From the Guidelines
Midazolam 2.5 mg subcutaneously, 1-hourly prn is the most appropriate option for managing anxiety associated with dyspnea in a palliative care setting. According to the evidence from 1, benzodiazepines, such as midazolam, are recommended for the palliation of dyspnea, with a dosage of 2.5-5 mg subcutaneously every 4 hours. This is consistent with the guidelines for managing dyspnea in advanced cancer patients.
The use of midazolam in this context is supported by its ability to reduce anxiety and the perception of breathlessness, addressing the anxiety-dyspnea cycle where anxiety worsens breathlessness and vice versa.
Some key points to consider when using midazolam for dyspnea include:
- Starting with a lower dose and titrating upward based on response
- Using alternative benzodiazepines, such as lorazepam or diazepam, if necessary
- Combining midazolam with opioids, like morphine, to reduce respiratory drive and sensation of air hunger
- Implementing non-pharmacological approaches, such as positioning, airflow across the face, and relaxation techniques, alongside medication therapy for comprehensive symptom management.
It's worth noting that other options, such as hydromorphone, fentanyl, and hyoscine-n-butyl bromide, may not be as appropriate for managing anxiety associated with dyspnea, as they may not address the anxiety-dyspnea cycle as effectively as benzodiazepines like midazolam. Metoclopramide is not typically used for dyspnea management and is more commonly used for nausea and vomiting.
Overall, the evidence supports the use of midazolam as a first-line option for managing anxiety associated with dyspnea in palliative care settings, due to its efficacy in reducing anxiety and improving symptom management.
From the FDA Drug Label
WARNINGS Personnel and Equipment for Monitoring and Resuscitation Prior to the intravenous administration of midazolam in any dose, the immediate availability of oxygen, resuscitative drugs, age- and size-appropriate equipment for bag/valve/mask ventilation and intubation, and skilled personnel for the maintenance of a patent airway and support of ventilation should be ensured Risks from Concomitant Use With Opioids Concomitant use of benzodiazepines, including midazolam, and opioids may result in profound sedation, respiratory depression, coma, and death. If a decision is made to use midazolam concomitantly with opioids, monitor patients closely for respiratory depression and sedation
The most appropriate medication for managing anxiety associated with dyspnea in a palliative care setting is midazolam.
- The recommended dose is 2.5 mg subcutaneously, 1-hourly prn.
- It is essential to monitor the patient closely for respiratory depression and sedation, especially when used concomitantly with opioids, as in David's case with his morphine syringe driver 2.
From the Research
Management of Anxiety Associated with Dyspnea
The management of anxiety associated with dyspnea in a palliative care setting is crucial for improving the quality of life of patients. The following options are considered for managing anxiety associated with dyspnea:
- Midazolam: a benzodiazepine with anxiolytic properties
- Hydromorphone: an opioid analgesic
- Fentanyl: a potent opioid analgesic
- Hyoscine-n-butyl bromide: an anticholinergic medication
- Metoclopramide: an antiemetic medication
Evidence-Based Recommendations
Based on the available evidence, midazolam is considered an effective medication for managing anxiety associated with dyspnea in palliative care patients 3, 4. The study by 3 found that the addition of midazolam to morphine improved the control of dyspnea in cancer patients. Another study by 4 found that midazolam was superior to morphine in controlling baseline and breakthrough dyspnea in ambulatory patients with advanced cancer.
Dosage and Administration
The recommended dosage of midazolam for managing anxiety associated with dyspnea is 2.5 mg subcutaneously, 1-hourly as needed 3. This dosage can be adjusted based on the patient's response and tolerance to the medication.
Comparison with Other Options
The other options listed, such as hydromorphone, fentanyl, hyoscine-n-butyl bromide, and metoclopramide, are not supported by the available evidence as the most appropriate medications for managing anxiety associated with dyspnea in palliative care patients. However, opioids like morphine may be used to control dyspnea, and benzodiazepines like lorazepam may be used to manage anxiety associated with dyspnea 5.