What can be used to alleviate shortness of breath in a hospice patient experiencing anaphylaxis due to codeine?

Management of Shortness of Breath in Hospice Patient with Codeine-Induced Anaphylaxis

For a hospice patient experiencing anaphylaxis from codeine with shortness of breath, immediately administer intramuscular epinephrine 0.3-0.5 mg (0.3-0.5 mL of 1:1000 solution) into the lateral thigh, provide 100% oxygen, and if bronchospasm persists after epinephrine, add nebulized albuterol 2.5 mg; for ongoing dyspnea management after the acute anaphylaxis resolves, use low-dose oral morphine 10 mg daily (avoiding codeine permanently) as the evidence-based palliative treatment for chronic breathlessness. 1, 2, 1

Immediate Anaphylaxis Management

First-Line Treatment: Epinephrine

• Administer epinephrine immediately - this is life-saving and the only definitive first-line treatment for anaphylaxis, even in hospice patients 1, 2, 3
• Intramuscular route is preferred initially: 0.3-0.5 mg (0.3-0.5 mL of 1:1000 solution) into the anterolateral thigh for rapid absorption 1, 2, 4
• Repeat every 5-15 minutes as needed if shortness of breath, bronchospasm, or hypotension persists 1, 2
• Epinephrine works through beta-adrenergic receptors to cause bronchial smooth muscle relaxation and alleviate bronchospasm, wheezing, and dyspnea 5, 6

Airway and Oxygen Support

• Administer 100% oxygen immediately via non-rebreather mask or nasal cannula at high flow 1, 2
• Oxygen is essential for patients with prolonged reactions or pre-existing respiratory compromise 1
• Monitor oxygen saturation continuously with pulse oximetry 2

Persistent Bronchospasm Management

• If bronchospasm continues after epinephrine, administer nebulized albuterol (salbutamol) 2.5 mg (0.5 mL of 5% solution) 1, 2
• Consider IV salbutamol infusion for refractory bronchospasm 1
• Alternative agents for severe cases include IV aminophylline or magnesium sulfate 1

Secondary Anaphylaxis Medications

Adjunctive Therapy

• Chlorphenamine 10 mg IV to reduce histamine-mediated symptoms 1, 2
• Hydrocortisone 200 mg IV to potentially prevent biphasic reactions (though this won't help acute bronchospasm) 1, 2
• These are secondary treatments only - never delay epinephrine to give antihistamines or steroids 1, 2

Post-Acute Dyspnea Management in Hospice

Opioid Selection for Chronic Breathlessness

• Once anaphylaxis resolves, use oral morphine for ongoing dyspnea management - morphine is the only medication with regulatory approval for chronic breathlessness and has the strongest evidence base 1
• Permanently avoid all codeine products - the patient has demonstrated anaphylaxis to this opioid 2
• Start with oral sustained-release morphine 10 mg once daily (or 5 mg twice daily, or 2.5 mg immediate-release four times daily) 1
• 63% of patients respond to morphine for breathlessness; of responders, 67% benefit at 10 mg/day, 25% require 20 mg/day, and 8% need 30 mg/day 1
• Initial response occurs within 24 hours, but full benefit may take up to one week 1
• Maximum dose for breathlessness is 30 mg/24 hours of oral morphine 1

Renal Considerations

• If the patient has Stage 4-5 chronic kidney disease (GFR <30 mL/min), avoid morphine or use with extreme caution due to accumulation of active metabolites 1
• Consider alternative opioids without renally-excreted active metabolites in significant renal impairment 1

Non-Pharmacological Approaches

• Use a hand-held fan directed at the face to stimulate facial trigeminal nerve receptors 1
• Breathing training and relaxation techniques may provide additional benefit 1
• Oxygen therapy only helps if the patient is hypoxemic; it does not benefit normoxemic patients 1

Critical Pitfalls to Avoid

Epinephrine Administration Errors

• Never delay epinephrine - it should be given immediately upon suspecting anaphylaxis, not after trying antihistamines or bronchodilators first 1, 2, 4
• Do not use IV epinephrine in hospice/home settings without continuous cardiac monitoring - IM route is safer 1, 2
• The lateral thigh (vastus lateralis) provides faster absorption than deltoid or subcutaneous routes 1, 3

Opioid Selection Mistakes

• Never rechallenge with codeine - document this as a severe allergy prominently in all medical records 2
• Do not assume all opioids are cross-reactive; morphine has a different structure and is safe to use 1
• Avoid undertreating dyspnea in hospice patients due to opioid fears - low-dose morphine (10-30 mg/day) for breathlessness does not cause excess mortality 1

Monitoring Requirements

• Observe for at least 4-6 hours after anaphylaxis as biphasic reactions can occur during symptom resolution 7
• In hospice settings, ensure caregivers understand when to call for emergency help versus managing symptoms at home 7