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End of Life Online Curriculum

Overview

Assisted Suicide

 Palliative Sedation  
Communication

Opioid Conversion

Transition to Death

 
Home Hospice

Dyspnea

Bereavement

  
Prognostication

     
 

 

Dyspnea: How to Assess and Palliate Dyspnea (Air-Hunger)

  
 

Introduction & Learning Objectives
Overview

Normal Breathing
Prevalence

Patient Distress
Pathophysiology
Causes Flowchart

Assessment

Flowchart 1
Flowchart 2
Flowchart 3
Tools
Palliation

Specific Situations

Case 1: John Silver (a 67 year old man with dyspnea)

Pearls
Resources
Authors

Appendices

Interventions

Correct interventions

  

Elevate the head of the bed and place an electric fan which blows air gently on his face.

Bedside Fan: A gentle breeze from a bedside fan directed at the patient’s face can help alleviate dyspnea (Rousseau 1996). This effect is thought to be mediated by stimulation of the thermal and mechanical receptors of the trigeminal nerve in the cheek and nasopharynx (Enck 1994)(Dudgeon 1996).
Morphine sulfate tablets 5mg orally every 4 hours as needed.

Opioids relieve dyspnea by:

  1. Altering perception of dyspnea (Bruera 1990) (Weil, 1975).
  2. Decreasing ventilatory drive to both hypoxia and hypercapnia.
  3. Reducing oxygen consumption at rest and during exercise.
Albuterol and ipratropium hand held nebulizer treatment as needed.  

Incorrect interventions

  
Nebulized morphine in a saline solution Patient has a h/o of bronchial asthma and wheezing by physical exam. Nebulized opioids may precipitate the release of histamine from the pulmonary mast cells and worsen dyspnea by causing bronchoconstriction.
Non-breather mask with 100% oxygen

The patient has a SaO2 of 100%. While supplemental oxygen is usually helpful in patients with low oxygen saturation it may not be very helpful in patients with normal oxygen saturation. It is not routinely indicated in all dyspneic patients. A trial of supplemental oxygen may be indicated using a nasal cannula. The Medicare Hospice Benefit will pay for a room-air concentrator for supplemental oxygen as a part of the routine hospice benefit. Medicare certified home hospices will provide a room-air concentrator as a part of their routine service for all terminally ill patients. No additional testing (SaO2 = 88% or PaO2 < 55%) is needed or required to justify the room-air concentrator.

See Rules Governing Supplemental Oxygen below.
Diazepam 5 mg every 8 hours Benzodiazepines are frequently used to alleviate dyspnea in patients with advanced illness when the dyspnea has been optimally treated with {bronchodilators, opioids} and if the patient is anxious secondary to dyspnea. A trial of low dose short acting benzodiazepines {lorazepam 0.5-1mg every 4-6 hours as needed} is indicated in the anxious patient who is dyspneic. There is no evidence that Mr. Silver is anxious at this time.

Rules Governing Supplemental Oxygen

CMS classifies oxygen and oxygen delivery equipment as durable medical equipment (DME); this definition allows oxygen to be reimbursed as a form of "medical equipment." As a result, a specific Certificate of Medical Necessity (CMN) called the HCFA–484 must be completed by the physician in order for oxygen therapy to be reimbursed at a level of 80 percent of the Medicare allowable charge. The patient or supplemental insurance is responsible for the remaining 20 percent of the cost.

2006-05-01 Update
 
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Home | Project Website | ©End of Life Curriculum Project, a joint project of the US Veterans Administration and SUMMIT, Stanford University Medical School. Funded by a grant to the Veterans Administration Nationwide Palliative Care Network by the National Library of Medicine. VJ Periyakoil, Principal Investigator.