“I can’t breathe”: The Challenge of

DyspneaComprehensive Approach to Dyspnea

Management

Pawandeep Brar Palliative Care Physician

Review Non-Pharmacological Treatment of Dyspnea

Review Pharmacological Treatment of Dyspnea

Review Interventional Approach to Dyspnea

Objectives

First things First

Simple interventions based on movement of air may relieve dyspnea for certain patients

• An RCT of a hand-held electric fan directed toward the face versus toward the leg for 5 minutes showed significant decrease I dyspnea when the moving air was directed toward the face

Electrice Fan

Oxygen reverses dyspnea caused by hypoxemia

Limitations: many dyspneic pts are not hypoxemic

Hypoxemia is a weaker stimulus for dyspnea than hypercarbia

Oxygen Therapy

Oxygen Therapy

First line of therapy for symptomatic control Opioid Receptors in central/peripheral

nervous system as well as tracheobronchial tree

Effects postulated to be secondary to their effects on ventilatory response to carbon dioxide, hypoxia, inspiratory flow resistive loading

Pharmacological Approach: Opioids

Dosing of opioids:◦ If opioid naïve begin with low dose of 2.5-5mg

morphine equivalent q4h & titrate to effect◦ If on opioids, increase current dose by 20-25% &

titrate to effect

Pharmacological Approach: Opioids

Concerns re Opioids fear of respiratory depression &

accelerated death◦ Opioids have been used for many years to

decrease dyspnea◦ Fear has been shown to be largely unfounded

Pharmacological Approach:Opioids

Benzodiazepines are commonly prescribed for anxiety related to dyspnoea.

evidence for their effectiveness is not persuasive

treatment of anxiety does have a role in a subset of patients for whom it is a prominent component of the distress

Pharmacological Approach: Benzodiazapines

Lorazepam: 0·5–1·0 mg/h orally until settled, then dose routinely every 4–6 h to keep settled

Diazepam: 5–10 mg/h orally until settled, and then dose routinely every 6–8 h

Clonazepam: 0·25-2·00 mg orally every 12 h Midazolam: 0·5 mg intravenously per 15 min until

settled, then by continuous subcutaneous or intravenous infusion

Pharmacological Approach: Benzodiazepines

Glucocorticoids useful in bronchospasm, superior vena cava syndrome, carcinomatous lymphangitis and radiation pneumonitis.

Antibiotics may be appropriate for infections.

Anticoagulants can prevent and treat thrombotic pulmonary emboli.

Bronchodilators such as salbutamol and ipratropium treat reversible bronchospasm.

Pharmacological Approach: Other

Counselling & support Complementary therapies

◦ Relaxation training◦ Tai chi◦ Yoga◦ Hypnosis◦ Therapeutic touch◦ accupuncture

Complementary Approach

Obstruction can be treated locally with laser therapy, cryotherapy, or stenting.

Malignant pleural effusions can be drained by thorocentesis, and if they recur, pleurodesis may be attempted. Fluid drainage may improve the mechanical advantage of the respiratory muscles to relieve dyspnoea.

Interventional Approach

Kamal et al. 2012

Summary of Interventions