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The Management of Dyspnea in a Palliative Care Setting: A Symptom-Based Approach

Nora McKee, MD
Assistant Professor
Department of Academic Family Medicine
University of Saskatchewan

What proportion of patients suffer from dyspnea in the last days of life?
Does oxygen administration ease terminal dyspnea?
Does correcting blood gas abnormalities influence patients' dyspnea?

This module is intended to introduce physicians to a symptom-based approach to the management of dyspnea in palliative care.

On completion of this module the physician will be able to:

The symptom based approach differs from the disease oriented approach in that it considers the 'wholistic' care of the patient and his family, and focuses on the aggressive management of symptoms, recognizing that everyone will require symptom management at the end of life, when treatment of the underlying cause is not available.

In all clinical situations dyspnea presents with the following characteristics:

In addition to this, in palliative care:

Dyspnea is caused by stimulation of chemo and mechano receptors in the lungs, but even though patient's will have similar levels of functional abnormality, there will be great variability in expression of dyspnea. The goal of treatment in palliative care, therefore, should be to improve the patient's subjective sensation rather than trying to modify any abnormality in blood gases or pulmonary function.

Figure: Control of Ventilation

Clinical Example

Mr. C.S.:

A 63-year old man with a long history of rheumatoid arthritis and diabetes mellitus who received a lung transplant in 1996 for probable interstitial lung disease related to rheumatoid arthritis. Over the past year he had been experiencing chronic rejection symptoms and had developed an aspergilloma in the left lung, which showed some response to steroids. He had a chronic cough productive of brownish sputum and ongoing symptoms of malaise, anorexia and weight loss. He was referred after 7 days of worsening dyspnea, with increased oxygen requirements from 4 to 5 litres/min.

Clinical Findings:

  • Temp 36.2; pulse 90, Resp. rate 40, BP 114/64
  • Flat JVP, grade 2/6 holosystolic murmur best heard at apex
  • Tachypnoea, bronchial breath sounds. Inspiratory and expiratory crepitations on lef.
  • Oxygen sat 88-90% on room air
  • Cachectic and fatigued

Current Medications:

  • Prednisone 30mg po od.
  • Tacrolimus 0.5mg po eod
  • Itraconazole 100mg po od
  • Azathioprine 50mg po od
  • Omeprazole 40mg po od
  • Cardizem SR 90 po od
  • Codeine 30mg po hs
  • Insulin, vitamins, combivent

After admission initial investigations (CXR, ABGs) showed no change from previous results. He was diagnosed with CMV and Mycoplasma, which were treated, and his previously written living will was updated. A DNR order was written.

The dyspnea did not improve significantly with therapy, and Mr CS was fatigued, dyspneic and had zerostomia from use of BIPAP. He was essentially bedridden and had no tolerance for activity. His appetite was poor, but he could take oral medications. He was also tearful and distraught, and stated that he no longer had the ability to fight, although his wife and family were very supportive. He stated that his sister had died of a respiratory illness one year previously and had found relief from nebulized narcotics; he wished to try this. He had used codeine off and on for the last few months with little effect, was constipated and had required a fleet enema.

Management Approach

Dyspnea warrants aggressive treatment, since it is a distressing symptom. The choice of diagnostic tests and treatment must be guided by the stage of disease, its prognosis, the risk-benefit ratio of interventions and the patient's wishes.

Oxygen: The mechanism of action of oxygen is uncertain, it has a clear role in the treatment of hypoxic patients (Reference 1 and 2), but its role in non-hypoxic patients is less clear. In studies with non-cancer patients only a possible benefit is suggested. In practical terms a therapeutic trial is appropriate and simple.

Nebulized Opiates: The systemic availability of nebulized morphine is poor (Reference 3), and one randomized controlled trial in non-cancer patients and three in non-cancer patients have shown no benefit. Current evidence does not support a role for nebulized opiates, but there are anecdotal reports, and personal experience to the contrary.

Systemic Opiates: These are effective and safe in cancer patients, one randomized controlled trial and three open trials have showed benefits in these cases (Reference 4 and 5). In non-cancer patients four out of six RCTs demonstrated benefit. The general rules for opiate use in dyspnea are:

Figure: WHO Analgesia Ladder

Equianalgesic Doses
Morphine 100 mg/day
Dilaudid 20 mg/day
Fentanyl 25 ug/hr q72hr
Codeine 1000 mg/day
Oxycodone 50 mg/day
Methadone 10 mg/day
Demerol 1000 mg/day

The use of other medications can be effective in particular situations. Studies of benzodiazepines have shown no benefit in cancer patients, and studies non-cancer patients have shown conflicting results, however if anxiety is the source of symptoms they may be useful. Palliative sedation, using versed or propofol can be helpful, and in the event of lymphangitic carcinomatosis corticosteroids are indicated.

Mr. C.S.

Management of symptoms

  • Zerostomia was treated by applying "oral balance" to the lips and tongue qid and prn
  • Senokot-S was used for bowel management
  • Nebulized morphine 2mg in 5 mls N/Saline was given qid and q1h prn
  • Morphine 2.5-5.0 mg po q1h prn for breathlessness and discomfort
  • Spiritual care consultant met with patient and wife
  • Social worker planned to return to teach relaxation exercises

Titration of medications

Feb 5th: nebulized morphine bid..........little effect
Feb 6th: morphine 15mg prn for breakthrough
Feb 7th: MS contin 15mg bid
Feb 9th: morphine 32mg used as prn, therefore MS Contin increased to 30mg bid
Feb 12th: morphine 50mg used as prn, therefore MS Contin increased to 45mg bid
Feb 14th: able to discontinue BIPAP at night
Feb 15th: morphine 45mg used as prn, therefore MS Contin increased to 60mg bid
Feb 18th: MS Contin increased to 60mg bid
Feb 19th: breakthrough dose of morphine increased to 10-20 mg po q1h prn.and ativan 1mg sl added for dyspnea
Feb 20th: unable to swallow oral meds, morphine changed to sc infusion starting at 4mg/hr and altering by 1mg/hr in either direction as needed
Feb 21st: all meds except morphine and ativan discontinued, morphine infusion increased to 8.5mg/hour
Feb 22nd: Patient rousing a little
Feb 23rd: Deceased

The management of this case indicates the symptom management approach in providing comfort to the patient and his family in the last weeks of life. The diagnosis of chronic transplant rejection had been made prior to admission, and the clinical disease progression had made any further investigation or attempt at curative intervention inappropriate. The needs of the patient, and of any patient in a terminal situation, are for symptom relief, and the need of his family was to be spared the distress engendered by watching their family members' suffering.

References:

  1. Bruera E, de Stoutz N, Velasco - Leiva A, Schoeller T, Hanson J. Effects of oxygen on dyspnea in hypoxaemic terminal cancer patients. Lancet 1993:342:13-4.
  1. Booth S, Kelly M, Cox N, Adams L, Guy A. Does oxygen help dyspnea in patients with cancer? AM J Respir Crit Care Med 1996:153:1515-8.
  1. Jennings AL, Davies A, Higgins JP, Broadley K. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database Syst Rev 2001p;(4):CDE002066
  1. Bruera E., MacEachern T, Ripamonti C, Hanson J, Subcutaneous morphine for dyspnea in cancer patients. Ann Intern Med 1993;119:906-7.