Elevate the head of the bed and place an electric fan which blows
air gently on his face.
Bedside Fan: A gentle breeze from a bedside fan directed at the patient’s
face can help alleviate dyspnea (Rousseau
1996). This effect is thought to be mediated by stimulation of the thermal
and mechanical receptors of the trigeminal nerve in the cheek and nasopharynx
(Enck 1994)(Dudgeon
1996).
Morphine sulfate tablets 5mg orally every 4 hours as needed.
Decreasing ventilatory drive to both hypoxia and hypercapnia.
Reducing oxygen consumption at rest and during exercise.
Albuterol and ipratropium hand held nebulizer treatment as needed.
Incorrect interventions
Nebulized morphine in a saline solution
Patient has a h/o of bronchial asthma and wheezing by physical exam. Nebulized
opioids may precipitate the release of histamine from the pulmonary mast
cells and worsen dyspnea by causing bronchoconstriction.
Non-breather mask with 100% oxygen
The patient has a SaO2 of 100%. While supplemental oxygen
is usually helpful in patients with low oxygen saturation it may not be
very helpful in patients with normal oxygen saturation. It is not routinely
indicated in all dyspneic patients. A trial of supplemental oxygen may
be indicated using a nasal cannula. The Medicare Hospice Benefit will
pay for a room-air concentrator for supplemental oxygen as a part of the
routine hospice benefit. Medicare certified home hospices will provide
a room-air concentrator as a part of their routine service for all terminally
ill patients. No additional testing (SaO2 = 88% or PaO2< 55%) is needed or required to justify the room-air concentrator.
See Rules Governing SupplementalOxygen
below.
Diazepam 5 mg every 8 hours
Benzodiazepines are frequently used to alleviate dyspnea in patients
with advanced illness when the dyspnea has been optimally treated with {bronchodilators,
opioids} and if the patient is anxious secondary to dyspnea. A trial of
low dose short acting benzodiazepines {lorazepam 0.5-1mg every 4-6 hours
as needed} is indicated in the anxious patient who is dyspneic. There is
no evidence that Mr. Silver is anxious at this time.
Rules Governing Supplemental Oxygen
CMS classifies oxygen and oxygen delivery equipment as durable medical
equipment (DME); this definition allows oxygen to be reimbursed as a form
of "medical equipment." As a result, a specific Certificate of
Medical Necessity (CMN) called the HCFA–484 must be completed by the
physician in order for oxygen therapy to be reimbursed at a level of 80 percent
of the Medicare allowable charge. The patient or supplemental insurance is responsible
for the remaining 20 percent of the cost.
