Dyspnea Stephanie Lindsay
What is dyspnea? An unpleasant sensation of difficult, labored breathing Shortness of air Dyspnea is not the same as tachypnea therefore patients may not present with rapid breathing Common illnesses with dyspnea at the end of life: end-stage heart disease, COPD, cancer, and AIDS. Common symptoms: Feelings of smothering, tightness in the chest, drowning or suffocation
Prevalence 21 to 78% of cancer patients reported dyspnea days or weeks before death Increased prevalence during the last 6 weeks of life 32% of patients with lung cancer reported severe dyspnea 56% of patients with COPD
Pathophysiology of Dyspnea The actual sensation of dyspnea is a result of cortical stimulation
Three Main Pathophysiological Abnormalities 1. An increase in respiratory effort to overcome a certain load a. Obstructive or restrictive lung disease 2. An increase in the proportion of respiratory muscle required to maintain a normal workload a. Neuromuscular weakness b. Cancer cachexia 3. An increase in ventilatory requirements a. Hypoxemia b. Hypercapnea c. Metabolic acidosis d. Anemia
Non-Pharmacologic Treatment Setting upright in a bed or chair Pursed lip breathing Cool, smoke-free, dust-free room with low humidity Patients often benefit from a fan directed toward their face If the dyspnea is exacerbated by anxiety patients could use guided imagery or distraction Music therapy Acupuncture
Pharmacologic Treatment Treatment of underlying cause Oxygen Benzodiazepines Corticosteroids Bronchodilators Opioids
Treatment of Underlying Cause Dyspnea due to fluid overload Diuretics Drainage of pleural or pericardial effusions to physically remove the volume Reversal of airway obstruction: Bronchodilators Corticosteroids Antibiotics Dyspnea associated with pneumonia may be treated with antibiotics
Oxygen Long-term use has positive effects in COPD Main objective for using oxygen in cancer patients is to improve function Most beneficial in cancer patients who are hypoxemic on room air
Benzodiazepines Commonly used in cancer related dyspnea Not first-line treatment when used alone but can be used in combination with opioids Useful when dyspnea is a somatic manifestation of a panic disorder or severe anxiety Educate patients that BZDs will not open their airways but will allow them to stop panicking so that they feel better Lorazepam is the most commonly used agent
Corticosteroids Highly effective in treating bronchospasm associated with asthma and COPD Must weigh the risk-benefit: Known to have negative effects on muscles This may be an unwanted side effect in cancer patients experiencing cachexia Commonly used agents: dexamethasone and prednisone
Bronchodilators May provide relief in patients with obstructive disease by relaxing muscles around airways and increasing muscle tone Commonly used agents: ipratropium/albuterol combination or albuterol sulfate
OPIOIDS
Opioids Mechanism of Action Produce their effects by binding mu, kappa, and sigma opioid receptors Reduced effects of arterial carbon dioxide (pco2) levels and oxygen levels (po2) on ventilation Reduced oxygen consumption at rest and exercise Altered central perception of dyspnea A Cochrane Review by Jennings et al. supported the use of oral and parental opioids to treat dyspnea
Commonly Used Opioids Morphine (oral, sustained release, subcut, IV) Oxycodone Hydromorphone Fentanyl
Opioid Dosing Recommended dose for treatment of severe dyspnea in an opioid-naiive patient: Morphine sulfate 5 mg po q4h with equivalent doses for break-through symptoms every 1 to 2 hours as needed Titrate in increments of 50-100% every 24 hours Oxycodone or hydromorphone in an equianalgesic dose could also be used Patients who have severe pulmonary disease may need half of the initial dose and titrate with 25% increments every 24 hours as needed
Common Adverse Effects Nausea Vomiting Sedation Constipation Lethargy Itching Myoclonus Delirium Respiratory depression
Opioid Stigma and Counseling Often referred to as the Angel of Death Explain to patients and their families that the opioid is helping them breathe This may seem counterintuitive to patients as they are known to cause respiratory depression Explain to patients that respiratory depression occurs at much higher doses Patients often fear addiction or abuse Explain the risk-benefit Opioids are not used to assist death, but instead calm a patients breathing so they can rest comfortably and hopefully interact with their loved ones
Opioid Inhalation There is no evidence to support the use of nebulized opioids Bronchospasm and cough are adverse effects of inhaled morphine Respiratory depression has been reported
References Berger, A.M., Portenoy, R.K., & Weissman, D.E. Management of Dyspnea. Cardiopulmonary and Vascular Syndromes. Principles and Practice of Palliative Care and Supportive Oncology. 2002. Indelicato, R. A. The Advanced Practice Nurse s Role in Palliative Care and the Management of Dyspnea. Topics in Advance Practice Nursing ejournal. Medscape. http://www.medscape.com/viewarticle/551364 Jennings, A.L., Davies, A.N, Higgins, J.P.T., & Broadley K. Opioids for Palliation of Breathlessness in Terminal Illness. Cochrane Database System. Rev 2001:CD002066. Lexicomp. Varkey, B. Opioids for Palliation of Refractory Dyspnea in Chronic Obstructive Pulmonary Disease Patients. Current Opinion in Pulmonary Medicine. 2010; 16(2): 150-154. http://www.medscape.com/ viewarticle/717217_4