Palliation to achieve maximal patient comfort is the main
goal.
Simple things such as positioning in bed, opening the window, instituting
oxygen therapy, and reassurance are often very helpful.
Look for simple, easily correctable problems such as oxygen on/off, kinked
oxygen tubing or other cause.
Cool air flowing from a fan directed at the face have provided some benefit
(Bredin 1999).
Psycho-Social Interventions
Assess and treat for underlying anxiety and depressive disorders.
Consider supportive counseling.
Reassurance and provision of psycho-social support by providers and patient's
family are often helpful.
Non-pharmacological approaches such as cognitive behavior therapy, relaxation
therapy, art therapy, massage therapy, guided imagery may be of benefit.
Consider care-giver support as care-giver stress affects the patient and
also influences the patient's site of death (increased emergency room visits
and increased hospitalizations).
Rehabilitative Measures
Pulmonary rehabilitation should be considered in consenting patients who
have a life expectancy of months to years. Breathing exercises if the patient
is capable if the patient is able to cooperate (Bredin 1999).
Rehabilitative measures may not be a feasible option in terminally ill
patients with a life expectancy of days to weeks. Such patients should be
encouraged to use a wheelchair and to rest.
Patients who have not stopped smoking should not be pressured to stop
at this time (as smoking may be one of the few remaining pleasures that
the patient experiences in the last few days of their lives).
Pharmacotherapy to alleviate dyspnea
Treatment of underlying cause
Problem
Drug intervention
Broncho-constriction
Albuterol and ipratropium bromide inhalers and nebulizers
Fluid overload
Diuretics
Cough
Anti-tussives and opioids (opioids help alleviate pain, dyspnea and cough)
Dyspnea secondary to end stage COPD with acute exacerbations
Steroids
Dyspnea secondary to Superior Vena Cava Obstruction
Steroids
Dyspnea secondary to lymphangitic carcinomatosis.
Steroids
CHF therapy optimization
Diuretics and afterload reduction
Anxiety and depression
Anxiolytics for patients who are anxious despite optimal management
of dyspnea.
Selective Serotonin Reuptake Inhibitors (SSRIs)
Anxiety and depression with panic attacks
Selective Serotonin Reuptake Inhibitors (SSRIs) in conjunction with benzodiazepines
Pneumonia or other infectious processes when intended for relieving dyspnea
Antibiotics
Terminal pneumonia
Note: Antibiotics are often not helpful in actively dying patients, many
of who may have "terminal pneumonia" in the last two or three
days of life. These patients should be managed symptomatically with supplemental
oxygen via nasal cannula, opioids to relieve dyspnea, anxiolytics for any
anxiety and drugs like atropine, scopolamine and glycopyrrolate to decrease
secretion (please see module on "last 48 hours")
Symptom palliation
Problem
Drug intervention
Dyspnea not responding to other interventions
Opioids (oral and parenteral) are the drugs of choice for palliation.
Palliation of dyspnea with opioids is often achieved with lower doses
of opioids than are usually required for palliation of pain. Start low
and go slow, in opioid naive patients (Abernethy
2003).
Higher doses will be needed for patients on chronic opioids (50% >
baseline).
Parenteral opioids (8) may be indicated for patients in acute dyspnea
(e.g. morphine 0.5 to 1 mg IV or SC Q 10-20min until relief or consider
low dose continuous infusion).
There is some anecdotal evidence that nebulized opioids, especially inhalational
fentanyl may be beneficial in acutely dyspneic patients (Chandler
1999) (Tanaka 1999) (Sarhill
2000) (Coyne 2002).
Anecdotal evidence has shown that nebulized furosemide may be helpful
(Shimoyama 2002).
Nicotine craving
Nicotine patches should be considered for smokers who are dying and
too weak to smoke, but may still have the craving induced by nicotine
addiction. The intent of the nicotine patch in these cases is palliation
and not smoking cessation.
A clonidine patch is also helpful in these situations as it decreases
the craving for nicotine while also serving as an adjuvant analgesic.
