What is the role of morphine in treating dyspnea (shortness of breath)?

From the Guidelines

Morphine is a highly effective treatment for dyspnea, particularly in palliative care and end-of-life settings, with a recommended starting dose of 10 mg per day, given to provide a steady state according to preparation. This is based on the most recent and highest quality study available, which suggests that morphine should be started at 10 mg per day, with a potential for dose escalation to a maximum of 30 mg/24 h of oral morphine if necessary 1. The use of morphine for dyspnea is supported by evidence from multiple studies, including a study that showed a valuable effect of morphine for dyspnea in advanced lung disease, with a standardized mean difference of −0.31 [CI, −0.50 to −0.13] 1.

Key Considerations for Morphine Use

• Morphine works by reducing respiratory drive, decreasing oxygen consumption, and modulating central perception of breathlessness, which helps alleviate the sensation of air hunger without necessarily affecting oxygen levels.
• Common side effects include constipation, nausea, sedation, and respiratory depression, so patients should be monitored closely.
• Prophylactic stool softeners and anti-emetics may be needed.
• For chronic dyspnea management, extended-release formulations can be considered.
• Morphine should be used cautiously in patients with renal impairment, and dose adjustments may be necessary.

Non-Pharmacological Approaches

• Non-pharmacological approaches like positioning, oxygen therapy, and breathing techniques should be used concurrently for comprehensive dyspnea management.
• A time-limited trial of mechanical ventilation, as clinically indicated, and/or oxygen therapy for hypoxia may also be beneficial.
• The use of handheld fans directed at the face has been shown to reduce breathlessness in patients.

Other Treatment Options

• Benzodiazepines can be tried for treatment of dyspnea when other options have failed, but their beneficial effect on breathing in patients with advanced cancer is small.
• Nebulized fentanyl has been shown to reduce the intensity and unpleasantness of dyspnea in patients with chronic obstructive pulmonary disease, but its use in patients with cancer is not well established.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Role of Morphine in Treating Dyspnea

• Morphine has been studied as a potential treatment for dyspnea in various clinical settings, including interstitial lung disease (ILD) 2, acute respiratory failure 3, 4, chronic obstructive pulmonary disease (COPD) 5, and idiopathic interstitial pneumonias (IIPs) 6.
• The evidence suggests that morphine can be effective in alleviating dyspnea in certain patient populations, such as those with COPD 5 and IIPs 6.
• However, the results are mixed, and some studies have found no significant improvement in dyspnea with morphine treatment, such as in patients with acute respiratory failure 4.
• The safety profile of morphine in patients with dyspnea has been evaluated, and low doses of morphine have been found to be generally well-tolerated 2, 5, 6.
• However, higher doses of morphine or prolonged use may be associated with adverse effects, such as increased risk of intubation 4.

Patient Populations

• Patients with ILD: Morphine has been found to have a tolerable safety profile in ILD patients with dyspnea, and may be effective in alleviating dyspnea in this population 2.
• Patients with acute respiratory failure: The evidence is mixed, with one study finding no significant improvement in dyspnea with morphine treatment 4, while another study found a statistically significant immediate effect of morphine on dyspnea 3.
• Patients with COPD: Oral morphine has been found to be effective in alleviating dyspnea in Japanese COPD patients 5.
• Patients with IIPs: Continuous subcutaneous morphine has been found to improve dyspnea in terminally ill IIP patients without noninvasive positive pressure ventilation (NPPV) 6.

Dosage and Administration

• The optimal dosage and administration of morphine for dyspnea treatment are not well-established, and may vary depending on the patient population and clinical setting.
• Low doses of morphine, such as 1-2 mg subcutaneously or 12 mg orally per day, have been found to be effective and well-tolerated in some studies 2, 5, 6.
• Continuous subcutaneous infusion of morphine has also been used in some studies, with doses ranging from 0.25 to 0.5 mg/hour 6.