Dyspnea

Short Answer

A. Incorrect. With an opioid-naive patient with episodic symptoms, the initial dosing should be a low dose of a short-acting agent prn. Codeine or hydrocodone would also be more appropriate given the prominence of cough as an additional symptom.

B. Correct! Codeine is effective for the management of dyspnea in this patient.

C. Incorrect. Benzodiazepines are often appropriate in the treatment of dyspnea when there is a significant anxiety component. However, functional limitation rather than anxiety appears to be the prominent manifestation of the dyspnea in this case, and codeine is more likely to be helpful.

D. Incorrect. Oxygen can often be helpful with dyspnea, but is less likely to be beneficial in this case, since significant desaturation does not occur with exertion. Codeine is more likely to help.

E. Incorrect. A pulse oximeter is unlikely to be helpful, since the patient only mildly desaturates with reproduction of her symptoms.


Long Answer

The correct answer is B. Codeine, 15-30 mg po q6h prn, to be taken 1/2 hr before desired activity.

Dyspnea can be debilitating and anxiety provoking, but it is often easily relieved. It can also be very distressing for caregivers. It is important to offer symptom management to patients and families as an alternative to the potential for intubation. Families may request intubation because alternative comfort measures are not made available. Common causes of dyspnea and their treatments can be remembered using the mnemonic BREATH AIR...

Dyspnea Cause...Treatment

B: Bronchospasm...Bronchodilators (albuterol, ipratroprium)

R: Rales (pulmonary edema)...Diuretics (furosemide 20-40 mg po)

E: Effusions, Embolism, Electrolytes (acidosis)...Consider thoracentesis/paracentesis. Consider evaluation vs. comfort care.

A: Airway obstruction...Consider evaluation with bronchoscopy and treatment with radiation or stenting if obstruction exists; or comfort care

T: Thick secretions...Suctioning, transdermal scopolamine q72h, guaifenesin 10-20 ml (100mg/5ml) po q4h

H: Hemoglobin low/hypoxemia...Consider transfusion/erythropoietin; oxygen if significant desaturation


A: Anxiety...Benzodiazepines, such as lorazepam 0.5-1 mg po q2-4h prn

I: Infection...Consider antibiotics for pneumonia

R: Religious/spiritual/interpersonal concerns...Social work/spiritual counselor intervention


Causes should be assessed and treated if the benefits outweigh the risks and discomfort, in light of the patient[base ']s prognosis and goals. This patient has no signs on exam of pneumonia, pleural effusion, or pulmonary edema. She does not complain of secretions, and did not have anemia or significant hypoxemia.

In a patient without other treatable causes (or where treatment does not completely relieve symptoms), who does not want intubation, and with significant disability and limited prognosis, opioids may be considered. A randomized, controlled trial (C Mazzocato et al. The effects of morphine on dyspnea and ventilatory function in elderly patients with advanced cancer: a randomized double-blind controlled trial. Ann Oncol 1999 Dec;10(12):1511-4 [abstract] showed that low doses of morphine relive dyspnea and do not affect respiratory function. Patients will become drowsy, confused, and comatose long before respiratory rate is compromised. Significant respiratory depression usually occurs when inappropriately high doses are given, particularly in an opioid-naïve patient, and dose escalation should be judicious. The risk of addiction is also unlikely in this situation.

As in the assessment of pain, it is important to ask the patient about the severity of the dyspnea (mild, moderate, or severe), its characteristics, and whether it is chronic or episodic. Objective findings (such as oxygen saturation or examination) may not correlate with symptoms. Patients who are dyspneic only with exertion may only require prn medications to be taken before activity is initiated. Since many patients with dyspnea experience anxiety along with shortness of breath, it is important to determine whether or not the complaint of dyspnea is really anxiety or if there is associated anxiety. For an anxiety component, benzodiazepines may be the most appropriate initial treatment or an important adjunct to other treatment. However, four out of 5 clinical trials of benzodiazepines for dyspnea without anxiety have shown no effect (E Bruera et al. Dyspnea in patients with advanced cancer. In: AM Berger et al, editors. Principles and practice of supportive oncology. Philadelphia: Lippincott-Raven Publishers; 1998. p. 295-308.)

As in pain, hydrocodone 5 mg q2-4h or codeine 15-30 mg po q2-4h is the most appropriate for mild dyspnea, especially if there is a significant cough component. Long-acting opioid preparations may be more appropriate in patients with chronic or night symptoms. Morphine (5-10 mg po) is more appropriate for severe symptoms, especially in patients with days or weeks to live, and IV morphine (2-4 mg) can be considered for acute episodes. Patients who are already on opioids should be given 25-50% of their 4-hour equivalent dose (25% is often effective). ( P Allard et al, How effective are supplementary doses of opioids for dyspnea in terminally ill cancer patients? A randomized continuous sequential clinical trial. J Pain Symptom Manage 1999 Apr;17(4):256-65 [abstract]. For example, if the patient is on 120 mg of long-acting morphine twice a day (240 mg total daily), the 4-hour opioid dose would be 240/6 or 40 mg, and the patient could be given 10-20 mg of oral morphine.

Nonpharmacologic treatments can also be helpful, including relaxation exercises, breathing exercises, reducing room temperature and humidifing air, eliminating smoke, treating psychosocial causes of anxiety or distress, and elevating the head of the bed (M Bredin et al, Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. BMJ 1999 Apr 3;318(7188):901-4).

Last update: 7/13/02; 3:38:34 PM.