Palliative Dyspnea

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Managing dyspnea in the palliative patient.

This comes down to 4 approaches:

  • Oxygen

  • Opiates

  • Benzodiazepenes

  • Addressing the underlying issue

  • Other measures of comfort

Oxygen

  • Several options here with pro's and con's to all

  • Nasal Cannula 

    • Comfortable at low flows

    • Limited in how much oxygen it can deliver as it provides no reservoir of oxygen; it depends on the patient's upper airway as the reservoir of oxygen

    • at high flow rates is uncomfortable and causes dryness and bleeding unless delivered with a humidifier)

    • Many patients mouth breathe at the end of life

  • Non-rebreather

    • provides more oxygen, enables oxygen delivery to mouth breathers

    • Uncomfortably noisy, must be drawn tightly against the face to be most effective

    • muffles communication at a time when it is of key importance in the dying patient

    • Dries patient's mouth and nares out

  • Venturi Mask

    • An underutilized therapy

    • Addresses mouth breathing

    • Mixes oxygen with room air

    • Able to provide relatively high flow rates of oxygen 

    • Does not need to be humidified as high flow rates of oxygen are mixed with ambient room air

  • High-flow nasal cannula

    • Comfortably provides humidified oxygen at extremely high rates

    • Does not provide oxygen to mouth breathers

    • If the patient is being admitted it requires admission to the MICU (or potentially PAMCU)

  • Non invasive ventilation (Bipap)

    • Noisy, uncomfortable, frightening

    • Decreases the ability to commmunicate

Opioids

  • THE KEY TO PALLIATIVE DYSPNEA

  • Can be delivered via the subcutaneous route, another underutilized therapy

  • Administer zofran to offset possible associated nausea

  • Decrease the intensity of air hunger and dyspnea related anxiety

  • Have been shown to NOT SHORTEN LIFE IN PALLIATIVE PATIENTS, which is important to communicate to the dying patient's family. 

Benzodiazepenes

  • Anxiety leads to worsening dyspnea; managing the anxiety therefore aids in management of dyspnea

  • Generally not used as monotherapy, however can be used in addition with opiates in the anxious and dyspneic patient

Other measures

  • Position the patient as they wish, though generally the more upright patient is the more comfortable patient

  • Death rattle: As patients lose consciousness they lose their ability to swallow and oral secretions can pool, causing gurgling noises. There is no evidence that this is disturbing to patients, but families often have a very hard time with these noises.

    • Glycopyrrolate can help mitigate this disturbing noise

Cause specific techniques = address the underlying issue

  • Must weigh the benefits vs. the discomfort of performing these interventions

  • Pleural effusions: Thoracentesis

  • Anemia: Transfusion

  • Obstructing airway mass: Steroids, palliative radiation if available

  • Pneumonia: Antibiotics

  • Fluid overload: Diuresis

  • Bronchospasm: Bronchodilators

See:

https://first10em.com/palliative-resuscitation-dyspnea/

https://www.rtmagazine.com/products-treatment/monitoring-treatment/therapy-devices/oxygen-administration-best-choice/

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