Palliative Care and the Management of Dyspnea

Abstract and Introduction

Dyspnea is one of the most common symptoms reported by patients receiving palliative care. It is not only a symptom of severe or chronic pulmonary disease, but is also associated with a wide variety of illnesses such as cancer, heart failure, and dementia, as well as neurologic disorders such as cerebral vascular accidents, amyotrophic lateral sclerosis, and AIDS. Given its subjectivity, the assessment and management of this distressing symptom can be challenging. This article will highlight the core principles of palliative care and will illustrate the role of the advanced practice nurse (APN) specifically in the management of dyspnea.

Dyspnea can be defined as "an uncomfortable sensation or awareness of breathing... patients may describe the feeling as shortness of breath, inability to get enough air or suffocation."^[1] It differs from tachypnea (increased respiratory rate) and hyperapnea (increased depth of ventilation). It is frequently described in terms of air hunger, choking, or heavy breathing, and it can be extremely distressing for families and caregivers to witness.^[2] The word "dyspnea" is derived from the Greek "dys," meaning "hard," and "pnoia," meaning "breathing."^[3]

Similar to pain, dyspnea is a subjective experience that is influenced by many factors, both physiologic and psychological. Due to its subjectivity, the patient's intensity report may not correlate with pulmonary dysfunction as evaluated by objective tests such as pulse oximetry, chest x-rays, or pulmonary function tests.^[4]

The prevalence of dyspnea in the palliative care patient has been well documented in the literature. In the cancer population, one study found that 21% to 78% of patients experience dyspnea days or weeks before death, with an increased prevalence during the last 6 weeks of life.^[5] The SUPPORT study reported severe dyspnea in 32% of patients with lung cancer and 56% of patients with chronic obstructive pulmonary disease (COPD).^[6] In the AIDS population, Greenberg and colleagues^[7] reported the incidence of dyspnea as 68% at the time of death.

Breathlessness can be quite prevalent in patients with congestive heart failure, with 61% experiencing dyspnea during the last year of life and 72% of them having the symptom for 6 months or longer.^[8] Similarly, dyspnea occurred in 37% of patients who sustained a cerebrovascular accident, and 57% of them experienced the symptom for 6 months or longer.^[9] Dyspnea was identified in 47% to 50% of patients with amyotrophic lateral sclerosis (ALS), and in 70% of patients with dementia.^[10]

Breathlessness is not limited to patients with known respiratory impairment caused by neoplasms, AIDS, or chronic cardiopulmonary disease. According to data from the 1986 National Hospice Study, 24% of the patients who complained of dyspnea did not have any evidence of pulmonary or cardiac impairment.^[11]

Cite this: The Advanced Practice Nurse's Role in Palliative Care and the Management of Dyspnea - Medscape - Dec 31, 2006.

Etiology of Dyspnea ^[1,15,16]
Physiologic System	Disorder
Pulmonary	Asthma
	Adult respiratory syndrome
	Bronchial obstruction
	COPD (bronchitis, emphysema)
	Cystic fibrosis
	Interstitial lung disease
	Lung cancer
	Patient/ventilatory asynchrony
	Pleural effusion
	Pneumonia
	Pneumothorax
	Pulmonary embolism
	Chemotherapy toxicity
	Chest wall fractures related to metastatic disease
Cardiovascular	Congestive heart failure
	Fluid overload
	Superior vena cava syndrome
	Arrhythmias
	Cardiomyopathies
	Valvular or pericardial disease
	Congenital abnormalities
	Chemotherapy toxicity
Hematologic/Metabolic	Anemia
Hematologic/Metabolic	Electrolyte abnormalities
Neuromuscular	ALS
	Muscular dystrophy
	Multiple sclerosis
	Myasthenia gravis
	Reduced respiratory muscle force (deconditioning)
Psychological/Spiritual	Anxiety
	Depression
	Spiritual distress

ALS = amyotrophic lateral sclerosis; COPD = chronic obstructive pulmonary disease.

Scheduling of Opioids for the Management of Dyspnea ^{[1,41,60,80,81]}
	Opioid Naive*	Opioid Tolerant*
Mild dyspnea	Hydrocodone (5 to 10 mg) or codeine (30 mg) orally every 4 hours	Increase dose by 25% to 50%
Severe dyspnea	Morphine sulfate 5 mg orally every 4 hours, or oxycodone 5 mg orally every 4 hours, or hydromorphone 1 mg orally every 4 hours	Increase dose by 25% to 50%
Severe dyspnea	Parenteral morphine 2.5-5.0 mg subcutaneously or intravenously every 3-4 hours	Increase dose by 25% to 50%
Titration	Increase orally by increments of 50% to 100% every 24 hours as needed; titrate parenterally to effect	Increase by increments of 50% to 100% every 24 hours as needed

*If a patient is elderly or has severe pulmonary disease, such as COPD, start at 50% of the above doses and titrate more conservatively with increments of 25%. If the patient requires frequent dosing, the 24-hour total can be calculated and then converted into a sustained-release preparation, with the availability of a short-acting breakthrough dose every 2 hours as needed.

Benzodiazepine Therapy for the Management of Dyspnea ^[1,24]
Benzodiazepine	Dosage and Titration
Short-acting Formulations
Lorazepam	Starting dose: 0.5 to 1.0 mg orally every hour until the symptom is controlled, with routine dosing every 4-6 hours thereafter
Midazolam	Starting dose: 0.5mg IV every 15 minutes until dyspnea is controlled, then maintenance of a continuous subcutaneous or intravenous infusion
Long-acting Formulations
Diazepam	Starting dose: 2-10 mg orally every hour, then routinely every 6-8 hours
Clonazepam	Starting dose: 0.25-2.0 mg orally every 12 hours

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.

My Alerts