What to do in case of dyspnea and pain in a 75-year-old patient with stage 4 adenocarcinoma on palliative care at home on Nasal Rebreathe Mask (NRM) with oxygen therapy at 10 liters per minute?

Management of Dyspnea and Pain in a 75-Year-Old Patient with Stage 4 Adenocarcinoma on Palliative Care

Opioids are the first-line treatment for both dyspnea and pain in this patient with stage 4 adenocarcinoma, with morphine or fentanyl being the preferred agents for immediate relief. 1, 2

Immediate Management of Dyspnea

Pharmacological Interventions

• Start with opioids as the mainstay of pharmacological management for refractory dyspnea 1, 2

  • For opioid-naïve patients: morphine 2.5-10 mg PO every 2 hours as needed or 1-3 mg IV every 2 hours as needed 2
  • For patients already on chronic opioids: increase the current dose by 25% to manage acute dyspnea 1, 2
  • Fentanyl is an appropriate alternative, especially in patients with renal impairment 1
  • Subcutaneous or intravenous administration provides more rapid onset of action for acute distress 1

• Add benzodiazepines if dyspnea is associated with anxiety 1

  • Lorazepam 0.5-1 mg PO/IV/SC every 4 hours as needed 2
  • Use cautiously and as an adjunct to opioids, not as monotherapy 1

• For excessive secretions contributing to respiratory distress, consider: 1

  • Glycopyrrolate 0.2-0.4 mg IV/SC every 4 hours (preferred in patients at risk for delirium as it doesn't cross blood-brain barrier) 1, 2
  • Scopolamine 0.4 mg SC every 4 hours or transdermal patches (note that patches take about 12 hours for onset of effect) 1

Non-Pharmacological Interventions

• Position the patient upright with arms elevated and supported to increase pulmonary capacity 1, 3
• Direct cool air toward the face using a fan to reduce the sensation of dyspnea 1, 3
• Balance rest with activity to decrease excessive oxygen consumption 1
• Space nursing care to prevent exhaustion 1
• Consider adjusting oxygen therapy based on goals of care 1
  • Continue oxygen at 10L/min via NRM if providing symptomatic relief
  • Note that oxygen therapy may not provide additional benefit over room air in non-hypoxemic patients 1

Pain Management

• Titrate opioids aggressively for moderate to severe pain 2
• Do not reduce opioid doses solely due to decreased blood pressure, respiratory rate, or level of consciousness when necessary for adequate symptom management 2
• For patients with renal impairment, avoid morphine and consider fentanyl or methadone as they have no active metabolites 1
• For patients already receiving chronic opioids for pain who develop dyspnea, increase the dose by 25% 1

Addressing Anxiety and Psychological Distress

• Implement psychologic interventions including relaxation techniques and stress management 2
• Provide emotional support to help reshape goals and hopes based on changing reality 2
• Address spiritual concerns and existential distress 2
• Facilitate completion of important personal matters and relationship closure 2

Care Coordination and Goals of Care

• Initiate conversations about prognosis and goals of care immediately 2
• Discuss benefits and burdens of continued aggressive interventions versus comfort-focused care 2
• Consider referral to specialized palliative care services or hospice if not already involved 2

Common Pitfalls to Avoid

• Do not withhold opioids due to exaggerated fears of respiratory depression in palliative care patients 3, 2
• Avoid relying on nebulized opioids, which have not shown superior efficacy to systemic administration 1, 3
• Do not delay symptom management while waiting for diagnostic tests 2
• Avoid focusing solely on oxygen therapy without addressing other aspects of dyspnea management 1, 4
• Remember that dyspnea is a subjective experience that may not correlate with objective measures like oxygen saturation 4

By implementing these evidence-based interventions promptly, you can effectively manage both dyspnea and pain in this patient with advanced cancer, focusing on comfort and quality of life as the primary goals.