 mg/kg/dose q4–6h

      • IV/SC: 0.05–0.15 mg/kg/dose q2–4h

Step 5: Evaluate response (using method used in Step 1). If dose is ineffective, increase by 25–50%. If there is excess sedation, decrease dose by 25–50%.

Step 6: Once effective dose and interval are established, schedule as needed or around the clock (may need to give as frequently as every hour at end of life.)

Step 7: Consider addition of benzodiazepine if anxiety is contributing to dyspnea.

  • LORAZEPAM (preferred)

    • Route: PO/SL/PR/SC/IV

    • Adult Dose: 0.5–2 mg q8h

      • Decrease dose by 50% if patient is elderly or liver disease is present.

    • Pediatric Dose: 0.05 mg/kg/dose q4–8h (max 2 mg, max starting dose 0.5 mg)

or

  • DIAZEPAM

    • Route: PO/SL/buccal/PR/IV

    • Adult Dose:

      • PO: 2–10 mg q6–8h

      • IV: 2–10 mg q3–4h

        • Decrease dose by 50% if patient is elderly or liver disease is present.

    • Pediatric Dose:

      • PO: 0.04–0.3 mg/kg/dose q6–8h

      • IV: 0.04–0.3 mg/kg/dose q3–4h

IV, intravenous; PO, oral; PR, rectal; SC, subcutaneous; SL, sublingual.

For an opioid-naïve adolescent or adult patient, consider starting 5 mg morphine equivalent by mouth or sublingual dose every 4 hours as needed for dyspnea. The dose may be decreased and the frequency extended if the patient seems too sedated; likewise, the dose may be increased by 25–50% or the frequency may be shortened to every 1 hour for severe, persistent dyspnea. For an opioid-naïve child or elderly patient, consider starting the morphine dose at half the above-recommended dose.

For patients who are actively dying and experiencing end-of-life dyspnea, consider a long-acting form of opiate for dyspnea, a continuous infusion of opiate, or a scheduled short-acting opiate.

Respiratory depression is almost always proceeded by drowsiness. One can consider a “hold for sedation” order when prescribing opiates for dyspnea.

A benzodiazepine such as lorazepam or diazepam may be considered as an anxiolytic if the patient is experiencing anxiety associated with shortness of breath.

A corticosteroid may be considered if the dyspnea is associated with COPD, lymphangitis, or asthma.

A bronchodilator may be added if bronchospasm is present.

Education

The patient, family, and staff should receive caring communication about the goal of dyspnea management, which is to manage the symptom of dyspnea, not to hasten death.

Provision of parameters for safe dosing of opiates for dyspnea, continual staff reassessment of the patient’s response to dyspnea interventions, and open communication regarding the goals of symptom management are encouraged.

Dyspnea is holistically addressed by considering the patient’s entire discomfort profile, including spiritual, psychological, and relational care needs in addition to physical needs.