What is the role of benzodiazepines in managing dyspnea (difficulty breathing)?

From the Guidelines

Benzodiazepines can be effective for managing dyspnea, particularly in palliative care settings, when used cautiously and alongside other treatments addressing the underlying cause of dyspnea. The use of benzodiazepines for dyspnea is supported by guidelines from reputable sources, including the National Comprehensive Cancer Network (NCCN) and the European Society for Medical Oncology (ESMO) 1. According to these guidelines, benzodiazepines such as lorazepam (0.5-1.0 mg orally or sublingually every 6-8 hours) or midazolam (2.5-5 mg subcutaneously every 4 hours) can be used to alleviate dyspnea, especially when it is associated with anxiety 1. It is essential to start with the lowest effective dose and titrate carefully, especially in elderly patients or those with respiratory compromise, due to the potential side effects of sedation, respiratory depression, and risk of dependence 1. Benzodiazepines work by reducing anxiety and the perception of breathlessness through their action on GABA receptors in the brain, which decreases respiratory drive and the subjective feeling of air hunger. However, their use should be prioritized in end-of-life care when symptom relief takes priority over concerns about respiratory depression. Some key points to consider when using benzodiazepines for dyspnea include:

• Assessing symptom intensity and treating underlying causes or comorbid conditions
• Using benzodiazepines alongside other treatments, such as opioids, for cough or dyspnea
• Considering nonpharmacologic therapies, including fans, cooler temperatures, stress management, relaxation therapy, and physical comfort measures
• Reducing excessive secretions with medications like scopolamine, hyoscyamine, atropine, or glycopyrrolate
• Providing emotional support and anticipatory guidance for patients and their families. Overall, the use of benzodiazepines for dyspnea should be individualized and based on a comprehensive assessment of the patient's symptoms, medical history, and treatment goals 1.

From the Research

Benzodiazepine Use for Dyspnea

• Benzodiazepines are not recommended as a first-line treatment for dyspnea in patients with advanced illnesses due to lack of benefit and potential adverse effects such as delirium and drowsiness 2.
• However, benzodiazepines may be considered in highly selected patients with severe anxiety associated with dyspnea, or as an adjunctive therapy in patients with severe dyspnea despite opioid use, particularly if life expectancy is limited 2.
• In patients with chronic obstructive pulmonary disease (COPD), benzodiazepines are not recommended for the symptomatic reduction of chronic breathlessness, and their use is associated with increased risk of drowsiness, somnolence, and respiratory tract infections 3.

Alternative Treatments for Dyspnea

• Effective symptom palliation for dyspnea is possible with interventions that reduce inspiratory neural drive, improve respiratory mechanics and muscle function, or address the affective dimension of dyspnea 4.
• Opioids, such as morphine, have been shown to be effective in managing dyspnea in cancer patients, and may be used orally or parenterally 5.
• Other treatments, such as exercise, behavioral therapy, and the use of fans, may also be effective in managing dyspnea, and should be considered as part of a multidisciplinary approach 6.

Considerations for Benzodiazepine Prescribing

• Benzodiazepines should be prescribed with caution in patients with COPD, and only for short-term use, due to the risk of dependence and adverse effects 3.
• Clinicians should carefully weigh the potential benefits and risks of benzodiazepine use in patients with dyspnea, and consider alternative treatments and therapies 2, 3.