Is diazepam (Valium) indicated for shortness of breath due to anxiety?

Diazepam for Shortness of Breath: Clinical Recommendation

Diazepam is NOT indicated for shortness of breath itself, but may be used specifically for anxiety-related dyspnea in highly selected patients, with significant caution due to respiratory depression risks. 1, 2

FDA-Approved Indications

The FDA label for diazepam does not include dyspnea or shortness of breath as an approved indication. 1 Approved uses are limited to:

• Management of anxiety disorders or short-term relief of anxiety symptoms 1
• Acute alcohol withdrawal (agitation, tremor, delirium tremens) 1
• Skeletal muscle spasm 1
• Adjunctive therapy in convulsive disorders 1

Evidence Against Use for Dyspnea

Current evidence does not support benzodiazepines as effective treatment for dyspnea in advanced illnesses. 2 Three independent expert groups reviewing this question concluded:

• Benzodiazepines alone confer no benefit for dyspnea based on existing data 2
• Significant concerns exist regarding adverse effects including delirium and drowsiness 2
• Benzodiazepines should NOT be used as first-line pharmacologic therapy for dyspnea 2

Respiratory Depression Risk

Diazepam causes significant respiratory depression, particularly in patients with chronic airways obstruction. 3 Key safety data:

• In patients with chronic airways obstruction, 10 mg intramuscular diazepam caused significant respiratory depression in 50% of patients studied 3
• Diazepam shifts the apneic threshold to a higher PCO2, indicating central respiratory depression 4
• This respiratory depressant effect is opposite to buspirone, which actually stimulates respiration 4

Limited Appropriate Clinical Scenarios

Benzodiazepines may have a role in three specific situations:

1. Severe Anxiety-Associated Dyspnea

• Consider only in highly selected patients where severe anxiety is clearly contributing to dyspnea 2
• Use short-acting benzodiazepines for panic episodes in emphysema patients 5
• Monitor closely for respiratory depression 3

2. Adjunctive Therapy with Opioids

• May be considered in patients with severe dyspnea despite opioids, particularly if life expectancy is limited 2
• Critical warning: Combined use with opioids significantly increases risk of fatal respiratory depression 6, 7

3. Palliative Sedation

• Benzodiazepines have a role in palliative sedation for refractory dyspnea in the last days of life 2

Safer Alternatives

For anxiety in patients with respiratory compromise, consider alternatives with better safety profiles:

• Buspirone stimulates rather than depresses respiration and may be preferable for anxiety in patients with respiratory disease 5, 4
• Haloperidol (5 mg IM) showed no significant respiratory depression in patients with severe chronic airways obstruction, making it safer than diazepam for acute agitation 3
• Selective serotonin reuptake inhibitors are effective for anxiety disorders without respiratory depression 5

Critical Safety Precautions

If diazepam must be used in a patient with dyspnea:

• Use the lowest effective dose and monitor continuously for respiratory depression 6, 7
• Avoid in patients with severe pulmonary insufficiency, severe liver disease, or myasthenia gravis 7
• Have flumazenil available, though its ability to reverse respiratory depression is inconsistent and short-lived 8
• Monitor oxygen saturation and be prepared to support ventilation 5
• Consider lorazepam over diazepam if a benzodiazepine is necessary, as it has more predictable pharmacokinetics 6

Common Clinical Pitfall

The case report describing diazepam use for a patient with shortness of breath 5 illustrates inappropriate prescribing: the patient received diazepam for anxiety and behavioral disturbances, NOT for dyspnea treatment, yet continued to report shortness of breath despite therapy, ultimately requiring evaluation for pulmonary embolism. This demonstrates that benzodiazepines do not treat the underlying cause of dyspnea. 5