Dyspnea is a feeling of being unable to catch one's breath. At the end of life, this symptom can be extremely frightening to patients and their families because of anxiety about suffocation. Dyspnea often does not correlate with any objective test findings and is probably generated by the greater workload of breathing in patients with progressive muscular weakness. An increase in ventilatory needs, which may occur because of sepsis, anemia, or cancer cachexia, can also contribute to the symptom. Treatment of dyspnea at the end of life can help make the approaching death easier for everyone involved. Many patients develop dyspnea without having a history of pulmonary disease. Mosenthal and Lee reviewed the evaluation of dyspnea during the final stages of life and discussed management strategies.
This subjective symptom is best evaluated using patient reporting of intensity, duration, and incidence. Although the majority of patients with dyspnea may not have a treatable cause, those with pleural or pericardial effusion, bronchial obstruction, broncho-spasm, hypoxia, or anemia may improve with treatment of the underlying pathology. Psychologic factors such as fear of choking can exacerbate symptoms of dyspnea.
Symptomatic therapies can be used in patients with dyspnea who do not have a clear etiology for the symptom. These therapies include oxygen (even when hypoxia is not present), opioids, and benzodiazepines. Oxygen has a strong placebo effect and is easy to use. A fan, cool air, or an open window may bring similar relief. Opioids can relieve dyspnea through analgesic and euphoric effects. They also offer some cardiopulmonary benefits, including decreased cardiac congestion and decreased pulmonary hypertension. Opioids can be administered by various routes, including cutaneous patches, subcutaneous injection, parenteral, oral, inhaled, or per rectum.
Dyspnea is probably better treated by intermittent dosing (see accompanying table) because continuous dosing may lead to undesired sedation. Constant infusions may be useful in patients with constant dyspnea or patients who are comatose. Benzodiazepines, starting at very low dosages, can be administered through a variety of routes and may relieve anxiety caused by dyspnea. Nonpharmacologic techniques, including the use of fans and open windows, removal of clutter, decreased show of anxiety among family members, and provision of emotional support, can alleviate the patient's feelings of breathlessness.
|Hydrocodone, 5 mg every four hours|
|Codeine, 30 mg every four hours|
|Patients can be given breakthrough doses every two hours as needed.|
|Morphine, 5 to 15 mg every four hours|
|Oxycodone, 5 to 10 mg every four hours|
|Patients being given fixed-dose opioids for pain can be given added medication at 50 percent of the base dose every hour during episodes of dyspnea.|
|Critically ill patients|
|Bolus followed by continuous infusion of morphine or fentanyl|
Protocols detailing procedures and dosing recommendations are available for symptom relief after withdrawal of ventilatory support. Such protocols can be found in Education for Physicians on End-of-Life Care, a physician training project developed by the American Medical Association. Tracheobronchial secretions, which can cause disquieting breathing sounds, can be minimized with the use of anticholinergic agents and judicious suctioning of the posterior oropharynx. The patient's family must receive explanations and reassurance during this difficult period.
The authors conclude that a peaceful death for many patients should include management of dyspnea. When appropriate, underlying conditions that exacerbate breathlessness should be relieved, but management with oxygen, opioids, benzodiazepines, psychologic support for the patient and family, and physical measures to make the environment more open and airy can be helpful.