Palliative Care and the Management of Dyspnea

Nonpharmacologic Interventions in the Management of Dyspnea

In addition to pharmacologic interventions and oxygen, there are a number of nonpharmacologic strategies that can be beneficial in the management of dyspnea. By changing a patient's physical environment and educating patients and their caregivers about some of these nondrug therapies, the APN can offer the patient a sense of control and an arsenal of strategies that, when added to medication management, may have a positive impact on the experience of breathlessness.

Patients may benefit from sitting upright in bed or a chair. They may also obtain relief from sitting on the edge of a bed, resting their upper body on a bedside table.^[14] Additionally, patients should be educated to prioritize and pace activities. Premedication with an opioid or a bronchodilator before engaging in any strenuous activities (eg, bathing, eating, walking) also may improve outcomes.

Pursed lip breathing promotes movement of air out of the lungs and increases airway pressure, thereby keeping the airway open.^[72] Slow breaths decrease respirations, allowing for less tiring and more efficient breathing.^[3,48,73] Teach this technique to a patient or caregiver, following these steps:

Begin with relaxing neck and shoulders,
Close your mouth and inhale slowly through your nose
Purse your lips as if you were going to whistle and exhale slowly over a count of 3.^[72]

Patients who experience dyspnea appear to benefit from a cool, smoke-free and dust-free room with low humidity. Breeze from an open window or from a fan directed toward a patient's face may lessen the sensation of breathlessness.

This phenomenon may be explained by the physiologic stimulation of the V2 branch of the fifth cranial nerve, creating a centrally inhibitory effect on the sensation of dyspnea.^[74]

In addition, the use of durable medical equipment such as a hospital bed, portable oxygen, walker, wheelchair, bedside table, or bedside commode may limit exertion, thus decreasing breathlessness.^{[27,48,73,75]}

Anxiety can be a significant cause and exacerbating factor in the occurrence of dyspnea. Some techniques that may assist a patient in coping with the emotional component of dyspnea include progressive muscle relaxation, guided imagery, and distraction.^[73,76]

Corner and colleagues^[77] implemented a nurse-run clinic that included counseling, breathing retraining, relaxation, and education related to coping and adaptation strategies for 20 patients with advanced lung cancer who were experiencing dyspnea. Distress from breathlessness was improved by a median of 53%, while the control group's distress worsened by 10%.

Music therapy also can help patients reduce their respiratory rates and may play an important role in the management of breathlessness, although further research is needed.^[60]

Finally, acupressure or acupuncture also may provide benefit in the management of dyspnea. In one study, cancer patients who had acupuncture needles applied to sternal points experienced improvements in breathing, the ability to relax, a reduction in anxiety, and a 90-minute to 6-hour decrease in respiratory rate.^[78] In a more recent, single-blind, randomized crossover study, acupuncture was compared with placebo in patients with disabling, nonmalignant breathlessness. Although the acupuncture did not show specific efficacy, those patients entered into the study did experience clinically significant benefit from both treatments.^[79]

Cite this: The Advanced Practice Nurse's Role in Palliative Care and the Management of Dyspnea - Medscape - Dec 31, 2006.

Etiology of Dyspnea ^[1,15,16]
Physiologic System	Disorder
Pulmonary	Asthma
	Adult respiratory syndrome
	Bronchial obstruction
	COPD (bronchitis, emphysema)
	Cystic fibrosis
	Interstitial lung disease
	Lung cancer
	Patient/ventilatory asynchrony
	Pleural effusion
	Pneumonia
	Pneumothorax
	Pulmonary embolism
	Chemotherapy toxicity
	Chest wall fractures related to metastatic disease
Cardiovascular	Congestive heart failure
	Fluid overload
	Superior vena cava syndrome
	Arrhythmias
	Cardiomyopathies
	Valvular or pericardial disease
	Congenital abnormalities
	Chemotherapy toxicity
Hematologic/Metabolic	Anemia
Hematologic/Metabolic	Electrolyte abnormalities
Neuromuscular	ALS
	Muscular dystrophy
	Multiple sclerosis
	Myasthenia gravis
	Reduced respiratory muscle force (deconditioning)
Psychological/Spiritual	Anxiety
	Depression
	Spiritual distress

ALS = amyotrophic lateral sclerosis; COPD = chronic obstructive pulmonary disease.

Scheduling of Opioids for the Management of Dyspnea ^{[1,41,60,80,81]}
	Opioid Naive*	Opioid Tolerant*
Mild dyspnea	Hydrocodone (5 to 10 mg) or codeine (30 mg) orally every 4 hours	Increase dose by 25% to 50%
Severe dyspnea	Morphine sulfate 5 mg orally every 4 hours, or oxycodone 5 mg orally every 4 hours, or hydromorphone 1 mg orally every 4 hours	Increase dose by 25% to 50%
Severe dyspnea	Parenteral morphine 2.5-5.0 mg subcutaneously or intravenously every 3-4 hours	Increase dose by 25% to 50%
Titration	Increase orally by increments of 50% to 100% every 24 hours as needed; titrate parenterally to effect	Increase by increments of 50% to 100% every 24 hours as needed

*If a patient is elderly or has severe pulmonary disease, such as COPD, start at 50% of the above doses and titrate more conservatively with increments of 25%. If the patient requires frequent dosing, the 24-hour total can be calculated and then converted into a sustained-release preparation, with the availability of a short-acting breakthrough dose every 2 hours as needed.

Benzodiazepine Therapy for the Management of Dyspnea ^[1,24]
Benzodiazepine	Dosage and Titration
Short-acting Formulations
Lorazepam	Starting dose: 0.5 to 1.0 mg orally every hour until the symptom is controlled, with routine dosing every 4-6 hours thereafter
Midazolam	Starting dose: 0.5mg IV every 15 minutes until dyspnea is controlled, then maintenance of a continuous subcutaneous or intravenous infusion
Long-acting Formulations
Diazepam	Starting dose: 2-10 mg orally every hour, then routinely every 6-8 hours
Clonazepam	Starting dose: 0.25-2.0 mg orally every 12 hours

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