1. What can we do to Palliate Dyspnea? Steve Dupuis DO Faith Hospice Associate Medical Director

2. Life is not measured by the number of breaths we take, but by the moments that take our breath away.... Anonymous

3. Objectives Review the common treatments that our colleagues have already tried Explore more creative modalities that our colleagues expect of us Share our expertise Create an update for WMMD manual

4. Dyspnea is not.... Tachypnea which is rapid breathing Hyperpnea which is increased ventilation in proportion to metabolism Hyperventilation which is ventilation in excess of metabolic requirement Comroe 1966

5. Dyspnea is instead…. ….difficult, labored, uncomfortable breathing; it is an unpleasant type of breathing, though it is not painful in the usual sense of the word. Comroe 1966

6. Dyspnea It is subjective, and like pain, it involves both the perception of the sensation by the patient and their reaction to the sensation…. Comroe 1966

7. Prevalence Reported to occur in 21-70% of all terminally ill patients National Hospice Study 25% patients experiencing breathlessness did not have underlying pulmonary diseases

8. Management

9. Oxygen Should be offered in any circumstance of dyspnea but no studies that show it to be any more effective than…. Environmental changes: Cool humidified air Circulating fan Fowler’s position Pursed lip breathing

10. Reassurance Calming, relaxation techniques Breathing exercises Music therapy Aromatherapy Social Work Chaplain

11. Nebs Duonebs q 3hrs & prn Decadron 4mgs q 4hrs For Pulmonary Edema 4 mls 50% Ethyl Alcohol/Vodka 3 treatments q 15 minutes & repeat 6-8 hrs

12. Nebulized Furosemide Bronchodilatory effects Inhibition of irritant-receptors of the lung Rocker, Horton 2010 Inhibition of stretch receptors (vagal nerve) Shimoyama, JPSM 2002 Anti-inflamatory effect Prandota, Am J Ther 2002 40 mgs IV soln dye free per neb prn

13. Corticosteroids Dexamethasone Start 4 mgs bid and titrate up 24 mgs to 96 mgs/day IVP Solumedrol IVP 550 mgs qid Prednsone Start 40 mgs/day and titrate up

14. Benzos Are they effective? Breaks Anxiety-Dyspnea Cycle….prevalence of fear, anxiety, or panic? Short Acting preferred….Versed is the shortest No studies that show effectiveness in Advanced Cancer or ES COPD Cause more drowsiness than Morphine Use 2 nd line or in combination with Opiods Ativan Infusion 1-5 mg's/hr starts to accumulate in 3 days and may have to cutback

15. Opiods Nebulized Morphine does not work…studies too small Oral opiods work but with the usual side effects Lack of adverse effect on blood gasses Jennings, Thorax 2002 Do decrease the perception of Air Hunger & ↓ ventilatory response to ↓ O2 & ↑CO2 Cause vasodilation of pulmonary vessels: ↓ preload to the Heart Improve Dyspnea without causing Respiratory Depression Opiod Phobia

16. Opiod Responsive Dyspnea Parallels to opiod responsive and opiod non responsive type of pain Dyspnea may have varying degrees of opiod responsiveness dependent on several specific factors

17. Opiod Delivery ClassPreparationOnsetDuration Short Acting Morphine Hydromorphone Oxycodone 30-60 Minutes 3-4 hours Long Acting Morphine SR Hydromorphone SR Oxycodone SR 3-4 Hours 8-12 hours Rapid Onset Fentanyl Oral Transmucosal Buccal Tablet Sublingual Tablet Intranasal Spray 10-15 minutes 1-3 hours

18. Canadian Dyspnea Protocol StepsMedication# mcgs SL (50 mcg/ml) 1Fentanyl25 2Fentanyl50 3Sufentanil10 4Sufentanil15

19. Terminal Sectretions Non- pharmacologic Interventions – Reposition the patient first….basic Nursing Technique – Suction is rarely useful – Secretions re-accumulate rapidly & is overstimulating Anticholinergic / Antimuscarinics – 1% Atropine Opthalmic Gtts 4 gtts SL q 15mins X 4 then prn – Transdermal Scopolamine Patches – Robinol 0.2 mgs q 1 hr subQ/IVP If secretions become wet/rattling but not foamy -Atropine Aerosol 1mg with Albuterol 2.5 mgs q 4hrs prn