What are the appropriate breathing treatments for a patient with a history of cancer presenting with dyspnea (difficulty breathing)?

Management of Dyspnea in Cancer Patients

For a cancer patient presenting with dyspnea, immediately assess symptom intensity and treat underlying reversible causes (pleural effusions, bronchospasm, anemia) while simultaneously initiating symptomatic relief with opioids and nonpharmacologic measures such as fans directed at the face. 1

Initial Assessment and Reversible Causes

Assess symptom intensity first using the patient's subjective report, as physiologic parameters correlate poorly with the patient's actual experience of breathlessness. 1, 2 In noncommunicative patients, use labored breathing or other physical signs of dyspnea as markers. 1

Identify and treat underlying causes based on prognosis:

For Patients with Life Expectancy of Years:

• Anticancer treatments: Radiation therapy or chemotherapy for tumor-related dyspnea 1
• Therapeutic procedures: Drainage of pleural, cardiac, or abdominal fluid 1
• Bronchoscopic therapy for airway obstruction 1
• Medications for comorbidities: Bronchodilators (albuterol 2.5-3 mg via nebulizer over 5-15 minutes for bronchospasm), diuretics for fluid overload, steroids for inflammation, antibiotics for infection, or transfusions for anemia 1, 3
• Anticoagulants for pulmonary emboli, which must be considered in all cancer patients with acute dyspnea 1, 2

Symptomatic Management: Nonpharmacologic Interventions (First-Line)

These interventions should be initiated immediately for all patients regardless of prognosis:

• Handheld fans directed at the face have proven effectiveness in reducing breathlessness 1
• Cooler room temperatures and opening windows 1
• Optimal positioning: Elevate the upper body or use the "Coachman's seat" position 1
• Educational and psychosocial support for patient and family regarding breathing techniques and stress management 1

Pharmacologic Management

Opioids (Primary Pharmacologic Treatment)

Opioids are the only pharmacologic agents with sufficient evidence for dyspnea palliation and should be used when nonpharmacologic measures are insufficient. 1, 2

Dosing for opioid-naive patients:

• Oral morphine: 2.5-10 mg PO every 2 hours as needed 1
• IV/subcutaneous morphine: 1-3 mg IV or subcutaneous every 2 hours as needed 1

For patients already on chronic opioids: Increase the dose by 25% 1

For acute progressive dyspnea: More aggressive titration may be required 1

Benzodiazepines (Adjunctive for Anxiety-Associated Dyspnea)

Add benzodiazepines only if dyspnea is not relieved by opioids AND is associated with anxiety, as evidence for their effectiveness is weak. 1, 2, 4

Dosing for benzodiazepine-naive patients:

• Lorazepam: 0.5-1 mg PO every 4 hours as needed 1

Oxygen Therapy

Oxygen is indicated only for symptomatic hypoxia or if the patient reports subjective relief. 1, 2 Supplemental oxygen is also beneficial in patients with concurrent chronic obstructive pulmonary disease. 2

Management Based on Life Expectancy

Months to Weeks:

• Continue all above interventions 1
• Consider noninvasive positive-pressure ventilation (CPAP, BiPAP) if clinically indicated for severe reversible conditions 1
• Intensify palliative care interventions and consult specialized palliative care services or hospice 1

Weeks to Days (Dying Patient):

• Focus exclusively on comfort 1
• Reduce excessive secretions with:
  • 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 (preferred as it does not cross blood-brain barrier and causes less delirium) 1
• If fluid overload contributes: Decrease or discontinue enteral/parenteral fluids and consider low-dose diuretics 1
• Consider sedation for intractable symptoms 1

Critical Pitfalls to Avoid

Do not use nebulized opioids - currently available evidence does not support their clinical use despite theoretical appeal. 4

Do not delay opioid initiation - opioids are safe and effective for refractory dyspnea and are significantly underused in cancer patients. 1, 2

Do not rely on oxygen for non-hypoxemic patients unless they report subjective benefit, as dyspnea correlates poorly with oxygen saturation. 1, 2

Be aware that scopolamine patches have a 12-hour onset and are inappropriate for imminently dying patients; use subcutaneous injection instead. 1