DYSPNEA MANAGEMENT
Always treat underlying cause + manage patient’s report of shortness of breath (SOB), not respiratory rate Mild SOB Non-pharmacologic Moderate SOB Opioids PRN Severe SOB Opioids ER + PRN Extreme / Refractory SOB Benzodiazepines • Pulmonary rehabilitation & education
When opioids ineffective, use benzodiazepines as • Anxiolytic / sedatives • Amnestics • Skeletal muscle relaxants Start PRN dosing, titrate using ‘catchup technique’ Lorazepam 1‒2 mg PO/Buccal q1H PRN 1‒2 mg SC q30min PRN or 1‒2 mg IV q15min PRN Maintenance = 50% of total dose in 24 hours q12H (t ½ = 12 hr) Typically 2‒10 mg / 24 hr or equivalent with an alternate benzodiazepine Midazolam Loading dose 0.2 mg/kg IV/SC Maintenance dose 0.075 mg/kg/hr IV/SC
Like pain management, calculate opioid use in 24 hr and offer as Morphine or Oxycodone ER PO q8‒12h + 10‒20% of 24 hr total dose as IR PO q1H PRN Anxiety If anxious, consider adding Trazodone 50‒100 mg PO q1H PRN (especially in elderly) Clonazepam 0.25 mg PO q24H (longer acting steady plasma levels) Lorazepam 0.5 mg PO/SL q12H
Opioids most often relieve SOB without respiratory drive Caution, not contraindication, if obesity or sleep apnea In naïve patients, typically Morphine IR 30‒60 mg / 24 hr or equivalent Start PRN dosing, titrate using ‘catchup technique’ to relief of SOB, not respiratory rate Morphine IR 5 mg PO q1H PRN or 2 mg SC q30min PRN or 2 mg IV q15min PRN Hydromorphone IR 1 mg PO q1H PRN or 0.3 mg SC q30min PRN or 0.3 mg SC q15min PRN Oxycodone IR 5 mg PO q1H PRN
• Fan to face relieves SOB through stimulation of baroreceptors of Cranial Nerve V (facial nerve)
• Open window, cool air • Relaxation techniques • Positioning • Pursed-lip breathing • Acupuncture
Oxygen • Potent symbol of medical care, only useful when % saturation or pO2 • For other causes, fan to face or compressed air via nasal canula may be equally effective
23 NB: These Reference Cards do not replace careful clinical judgment specific to each patient / family situation. PCIC: Palliative Care Interdisciplinary Curriculum is a collaborative effort of OhioHealth, The Ohio State University Wexner Medical Center, and Nationwide Children’s Hospital in Columbus, Ohio, USA, and other contributors. Permission to reproduce any or all of these PCIC Reference Cards is granted for non-commercial educational purposes only, provided that the attribution statement and copyright are displayed. To reproduce for all other purposes, contact Frank D. Ferris at info@pallmed.us. Copyright © Frank D Ferris 2013-2024. All rights reserved. V14.1, 2024
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