What is the best treatment for dyspnea (air hunger) in a hospice patient with a terminal illness?

Treatment of Air Hunger in Hospice Patients

Opioids are the mainstay and most effective pharmacological treatment for air hunger in hospice patients, with morphine 2.5-10 mg PO every 2 hours PRN (or 1-3 mg IV every 2 hours PRN) for opioid-naïve patients, and a 25% dose increase for those already on chronic opioids. 1

Pharmacological Management

First-Line: Opioids

Opioids are the only pharmacological agents with sufficient evidence for dyspnea palliation and reduce the unpleasantness of air hunger without causing clinically significant respiratory depression when properly dosed. 1 The evidence supporting opioids has been demonstrated in numerous clinical trials. 2

Dosing for opioid-naïve patients:

• Morphine 2.5-10 mg PO every 2 hours PRN 1
• Morphine 1-3 mg IV every 2 hours PRN 1
• Use "low and slow" IV titration, repeated every 15 minutes until relief is achieved 2

Dosing for patients on chronic opioids:

• Increase current opioid dose by 25% 2, 1
• Consider around-the-clock dosing if dyspnea is continuous or present at rest, with PRN dosing for episodic dyspnea 2

Critical point: Do not reduce opioid doses solely based on decreased respiratory rate, blood pressure, or level of consciousness when opioids are necessary for adequate symptom control in dying patients. 3 Fears of respiratory depression are often exaggerated and should not prevent adequate symptom management. 2, 3

Adjunctive: Benzodiazepines

Benzodiazepines should be added when air hunger is associated with anxiety or panic, or when opioids alone provide insufficient relief. 2, 1 They are not effective as primary treatment for dyspnea but work well as adjuncts. 2

Dosing for benzodiazepine-naïve patients:

• Lorazepam 0.5-1 mg PO every 4 hours PRN 1, 3
• Titrate to effect based on patient response 2

Managing Secretions (Death Rattle)

Excessive secretions can worsen the sensation of air hunger and cause distressing noisy breathing for families. 2

Anticholinergic options:

• Glycopyrrolate 0.2-0.4 mg IV or subcutaneous every 4 hours PRN - preferred because it does not cross the blood-brain barrier and is less likely to cause delirium 2, 3
• Scopolamine 0.4 mg subcutaneous every 4 hours PRN, or 1.5 mg patches (1-3 patches every 3 days) 3
• Important caveat: Transdermal scopolamine patches have a 12-hour onset and are inappropriate for imminently dying patients 2, 1
• Atropine 1% ophthalmic solution 1-2 drops sublingual every 4 hours PRN 3

Non-Pharmacological Interventions

Handheld Fan (Strongly Recommended)

Direct a handheld fan toward the patient's face - this simple intervention has been shown in randomized controlled trials to reduce breathlessness and provides immediate relief. 2, 1 Cooling the face stimulates facial receptors that can alleviate the sensation of air hunger. 1

Positioning

• Elevate the upper body or use the "coachman's seat" position 1
• Position for comfort rather than optimal respiratory mechanics in dying patients 3

Oxygen Therapy (Use Selectively)

Oxygen should only be used if the patient is hypoxemic AND reports subjective relief. 3 Evidence shows:

• No predictable relationship exists between degree of hypoxemia and symptomatic response to oxygen 2
• Patients with advanced lung disease who are not hypoxemic receive no benefit from oxygen compared to room air 2
• Patients near death remained comfortable without oxygen 2
• Do not continue oxygen therapy based solely on oxygen saturation numbers - the patient's subjective experience is what matters 3

Environmental Modifications

• Maintain cooler room temperatures 3
• Ensure adequate airflow in the room 1

Treatment Algorithm Based on Life Expectancy

As life expectancy decreases, the role of mechanical ventilation and oxygen diminishes while the role of opioids, benzodiazepines, glycopyrrolate, and scopolamine increases. 2

For Patients with Days to Weeks to Live:

1. Start with opioids at doses listed above 1
2. Add benzodiazepines if anxiety is present or opioids insufficient 1
3. Use handheld fan directed at face 1
4. Manage secretions with glycopyrrolate or scopolamine 3
5. Consider oxygen only if hypoxemic and patient reports relief 3

For Imminently Dying Patients:

1. Aggressive opioid titration - do not hesitate to increase doses rapidly for comfort 3
2. Continue or increase opioids regardless of respiratory rate, blood pressure, or consciousness level 3
3. Add benzodiazepines liberally for anxiety or refractory symptoms 3
4. Manage secretions with immediate-acting agents (avoid transdermal scopolamine) 1
5. Focus on comfort measures - fan, positioning, family presence 3

Critical Pitfalls to Avoid

Do not withhold adequate opioid doses due to exaggerated fears of respiratory depression. 2, 3 This is the most common error and leads to unnecessary suffering. 3

Do not allow distressing symptoms to persist as a way to maintain blood pressure or stimulate respiratory effort. 2 The goal of hospice care is comfort, not physiologic parameters. 3

Do not use transdermal scopolamine patches for imminently dying patients - the 12-hour onset makes them inappropriate. 2, 1

Do not rely on oxygen therapy alone - it is not effective for non-hypoxemic patients and should not replace opioids as primary treatment. 2, 3

Family Education and Support

Provide proactive education to families that changes in breathing patterns, including slow or irregular breathing (agonal breathing), are normal parts of the dying process and do not indicate suffering. 3 Reassure families that the patient is not experiencing agony when exhibiting these patterns. 3 Explain that medications are being given for comfort, not to hasten death. 3

Palliative Sedation for Refractory Symptoms

If air hunger remains refractory despite optimal opioid and benzodiazepine management, consider palliative sedation after consultation with palliative care specialists and careful discussion with the patient (if able) and family about goals of care. 3