Dyspnea

KEYPOINTS

  • Dyspnea has a prevalence of 50% in people with any type of cancer (not just lung cancer)
  • Dyspnea is moderate to severe in more than 28% of terminally ill cancer patients
  • Opioids (e.g. morphine) play an important and effective part in the management of dyspnea
  • Dyspnea (like pain) is a subjective symptom and therefore it is important to ask the patient about their feelings of dyspnea rather than rely on clinical exam findings
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  • Breathlessness is common in children in the terminal stages of life

ASSESSMENT

(see Foreword)

  • A good clinical assessment is important to try and identify the underlying cause of the dyspnea (e.g. pneumonia, CHF, pleural effusion, etc.)
  • Investigations to consider may include:
    • Chest x-ray to assess possible chest disease
    • CBC to rule out anaemia or infection
    • Oxygen saturation (not necessarily arterial blood gases) can sometimes be helpful
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  • Dyspnea (like pain) is a subjective experience, so simply asking a child ‘is your breathing troubling you?’ can be very helpful in assessment. However, tests such as carbon dioxide/oxygen saturation or spirometry have not been shown to relate closely to the actual experience of dyspnea
  • Validated assessment tools for children suffering from dyspnea are available e.g. the Dalhousie Dyspnea Scale

MANAGEMENT

  • Consider treatment of the underlying cause (e.g. oncological treatment of tumour, draining of pleural effusion, treatment of infection, COPD, CHF, etc.)
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Consider if patient is well enough to benefit

  • Simple measures such as repositioning, opening a window or providing a fan and relaxation techniques can be very helpful
  • Ensure patients do not "feel trapped” by being crowded by people and equipment
  • Oxygen may or may not be helpful for dyspnea and is not necessary for all patients. For some patients it may make their feeling of dyspnea worse to have their face covered by an oxygen mask or nasal prongs. Treat the patient’s symptoms, not the lab test (i.e. the oxygen saturation)
  • Fresh air may be as helpful as oxygen for many patients
  • Morphine and other opioids are an effective treatment for dyspnea. The initial starting dose will depend on the patient’s previous exposure to opioids
    • A dose of morphine 2.5 mg regularly q4h PO (or 1 to 2 mg SC/IV) and a breakthrough or rescue dose as required (see Breakthrough or Rescue Doses of Morphine) is suitable for an opioid-naive patient
    • A dose of morphine 5-10 mg regularly q4h PO (or 2.5–5 mg q4h SC/IV) and a breakthrough or rescue dose as required (see Breakthrough or Rescue Doses of Morphine) should be used for patients who have already been on codeine
    • Patients who are already on strong opioids for pain will usually benefit from an increase in their regular dose
    • Titrate morphine in the same way as for pain management (see Pain). Some patients may require high doses for dyspnea. Benzodiazepines, corticosteroids and bronchodilators may also be helpful
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  • Correctable causes of dyspnea in children such as anaemia, infection and effusion can be treated
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Consider if patient is well enough to benefit
  • As with adults, opioids such as morphine are accepted as an important and effective treatment for dyspnea in advanced cancer and other diseases
  • Morphine
    • Starting doses for opioid naïve infants less than 6 months: 0.01 mg/kg q4h SC/IV or 0.02 mg/kg q4h PO
    • Starting dose for opioid naïve infants/children more than 6 months: 0.02 mg/kg q4h SC/IV or 0.04 mg/kg q4h PO
  • Benzodiazepines, corticosteroids and bronchodilators are also useful
  • Lorazepam
    • 25-50 mcg/kg (max 1 mg) as single dose or q4-8h PO/SL/SC
  • Midazolam
    • 500 mcg/kg (max 10 mg) SL as single dose
    • 100 mcg/kg SC as a single dose
    • 300-700 mcg/kg over 24 hours as continuous SC infusion
  • Dexamethasone
    • 2-5 years: 0.5-1 mg bid PO/IV (if IV give over 3-5 minutes)
    • 5-12 years: 1-2 mg bid PO/IV (if IV give over 3-5 minutes)
  • Salbutamol (Ventolin) nebulizer solution
    • 6 months-5 years: 2.5 mg prn/q4h
    • 5-12 years: 5 mg prn/q4h via nebulizer
  • Ipratropium (Atrovent) nebulizer solution
    • 1-5 years: 125 mcg prn/q6h
    • 5-12 years: 250 mcg prn/q6h via nebulizer

PITFALLS/CONCERNS

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In patients in the final terminal phase – i.e. hours to days, antibiotics will make little difference to the course of events even if infection is suspected. Intubation is not appropriate for palliative care patients

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  • Fear of using opioids in children can result in unnecessary suffering at the end of life

PALLIATIVE TIPS

  • Remember to ask the patient about their feelings of dyspnea – physical examination findings and medical staff’s observations of tachypnea or perceived difficulty in breathing do not always correlate with the level of distress
  • Educating the patient about dyspnea can reduce the anxiety that patients feel when short of breath
  • Sedation may be needed in severe cases
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  • Psychological treatment such as reassurance by adults and calm surroundings are helpful
  • As with adults, supplemental oxygen titrated to comfort can be helpful

SOURCES/REFERENCES

  1. Downing GM, Wainwright W, editors. Medical care of the dying. 4th ed. Victoria (BC): Victoria Hospice Society; 2006. p. 365-376.
  2. Pianosi P, McGrath PJ, Smith C. Four pictorial scales to evaluate dyspnea in children. Am J Resp Crit Care Med 157 (Suppl), A782.
  3. NHS Clinical Knowledge Summaries. Palliative cancer care - dyspnoea. [Online]. Available from: URL:http://cks.library.nhs.uk
  4. Ripamonti C, Fulfaro F, Bruera E. Dyspnea in patients with advanced cancer; incidence, causes and treatments. Cancer Treat Rev 1998;24(1):69-80. http://www.ncbi.nlm.nih.gov/pubmed/9606369
  5. Ripamonti C. Management of dyspnea in advanced cancer patients. Support Care Cancer 1999;7:233-243. http://www.ncbi.nlm.nih.gov/pubmed/10423049
  6. Twycross R. Palliative care formulary. 2nd ed. Oxford: Radcliffe Publishing; 2002. p. 59-61.
  7. Wolfe J, Grier HE, Klar N, Levin SB, Ellenbogen JM, Salem-Schatz S et al. Symptoms and suffering at the end of life in children with cancer. N Engl J Med 2000;342:326-333. http://www.ncbi.nlm.nih.gov/pubmed/10655532

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