Dyspnea: The top things you

need to you know!

Dr. Megan Sellick & Dr. Lawrence Lee

Edmonton Zone Palliative Care Program

Faculty / Presenter Disclosure

• Faculty: Dr. Lawrence Lee

• Relationships with commercial interests:

• Grants/Research Support: none

• Speakers Bureau/Honoraria: none

• Consulting Fees: none

• Other: none

Faculty / Presenter Disclosure

• Faculty: Dr. Megan Sellick

• Relationships with commercial interests:

• Grants/Research Support: none

• Speakers Bureau/Honoraria: none

• Consulting Fees: none

• Other: none

Disclosure of Commercial

Support

• This program has received financial support

from: none

• This program has received in-kind support

from: none

Objectives

By the end of our time together, you will be able to :

• Recognize the subjective nature of dyspnea

• Provide an initial management plan for dyspnea

(non-pharmacological and pharmacological)

• Briefly describe “palliative sedation” and describe the medication

used

Dyspnea

This man has metastatic lung cancer.

Which of the following is the best

measure of his dyspnea?

A- respiratory rate

B- use of accessory breathing muscles

C- oxygen requirements

D- oxygen saturations

E- all of the above

F- none of the above (patient’s report is

best)

Dyspnea

Definition:

“feeling like one cannot breathe well enough”

American Thoracic Society:

“a subjective experience of breathing discomfort that

consists of qualitatively distinct sensations that vary in

intensity.”

Dyspnea

Overall Management Approach:

Screen+Assess

Identify Cause(s)

Management

Underlying Cause

Symptoms

Dyspnea

Screen for it

ESAS-R

ECG of symptoms (here and now)

Patient completes if possible

Dyspnea/Shortness of breath is

included

Dyspnea

Assessment:

History

Duration

Onset

Pattern

Severity: Rest vs Exertion

Triggers/Alleviating Factors

Physical Examination

Dyspnea

Identify +

Manage

Underlying

Causes

in accordance

with Goals of

Care*

Cause Investigations* Treatments*

Pleural Effusion CXR Thoracentesis

Pneumonia CXR + Bloodwork Antibiotics

Airway

Obstruction

Imaging +/-

Bronchoscopy

Radiation

Stenting/Steroids

Lymphangitic

Carcinomatosis

Imaging: CXR/CT Steroids

Anemia Bloodwork Blood Transfusion

COPD

CHF

Bronchodilators, Steroids

Cardiac meds, Lasix

ALS BiPAP

Dyspnea

Symptomatic Management: Non-Pharmacological

Fan

Position: leaning forward, head up

Avoid irritants

Avoid exacerbating activities: mobilization, transfers, constipation

Dyspnea

*Symptomatic Management: Pharmacological

Oxygen

Opioids

Other Therapies

Dyspnea

Symptomatic Management: Oxygen

Useful for patients with hypoxia

Use cautiously in patients with severe COPD (ie. CO2 retainers)

Role in non-hypoxic patients less clear: some may still benefit

Not clear whether it is the oxygen or the airflow that is helpful

Dyspnea

Symptomatic Management: Oxygen

When used for comfort, oxygen should be titrated to:

A-Improved Oxygen Saturations (ie. O2>95%)

B-Reduce Tachypnea (ie. Decrease respiratory rate)

C-Decrease Work of Breathing

D-All of the Above

E-None of the above (titrate to decrease pt’s sensation of dyspnea)

Dyspnea

Symptomatic Management: Oxygen

When using O2 for comfort:

No need to start if the patient is not complaining of dyspnea

No need to continue measuring oxygen saturations at end of life

Increase O2 around periods when patient has more dyspnea (ie. Could increase on

exertion)

Dyspnea

Symptomatic Management: Opioids

Which is the following is true regarding the use of opioids for dyspnea:

A- They block lung opioid receptors to decrease the sensation of dyspnea

B- Opioids diminish the sensation of being short of breath in the brain

C- They reduce the respiratory rate and allow the patient to rest

D- All of the above

E- None of the above

Dyspnea

Symptomatic Management: Opioids

Opioids are safe and effective for dyspnea

When you “start low and go slow”, low risk of respiratory depression

Similar to cancer pain, they can be provided ATC + PRN

(ie. Morphine 2.5 mg PO q6h + q1h PRN for shortness of breath)

Diminish the sensation of dyspnea in the brain

Nebulized opioids do not show significant benefit

Dyspnea

Symptomatic Management: Anxiolytics

Anti-psychotics: helpful in managing dyspnea-related anxiety

Haldol 1 mg PO/SC q12h-q4h ATC + q1h PRN

Olanzapine 2.5-5 mg PO/Zydis q12h-q4h ATC + q1h PRN

Nozinan 6.25-25 mg PO/SC q12h-q4h ATC + q1h PRN

Dyspnea

Palliative Sedation • Process of inducing/maintaining deep and permanent sleep in order to relieve

refractory symptoms in palliative pts who are close to death.

NOT EUTHANASIA

• Most common indications: delirium, dyspnea

• ?Risk of hastening death → No evidence!

• Midazolam: Benzodiazepine with short t1/2 easily titratable by SC infusion

Dyspnea

Palliative Sedation: Communicating with Family • Discuss proactively

• Review understanding of illness/prognosis, goals of care

• Sedation used only if symptoms refractory to all other measures

• Patient will lose ability to communicate

• Usually irreversible, with death from underlying illness occurring within days

Dyspnea

Take Home Messages • Dyspnea is what the patient self-reports

• Screen for dyspnea

• Determine and treat underlying causes when possible/appropriate

• Use oxygen if it helps and titrate it to comfort, not oxygen saturations

• Opioids are safe and effective for symptomatic management of dyspnea

• Treat the anxiety component of dyspnea if it is present

• Palliative sedation is available for intractable dyspnea