DYSPNEA Downloadable PDF file

Sharon Watanabe, MD, Tertiary Palliative Care Unit, Grey Nuns Community Hospital - Issue #4 (Collect them all) (re-issued with changes June 2005)

Dyspnea: an uncomfortable awareness of breathing a frequent and often devastating symptom of cancer and other end of life illness

Causes:
1.Direct effect of cancer, eg:

• airway obstruction
• pleural effusion
• parenchymal lung involvement
• pericardial effusion
• lymphangitic carcinomatosis
• superior vena cava obstruction

• pneumonia
• anemia
• pulmonary embolus

• radiation - or chemotherapy-induced pneumonitis

• chronic obstructive lung disease
• congestive heart failure
• motor neuron disease

Approach:
1. Determine underlying cause(s):

• history and physical
• chest x-ray

• consider radiotherapy (consult oncologist)
• try dexamethasone 10 mg po/sc qid x 48 hrs; if effective, taper to minimal dose required

• try dexamethasone

• consider thoracentesis; if effective, consider pleurodesis for recurrent effusion (consult respirologist/thoracic surgeon)

• may be of benefit even if saturation >90%

• if already prescribed for pain, titrate to relieve dyspnea
• if opioid naive, start morphine 5-10 mg po/2.5-5 mg sc q4h around the clock and 2.5-5 mg po/1.5-2.5 mg sc q1h prn titrate (remember laxatives and antiemetic)
• nebulized opioids not proven to be effective

• if history of asthma, chronic obstructive lung diseases or smoking

(d) Midazolam

• for intractable severe dyspnea
• start at 1 mg/ hr sc titrate until patient sedated. Refer to Tips on Terminal Sedation

Remember that endpoint is relief of subjective dyspnea, not physical signs of respiratory effort (family may need to be educated).

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