How do you manage a patient with severe dyspnea?

Management of Severe Dyspnea

Opioids are the first-line pharmacological treatment for severe dyspnea and should be initiated promptly while simultaneously addressing underlying causes if death is not imminent. 1

Initial Assessment and Immediate Interventions

Physical Signs of Severe Respiratory Distress

• Respiratory rate ≥30 breaths/min
• Oxygen saturation <90%
• Accessory muscle use
• Nasal flaring
• Tachycardia
• Paradoxical breathing

Immediate Non-Pharmacological Interventions

• Position patient upright to maximize respiratory mechanics
• Direct cool air with a fan toward the face
• Open windows or increase ambient air flow
• Ensure proper positioning (e.g., coachman's seat, elevation of upper body)

Pharmacological Management

Opioids (First-Line)

• Morphine: 2.5-5 mg orally every 4 hours or 1-2.5 mg subcutaneously every 4 hours for opioid-naïve patients 2
• For patients already on opioids: increase regular dose by 25-50% or add 1/6 of daily opioid intake 2
• Titrate dose based on dyspnea response using visual or analog scales
• Note: Morphine should be avoided in patients with severe renal insufficiency; adjust dosage of all μ-opioids based on renal function 2

Benzodiazepines

• Add when dyspnea is associated with anxiety or when there is insufficient response to opioids 2, 1
• Can be used alone or in combination with opioids

Treatment of Underlying Causes

Identify and Address Common Causes

• COPD/Asthma: Bronchodilators, corticosteroids
• Heart Failure: Diuretics, afterload reduction
• Pneumonia: Appropriate antibiotics
• Pneumothorax: Needle decompression or chest tube placement
• Pleural Effusion: Therapeutic thoracentesis
• Malignancy-related: Consider radiation or chemotherapy
• Airway Obstruction: Bronchoscopic therapy

For COPD Exacerbations 2

1. Treat bacterial infection if present
2. Remove excess secretions
3. Increase maximum airflow
4. Improve respiratory muscle strength

Advanced Interventions

Oxygen Therapy

• Provide supplemental oxygen for patients with symptomatic hypoxia (O₂ saturation <90%)
• For COPD patients: target oxygen saturation 88-92% to avoid CO₂ retention

Non-Invasive Ventilation

• Consider high-flow nasal cannula (HFNC) or continuous positive airway pressure (CPAP) in appropriate settings with trained staff 1

End-of-Life Care for Intractable Dyspnea

• Focus on comfort measures
• Titrate medications to symptoms with no dose limit
• Consider sedation for intractable symptoms
• Provide emotional and spiritual support to patients and families

Common Pitfalls to Avoid

1. Focusing only on oxygen therapy without addressing underlying causes
2. Underutilizing non-pharmacological approaches
3. Fearing respiratory depression with opioids (appropriate opioid use for dyspnea does not hasten death)
4. Overlooking psychological components of dyspnea
5. Attributing dyspnea to a single cause when multiple etiologies may be present

Patient and Caregiver Education

• Teach simple measures for symptom relief (cooling face, positioning, breathing techniques)
• Provide psychological training (relaxation) to prevent panic attacks
• Ensure patients and caregivers are familiar with treatment options to reduce helplessness and anxiety 2

Remember that dyspnea encompasses physical, psychological, social, and spiritual domains, often described as "total dyspnea," requiring a multidisciplinary approach that addresses all these aspects 2.