The Advanced Practice Nurse's Role in Palliative Care and the Management of Dyspnea

Rose Anne Indelicato, MSN, APRN-BC, PCM-BC, OCN

Topics in Advanced Practice Nursing eJournal. 2006;6(4)

Conclusion

Given the opportunities provided by the model of palliative care, the APN is poised to fulfill the roles of expert clinician, supporter, and advocate for the patient and family facing life-threatening illness. The management of dyspnea can be complex, but by implementing comprehensive assessment, discussions related to goals of care, and appropriate pharmacologic and nonpharmacologic interventions, the APN can positively impact the quality of life for the patient and family.

1 2 3 4 5 6 7

Next Section

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

Comments

Commenting is limited to medical professionals. To comment please Log-in.

Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.