“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