What is the best approach to manage shortness of breath in a senior patient with Chronic Obstructive Pulmonary Disease (COPD) on a palliative approach?

Management of Shortness of Breath in Seniors with COPD on a Palliative Approach

Low-dose opioids should be the first-line pharmacological treatment for shortness of breath in seniors with COPD on a palliative approach, starting with oral sustained-release morphine at 10 mg daily. 1

Comprehensive Management Approach

Non-Pharmacological Interventions (First Line)

• Implement breathing training techniques and relaxation exercises to improve respiratory efficiency and reduce anxiety 1
• Use a hand-held fan directed at the face to help relieve breathlessness (should be tried before oxygen therapy) 1
• Provide appropriately tailored exercise programs to improve functional capacity and address skeletal myopathy 1
• Consider physiotherapeutic approaches including neuro-electrical leg muscle stimulation and walking aids to reduce energy expenditure 1
• Ensure proper positioning to optimize breathing mechanics 1
• Provide educational, psychosocial, and emotional support for both patient and family 1

Oxygen Therapy

• Provide supplemental oxygen therapy only for patients with documented hypoxemia (SpO2 <90%) 1
• Discontinue oxygen if no symptomatic benefit is observed or if disadvantages (e.g., discomfort from masks, drying of mucous membranes) outweigh benefits 1
• For patients who are only mildly hypoxemic or normoxemic, oxygen therapy is not recommended as data do not support its use 1

Pharmacological Management

Opioids

• Start with oral sustained-release morphine at 10 mg daily (either as 5 mg modified release twice daily or 10 mg modified release once daily) 1, 2
• If response is inadequate, dose increases should not occur for at least one week 1
• Doses can be titrated up to a maximum of 30 mg/24h if needed 1
• Monitor for clinical response - improvement is typically seen within 24 hours, with magnitude increasing over the first week 1
• Use with caution in patients with significant renal impairment (GFR <30 mL/min); consider alternative opioids without active metabolites requiring renal excretion 1, 3
• Patients with higher BMI and worse baseline breathlessness are more likely to experience meaningful improvement with morphine 4

Benzodiazepines

• Consider adding benzodiazepines only when breathlessness is associated with significant anxiety or when opioids alone are insufficient 1
• If initiating benzodiazepines, start with lorazepam 0.5-1 mg PO every 4 hours as needed 1
• Use with extreme caution due to increased risk of respiratory depression when combined with opioids 1, 3

Management of Secretions

• For excessive secretions, consider scopolamine 0.4 mg subcutaneously every 4 hours as needed, or 1-3 patches every 3 days 1
• Alternative options include atropine 1% ophthalmic solution 1-2 drops sublingually every 4 hours as needed, or glycopyrrolate 0.2-0.4 mg IV/subcutaneously every 4 hours as needed 1

Special Considerations and Monitoring

Monitoring

• Regularly assess response to treatment using validated breathlessness scales 1
• Monitor for adverse effects, particularly respiratory depression, constipation, and sedation 3
• For patients on opioids, ensure prophylactic treatment for constipation 1

End-of-Life Care

• In the last days of life, focus on comfort and symptom management rather than oxygen saturation levels 1
• Consider intensifying palliative care interventions and consultation with palliative care specialists 1
• For intractable symptoms, palliative sedation may be considered 1

Pitfalls and Caveats

• Avoid using oxygen therapy in non-hypoxemic patients, as it provides no benefit and may create unnecessary dependency 1
• Be cautious with opioid dosing in elderly patients with COPD due to increased risk of respiratory depression 3
• Do not delay opioid initiation due to unfounded fears of respiratory depression - studies show low-dose morphine is safe in COPD when properly monitored 2
• Avoid concomitant use of opioids with benzodiazepines unless absolutely necessary due to increased risk of respiratory depression 3
• Remember that in palliative care for COPD, symptom management takes precedence over oxygen saturation values 1