Treatment of Dyspnea
The primary treatment for dyspnea should focus on optimizing management of the underlying disease, followed by opioids for refractory symptoms when other measures fail. 1
Assessment and Diagnosis
Before initiating treatment, a systematic approach to identify the cause of dyspnea is essential:
Evaluate for underlying causes including:
First-line diagnostic tests:
- Complete blood count
- Basic chemistry panel
- Electrocardiography
- Chest radiography
- Spirometry
- Pulse oximetry 3
Treatment Algorithm
Step 1: Treat Underlying Cause
- For asthma/COPD: Optimize inhaled bronchodilators and corticosteroids
- For heart failure: Optimize diuretics and afterload reduction
- For pleural effusions: Consider thoracentesis and pleurodesis or drainage procedure for recurrent effusions 1
- For anemia: Blood transfusion if appropriate
- For infections: Appropriate antimicrobial therapy 1
Step 2: Non-Pharmacological Interventions
- Positioning (upright position often helps)
- Cooling the face (fan therapy)
- Breathing techniques and relaxation training
- Pulmonary rehabilitation for chronic lung disease 2
Step 3: Oxygen Therapy
- Provide supplemental oxygen for patients with hypoxemia
- May be beneficial even in non-hypoxemic patients with advanced heart or lung disease 1, 2
Step 4: Pharmacological Management for Refractory Dyspnea
Opioids:
- First-line pharmacological therapy for refractory dyspnea 1, 2
- Starting doses:
- Titrate slowly based on symptom response 2
Benzodiazepines:
- Add when dyspnea is associated with anxiety
- Not recommended as monotherapy (small benefit when used alone) 1, 2
- Consider combination therapy with opioids for severe refractory dyspnea 1
Special Considerations
Safety of Opioids
- Clinically significant respiratory depression is uncommon with doses used to treat dyspnea, even in elderly patients 1, 2
- Common side effects include constipation, nausea, and drowsiness 2
- In dying patients, opioid doses should not be reduced solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for dyspnea management 1
Route of Administration
- Oral and parenteral routes are effective 2
- Nebulized opioids are not recommended as they are no more effective than placebo 2, 4
Renal Considerations
- For patients with renal insufficiency, avoid morphine and consider hydromorphone or fentanyl with adjusted dosing 2
Treatments with Insufficient Evidence
- Nebulized furosemide: Insufficient data to support use 1, 4
- Heliox: May help in obstructive lung disease but no studies on long-term use 1
- Anxiolytics alone, antidepressants, phenothiazines, indomethacin, inhaled anesthetics, nitrous oxide, and sodium bicarbonate: Insufficient evidence 1
Monitoring and Follow-up
- Use validated assessment tools to monitor response:
- Numeric rating scales or visual analog scales for patients who can self-report
- Respiratory Distress Observation Scale for patients who cannot self-report 4
- Six-minute walk test can help measure the effect of ongoing interventions 3
By following this systematic approach to dyspnea management, clinicians can effectively address this distressing symptom and improve quality of life for patients with various underlying conditions.