"How people die lives in the memories of those who live on"
- DAME CICELY SAUNDERS
Managing Dyspnea
Written by Brenda Derdaele RN CHPCN(c)
What is Dyspnea?
Dyspnea is the uncomfortable feeling of being short of breath. It may or may not be associated with hypoxia.
Because dyspnea is subjective, it is recommended that the patient’s self report of symptoms should be acknowledged and accepted. - Fraser Health

Be sure to complete...

Complete past medical history.

Review medications.

Complete PPS - to report the patient’s overall functional status.

Complete ESASr with patient or caregiver (if patient unable to speak).


Assessment

OPQRSTUV Acronym - suggests some assessment questions; however these may need to be tailored to each patient. Where a patient is not able to complete an assessment by self reporting, then the health professional and/or the caregiver may act as a surrogate.


Carry out a relevant physical examination and relevant investigations, if tolerated by, and acceptable to the patient.

Non-Pharmacological Management

Dyspnea can be a very frightening experience for patients and their families. Many of the suggestions here should be taught as preventative strategies, when patients are not dyspneic, and regular practice should be encouraged.
1. Assessment of breathlessness, what improves and what worsens it.

2. Provision of information and support for patients and families in the management of breathlessness.

3. Exploration of the significance of breathlessness with patients, their disease, and their future.

4. Instruction on breathing control, relaxation and distraction techniques.

5. Goal setting to enhance breathing and relaxation techniques as well as to enhance function, enable participation in social activities and develop coping skills.

6. Identification of early signs of problems that need medical or pharmacotherapy intervention.
Additional stand alone recommendations for managing dyspnea based on expert opinion: (please view Cancer Care Ontario’s Symptom Management Guide-to-Practice: Dyspnea for more in depth information)

- Upright positioning.

- Breathing exercises.

- Assisting patients to recognize precipitants of dyspnea.

- Access assistive mobility devices. Consider referral to Occupational Therapist for further education and techniques.

- Increase ambient air flow directed at the face or nose such as generated by a fan - Providing cooler temperatures.

Pharmacological Management
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Oxygen

  • Useful for patients with hypoxia. Start with lower volumes in patients with severe COPD.
  • Role in non-hypoxic patients less clear (Some individuals may benefit but not generally recommended).
  • Palliative oxygen for comfort (usually more psychological).
  • If a patient is terminal and not complaining of shortness of breath, there is no need to start oxygen.

Opioids

  • Safe and effective.
  • Diminishes the sensation of being short of breath.
  • Safe to be used in client's with cancer, ALS and end-stage heart and lung diseases .
  • Start with lower doses and titrate slow.
  • Usually given PO or SQ. Nebulized opioids not generally recommended.

Benzodiazepines

Clonazepam or Ativan
  • Limited to patients with significant underlying panic disorder and anxiety disorder.
  • May be helpful in select cases where dyspnea causes severe anxiety.

Midazolam
  • In case of severe dyspnea crisis or intractable dyspnea at EOL (palliative sedation)- if so, ensure criteria for palliative sedation are met.

Adjuvant Medications

Methotrimeprazine (Nozinan)
  • Role unclear, but consider a trial if dyspnea severe and not responding to opioids & oxygen.
  • Regular or as needed dosing

Steroids
  • For lymphangitic carcinomatosis, severe COPD.

Bronchodilators
  • Only if bronchoconstriction (wheezing heard).

Diuretics
  • For congestive heart failure, pulmonary edema.
Please note:


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