What are the recommended treatments for dyspnea?

Treatment of Dyspnea

Opioids are the first-line pharmacological treatment for dyspnea, with sufficient evidence supporting their efficacy in palliation of breathlessness in advanced disease. 1

Initial Approach to Dyspnea Management

Treating Reversible Causes

• Before initiating symptomatic treatment, identify and address underlying causes through appropriate diagnostic tests (blood count, electrolytes, imaging) based on the patient's condition 1
• Consider causative therapeutic options when appropriate, except in emergency situations like acute suffocation 1

Non-Pharmacological Interventions

• Non-pharmacological measures should be implemented before and alongside pharmacological treatments 1
• Effective non-pharmacological interventions include:
  • Cooling the face, opening windows, using small ventilators 1
  • Proper positioning (elevation of upper body, coachman's seat) 1
  • Respiratory training and use of walking aids 1
  • Handheld fans directed at the face, which have demonstrated effectiveness in randomized controlled trials 1
• Patient and caregiver education about these measures is crucial to reduce helplessness and anxiety 1
• Psychological training and relaxation techniques help prevent panic attacks during episodes of breathlessness 1

Pharmacological Management

Opioids

• Opioids are the only pharmacological agents with sufficient evidence for dyspnea palliation 1
• They can be safely used in both opioid-naïve and opioid-tolerant patients without causing significant respiratory depression 1
• Mechanism of action includes:
  • Modulation of opioid receptors in the cardio-respiratory system and central nervous system 1
  • Reduction of the unpleasantness of dyspnea 1
  • Decreasing respiratory drive and anxiety 2

Dosing Guidelines:

• For opioid-naïve patients:
  • Morphine: 2.5-5 mg/4h orally or 1-2.5 mg/4h subcutaneously 1
  • Hydromorphone: 1.3 mg/4h orally or 0.2-0.5 mg/4h subcutaneously 1
• For patients already on opioids for pain:
  • Increase regular opioid dose by 25-50% 1
  • Add 1/6 of the daily opioid intake 1

Administration Routes:

• Oral and parenteral routes (subcutaneous, intravenous) are effective 1
• Intravenous administration has the most rapid onset 1
• No evidence supports the efficacy of nebulized or inhaled opioids 1
• Normal-release preparations can be used for titration, then switch to sustained-release formulations 1

Special Considerations:

• Avoid morphine in patients with severe renal insufficiency 1
• Adjust dosage and intervals for all μ-opioids based on renal function 1
• Monitor for common side effects: nausea and constipation 1

Benzodiazepines

• Indicated for patients with insufficient response to opioids or when anxiety is a significant component 1
• Can be used alone or in addition to opioids 1
• Recommended options:
  • Lorazepam: 0.5-1.0 mg/6-8h orally or sublingually 1
  • Midazolam: 2.5-5 mg/4h subcutaneously or 10-30 mg/24h subcutaneously 1
• Particularly useful in advanced stages and for dying patients 1
• Caution: muscle relaxation may potentially worsen dyspnea in patients with cachexia or sarcopenia 1

Other Medications

• Steroids: Effective for specific conditions such as lymphangiosis carcinomatosa, radiation pneumonitis, superior vena cava syndrome, inflammatory conditions, or airway obstruction 1
• Anticholinergics (scopolamine, atropine, hyoscyamine, glycopyrrolate): Useful for reducing excessive secretions associated with dyspnea 1
  • Glycopyrrolate is less likely to cause delirium but can produce anticholinergic side effects 1
  • Transdermal scopolamine patches have a 12-hour onset of action 1
• Neuroleptics and antidepressants: Insufficient evidence to recommend for routine use in dyspnea 1

Management in End-of-Life Care

• In dying patients, dyspnea is a frequent and distressing symptom 1
• Treatment focus shifts to more aggressive pharmacological management 1
• Terminal sedation with benzodiazepines in addition to opioids may be necessary for refractory symptoms 1
• Opioid doses should not be reduced solely for decreased blood pressure, respiration rate, or consciousness when necessary for adequate symptom management 1
• Human presence and empathy are paramount 1

Common Pitfalls and Caveats

• Delaying opioid therapy due to unfounded fears of respiratory depression - studies show opioids used for dyspnea do not significantly compromise respiratory function 3
• Failing to address the anxiety component of dyspnea, which often requires benzodiazepine therapy 1
• Overlooking non-pharmacological interventions, which should be first-line and continued alongside medications 1
• Using nebulized opioids despite lack of evidence for efficacy 1
• Applying the same opioid dosing strategy for pain and dyspnea (dyspnea requires lower initial doses in opioid-naïve patients) 1