II. Signs
- Tachypnea
- Increased work of breathing
- Grunting
III. Grading
- Respiratory Distress Observation Scale
IV. Management: General
- Direct symptomatic treatment at Dyspnea not Tachypnea
- Provide aggressive palliative Resuscitation to get a patient to maximal possible comfort
- DNR does not mean less care
- Assign 1:1 nursing
- Employ General Measures
- Maximize environmental air-flow
- Fans for better air circulation
- Cool room as tolerated
- Humidifier
- Oxygen as tolerated
- May start with oxygen mask or Nasal Cannula but remove if uncomfortable
- Consider cutting off Nasal Cannula probes and family member holds near patient
- Oxygen has not been shown to relieve end-of-life Dyspnea in non-hypoxic patients
- Noninvasive Positive Pressure Ventilation (Bipap, humidified high flow nasal oxygen)
- May be tried if patient wishes, and discontinued if uncomfortable or not effective
- High Flow Nasal Cannula
- May be better tolerated than BiPap/CPaP, and more relief than Supplemental Oxygen
- Ruangsomboon (2020) Ann Emerg Med 75(5): 615-26 [PubMed]
- Maximize patient comfort
- Patient in sitting position
- Seat family in chairs near bed
- Postural drainage
- Massage
- Distraction by reading or music
- No disagreements in front of patient
- Turn off monitors
- Maximize environmental air-flow
- Consider treatment for most common reversible causes
- Bronchospasm
- Bronchial obstruction
- Pleural Effusion
- Pericardial Effusion
- Hypoxia
- Anemia
- Transfusion
- Erythropoietin 10,000 units for 2 weeks
- Consider treatment for other underlying causes
- Pleural Effusion
- Pericardial Effusion
- Congestive Heart Failure
- Pulmonary Embolus
- Chronic Obstructive Pulmonary Disease
- Anxiety Disorder
- Infection
- Superior Vena Cava Syndrome
- Radiation Therapy
- High dose Corticosteroids
- Lymphangitic cancer spread
- Short-term high dose Corticosteroids
- Involve other teams as available
- Palliative Care
- Social services
- Chaplain
V. Management: Pharmacologic (Empiric)
-
Opioids
- Mechanism
- Reduces sense of Air Hunger in Dyspnea
- When appropriately dosed, does not compromise respiratory status or hasten death
- Approach
- Intermittent dose to avoid excessive sedation
- Start at low dose with short dosing interval as needed and titrate to effect
- Mild Dyspnea
- Hydrocodone 5 mg orally every 4 hours
- Severe Dyspnea
- Morphine 5 mg, titrate up to 15 mg orally every 4 hours
- Oxycodone 5 mg, titrate to 10 mg orally every 4 hours
- Hydromorphone 0.5 to 2 mg orally titrate dose every 4 hours
- Extended use of fixed dose Opioids used for pain
- Give 50% of base dose hourly during Dyspnea
- Critically ill patient
- Consider continuous Opioid infusion
- Bolus dosing
- Morphine 1-2 mg IV
- Fentanyl 25-50 mg IV
- Hydromorphone 0.2 mg IV
- Mechanism
- Adjunctive Measures
- Benzodiazepines for anxiety reduction
- Risk of significant sedation
- Dexamethasone 2-4 mg twice daily
- Fan directed toward face
- Diuretics
- \ Consider trial for Fluid Overload
- Benzodiazepines for anxiety reduction
- Unhelpful measures
VI. Management: Increased Respiratory Secretions
- With loss of consciousness, patient's respirations become gurgling or noisy ("death rattle")
- Does not appear to cause patient discomfort, but often distressing to family
- Attempt to reposition patient and reassure patient
- Measures that may dry secretions
- Atropine eye drops 1% one to two drops orally or under Tongue every 8 hours (titrate to effect)
- Glycopyrolate 1 mg orally or 0.2 mg SQ or IV every 4-8 hours
- Hyoscyamine (Levsin) 0.125 to 0.5 mg orally, sublingual or IV every 4 hours as needed
- Scopolamine patch reapplied every 48 to 72 hours