How is bradypnea (abnormally slow breathing rate) managed in a hospice setting?

Management of Bradypnea in Hospice Settings

In hospice patients with bradypnea (slow breathing rate), do not reduce opioid doses solely based on decreased respiratory rate when opioids are necessary for adequate management of dyspnea and pain—instead, focus on comfort and symptom control as the primary goal. 1

Understanding Bradypnea in the Dying Process

Bradypnea in hospice patients is often part of the natural dying process rather than a complication requiring intervention. 1

• Agonal breathing (slow, irregular, noisy breathing mimicking grunting or gasping) commonly occurs in the minutes before death and should be anticipated rather than treated. 1
• Families should be informed in advance that agonal breathing is part of the dying process and does not indicate patient discomfort or agony. 1
• By itself, agonal breathing is not an indication for increasing opioid doses. 1

Key Management Principles for Dying Patients

Opioid Management

Continue or increase opioids as needed for symptom control, regardless of respiratory rate. 1

• Opioid doses should not be reduced solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate dyspnea and pain management. 1
• For dying patients with moderate to severe pain or dyspnea, opioids can be titrated aggressively. 1
• If opioid naive: morphine 2.5-10 mg PO every 2 hours as needed, or 1-3 mg IV every 2 hours as needed. 1
• If already on chronic opioids: consider increasing dose by 25%. 1

Adjunctive Medications

Add benzodiazepines when anxiety accompanies respiratory symptoms. 1

• If benzodiazepine naive: lorazepam 0.5-1 mg PO every 4 hours as needed. 1
• Benzodiazepines are particularly useful when dyspnea is associated with anxiety, though they should not be used as primary treatment for dyspnea alone. 1

Managing Secretions (Death Rattle)

Reduce excessive secretions that may cause noisy breathing to relieve family distress. 1

• Scopolamine 0.4 mg subcutaneous every 4 hours as needed, or 1.5 mg patches (1-3 patches every 3 days). 1
• Atropine 1% ophthalmic solution 1-2 drops sublingual every 4 hours as needed. 1
• Glycopyrrolate 0.2-0.4 mg IV or subcutaneous every 4 hours as needed. 1
• Eliminate or decrease IV fluids if fluid overload contributes to secretions. 1

Non-Pharmacologic Comfort Measures

Focus on physical comfort and environmental modifications. 1, 2

• Use fans directed at the patient's face for subjective relief. 1, 2
• Maintain cooler room temperatures. 1
• Continue oxygen only if the patient is hypoxic and reports subjective relief—oxygen is not indicated for comfort in non-hypoxemic dying patients. 1
• Position for comfort rather than optimal respiratory mechanics. 1

Critical Pitfalls to Avoid

Do not withhold adequate symptom control due to exaggerated fears of respiratory depression. 1, 3

• Fears of hypotension, respiratory depression, and excessive sedation often lead to inadequate symptom management but are typically exaggerated concerns in dying patients. 1
• Clinicians should not allow distressing symptoms to persist as a way to maintain blood pressure or stimulate respiratory effort. 1, 3
• The goal is comfort, not physiologic parameters. 1

Do not interpret bradypnea as requiring intervention unless the patient is in distress. 1

• Slow breathing near death is expected and natural. 1
• Intervention is only warranted if the patient shows signs of respiratory distress (use of accessory muscles, tachycardia, agitation). 2

Palliative Sedation for Refractory Symptoms

Consider palliative sedation for intractable symptoms after consultation with palliative care specialists. 1

• This is appropriate when symptoms remain refractory despite optimal management. 1
• Requires careful discussion with the patient (if able) and family about goals of care. 1

Family Support and Anticipatory Guidance

Provide proactive education to families about the dying process. 1

• Explain that changes in breathing patterns, including both slow and irregular breathing, are normal parts of dying. 1
• Reassure families that the patient is not suffering when exhibiting agonal breathing or bradypnea. 1
• Maintain a health care team member's availability to the patient and family until death occurs. 1