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

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

First things First

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

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

Oxygen Therapy

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

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

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

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

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

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.

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

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.

Kamal et al. 2012

Summary of Interventions