From the Guidelines
I recommend using opioids, specifically morphine, as the optimal medication for subjective dyspnea (shortness of breath) in patients with advanced cancer or other life-limiting illnesses. The dosage of morphine can be titrated to effect, starting with a low dose of 2.5-10 mg orally every 2 hours as needed, or 1-3 mg intravenously every 2 hours as needed 1. For patients who are already receiving chronic opioids, a 25% dose increase may be considered to manage dyspnea 1. Opioids have been shown to be effective in reducing the intensity and unpleasantness of dyspnea in patients with advanced cancer and other life-limiting illnesses 1.
Some key points to consider when using opioids for dyspnea include:
- Starting with a low dose and titrating to effect to minimize side effects
- Using a short-acting opioid such as morphine for acute dyspnea exacerbations
- Considering around-the-clock dosing for patients with continuous or resting dyspnea
- Adding an adjunctive benzodiazepine to the opioid regimen for patients with advanced COPD or other conditions that may benefit from anxiolysis 1
Non-pharmacologic interventions, such as the use of handheld fans directed at the face, supplemental oxygen, and mechanical ventilation, may also be considered as part of a comprehensive approach to managing dyspnea 1. However, the evidence suggests that opioids are the most effective pharmacologic treatment for subjective dyspnea in patients with advanced cancer or other life-limiting illnesses.
It's worth noting that other medications, such as benzodiazepines, may be used in certain situations, such as when dyspnea is associated with anxiety, but the evidence for their use is less strong than for opioids 1. Additionally, other medications, such as phenothiazines and antidepressants, have not been shown to be effective in treating dyspnea and are not recommended 1.
From the Research
Optimal Medication for Subjective Dyspnea
The optimal medication for subjective dyspnea, or shortness of breath, can vary depending on the underlying cause and severity of the condition.
- For patients with advanced chronic obstructive pulmonary disease (COPD), low-dose systemic opioids have been shown to be an effective treatment option for refractory dyspnea 2.
- A low starting dose of opioids, such as 1.0mg of morphine, is recommended, with subsequent doses titrated to achieve the lowest effective dose based on symptom relief and side effects 2.
- In patients with acute respiratory failure, low-dose titrated opioids, such as morphine hydrochloride, may help reduce dyspnea intensity 3.
- Non-pharmacological therapies, such as pulmonary rehabilitation, long-term oxygen therapy, and lung volume reduction, can also help improve dyspnea in patients with COPD 2.
- Other medications, such as bronchodilators, including long-acting anticholinergics and long-acting beta agonists, are also used to treat dyspnea in COPD patients 2, 4.
Treatment Options
Treatment options for dyspnea also include:
- Non-invasive ventilation (NIV) as a rescue therapy to relieve exertional dyspnea in patients with stable severe COPD 5.
- Oxygen therapy to reduce dyspnea intensity 5.
- Inhaled furosemide as an alternative to opioids for reducing dyspnea 6.
- Benzodiazepines to reduce dyspnea and associated fear or anxiety 6.