What is the treatment for dyspnea?

Treatment of Dyspnea

Opioids are the first-line pharmacological treatment for dyspnea, with sufficient evidence supporting their effectiveness in relieving this distressing symptom. 1

Step-by-Step Management Approach

1. Identify and Treat Underlying Causes

• Perform appropriate diagnostic tests (complete blood count, electrolytes, creatinine, oximetry, blood gas assessment, ECG, BNP, chest imaging) based on the patient's condition to identify reversible causes 1
• Address specific underlying conditions before symptomatic treatment, except in emergencies such as acute suffocation 1
• When death is not imminent, treating the etiology of dyspnea is recommended 1

2. Non-Pharmacological Interventions

• Implement non-pharmacological measures before starting medications 1
• Position the patient optimally (elevated upper body, coachman's seat) 1
• Use cooling methods for the face (cold air, fans, open windows) 1
• Provide respiratory training and consider walking aids 1
• Educate patients and caregivers about these techniques to reduce helplessness and anxiety 1
• Consider psychological training (relaxation techniques) to prevent panic during episodes of breathlessness 1

3. Pharmacological Management

First-Line: Opioids

• Opioids have the strongest evidence base for dyspnea relief 1
• They can be used safely in opioid-naïve and opioid-tolerant patients without causing significant respiratory depression 1
• Dosing recommendations:
  • For opioid-naïve patients: Morphine 2.5-5 mg PO every 4 hours or 1-2.5 mg SC every 4 hours 1
  • For patients already on opioids for pain: Increase regular dose by 25-50% 1
  • Hydromorphone can be used as an alternative: 1.3 mg PO every 4 hours or 0.2-0.5 mg SC every 4 hours 1
• Avoid morphine in patients with severe renal insufficiency; adjust dosing intervals for all μ-opioids based on renal function 1
• Use normal-release preparations initially for titration, then switch to sustained-release formulations 1

Second-Line: Benzodiazepines

• Add benzodiazepines when opioids provide insufficient relief, especially when anxiety is present 1
• Recommended options:
  • Lorazepam 0.5-1.0 mg PO or SL every 6-8 hours 1
  • Midazolam 2.5-5 mg SC every 4 hours or 10-30 mg/24 hours SC 1
• Be cautious about muscle relaxation effects, particularly in patients with cachexia 1

Other Pharmacological Options

• Bronchodilators (e.g., albuterol) for patients with reversible obstructive airway disease 2
• Steroids may be effective for specific conditions: lymphangiosis carcinomatosa, radiation pneumonitis, superior vena cava syndrome, inflammatory conditions, or airway obstruction 1
• Avoid routine use of steroids outside these specific indications 1
• Anticholinergics (glycopyrrolate, scopolamine, atropine) can reduce excessive secretions associated with dyspnea 1

4. Management in End-of-Life Care

• In dying patients, focus shifts primarily to pharmacological interventions 1
• Opioid doses should not be reduced solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for symptom management 1
• Consider terminal sedation with benzodiazepines in addition to opioids for refractory dyspnea 1
• For death rattle that distresses relatives, consider reducing artificial hydration and adding antisecretory medications 1

Special Considerations

• For patients with chronic dyspnea and reduced functional capacity, consider pulmonary rehabilitation and exercise training 1
• Non-invasive ventilation techniques (oxygen therapy, HFNC, CPAP) should only be used until proper sedation is achieved or when sedation is inadequate 1
• The experience of dyspnea encompasses physical, psychological, social, and spiritual domains, suggesting a multidisciplinary approach is needed 1
• Dyspnea is one of the most distressing symptoms in cancer patients and is associated with increased mortality in those with chronic lung disease 1