1. “I can’t breathe”: The Challenge of Dyspnea
Comprehensive Approach to Dyspnea Management
Pawandeep Brar
Palliative Care Physician

2. Objectives Review Non-Pharmacological Treatment of Dyspnea
Review Pharmacological Treatment of Dyspnea
Review Interventional Approach to Dyspnea

3. First things First

4. Electrice Fan
Simple interventions based on movement of air may relieve dyspnea for certain patients
An RCT of a hand-held electric fan directed toward the face versus toward the leg for 5 minutes showed significant decrease I dyspnea when the moving air was directed toward the face

5. Oxygen Therapy Oxygen reverses dyspnea caused by hypoxemia
Limitations: many dyspneic pts are not hypoxemic
Hypoxemia is a weaker stimulus for dyspnea than hypercarbia

6. Oxygen Therapy

7. Pharmacological Approach: Opioids
First line of therapy for symptomatic control
Opioid Receptors in central/peripheral nervous system as well as tracheobronchial tree
Effects postulated to be secondary to their effects on ventilatory response to carbon dioxide, hypoxia, inspiratory flow resistive loading

8. Pharmacological Approach: Opioids
Dosing of opioids:
If opioid naïve begin with low dose of 2.5-5mg morphine equivalent q4h & titrate to effect
If on opioids, increase current dose by 20-25% & titrate to effect

9. Pharmacological Approach:Opioids
Concerns re Opioids
fear of respiratory depression & accelerated death
Opioids have been used for many years to decrease dyspnea
Fear has been shown to be largely unfounded

10. Pharmacological Approach: Benzodiazapines
Benzodiazepines are commonly prescribed for anxiety related to dyspnoea.
evidence for their effectiveness is not persuasive
treatment of anxiety does have a role in a subset of patients for whom it is a prominent component of the distress

11. Pharmacological Approach: Benzodiazepines
Lorazepam: 0·5–1·0 mg/h orally until settled, then dose routinely every 4–6 h to keep settled
Diazepam: 5–10 mg/h orally until settled, and then dose routinely every 6–8 h
Clonazepam: 0·25-2·00 mg orally every 12 h
Midazolam: 0·5 mg intravenously per 15 min until settled, then by continuous subcutaneous or intravenous infusion

12. Pharmacological Approach: Other
Glucocorticoids useful in bronchospasm, superior vena cava syndrome, carcinomatous lymphangitis and radiation pneumonitis.
Antibiotics may be appropriate for infections.
Anticoagulants can prevent and treat thrombotic pulmonary emboli.
Bronchodilators such as salbutamol and ipratropium treat reversible bronchospasm.

13. Complementary Approach
Counselling & support
Complementary therapies
Relaxation training
Tai chi
Yoga
Hypnosis
Therapeutic touch
accupuncture

14. Interventional Approach
Obstruction can be treated locally with laser therapy, cryotherapy, or stenting.
Malignant pleural effusions can be drained by thorocentesis, and if they recur, pleurodesis may be attempted. Fluid drainage may improve the mechanical advantage of the respiratory muscles to relieve dyspnoea.

15. Kamal et al. 2012

16. Summary of Interventions