Elder Care Interprofessional Provider Sheets

Palliative Care of Dyspnea in Patients with Advanced COPD

Janet Campion, MD, Sue Cassidy, ANP-BC, ACHPN, Laura Harrison, GNP-BC, ACHPN,
Linda Snyder, MD, College of Medicine, University of Arizona

October 2018

TIPS FOR PALLIATIVE CARE OF DYSPNEA IN PATIENTS WITH ADVANCED COPD
  • Use patient report as the gold standard for diagnosing dyspnea. Dyspnea is subjective and often unrelated to objective findings like tachypnea, oxygen saturation, or respiratory muscle use.
  • Prescribe low-dose oral or parenteral opioids as a palliative treatment of dyspnea. Opioids can alleviate dyspnea and improve quality of life in advanced COPD.
  • Consider non-pharmacological modalities, like an appropriate room environment, attention to body positioning and breathing technique, and use of physical therapy modalities like muscle strengthening and walking aids to conserve strength.
  • Recent reviews suggest acupuncture and CBT modalities may be beneficial in relieving breathlessness in appropriate patients.

Dyspnea is a common symptom in patients with advanced chronic obstructive pulmonary disease (COPD), with increasing prevalence at the end of life. Dyspneic patients experience difficult, labored, or uncomfortable breathing and often describe breathlessness, air hunger, or excessive effort to breathe. Patients with dyspnea may also experience anxiety, fear, and panic, all of which may increase dyspnea severity in the so-called "dyspnea-anxiety-dyspnea cycle." 

Diagnosis

The gold standard for diagnosing dyspnea in patients with advanced COPD is the patient's self-report. The severity of dyspnea can be assessed with rating scales, such as a visual analog or numeric rating scale similar to those used to assess severity of pain. Objective signs like tachypnea, oxygen saturation, and arterial blood gas results may not accurately reflect the patient's distress. 

General Management

The initial step in the treatment of dyspnea in patients with advanced COPD is to evaluate and treat underlying causes. Potential contributors to worsening dyspnea include bronchospasm, pleural effusion, pulmonary edema, pulmonary embolism, hypoxemia, or infection. Even if the cause is unclear, however, or if disease-specific therapies have been exhausted, aggressive symptom management is crucial. The goal of palliative symptom management is to relieve the patient's sense of breathlessness. Management can be pharmacologic and/or non-pharmacologic.

Pharmacological Management

Pharmacologic palliation of dyspnea involves the use of opioids, oxygen, and/or benzodiazepines (Table 1).

Opioids Systemic opioids are the mainstay of palliative pharmacologic management of severe dyspnea, and their effectiveness has been demonstrated in numerous clinical trials. 

A recent Cochrane review and research letter report low-to-moderate-level evidence supporting the effectiveness of low-dose opioids for the relief of breathlessness in severe illness. Both oral and parenteral opioids can provide relief from dyspnea, and they should be dosed and titrated with consideration of a patient's renal, hepatic, and pulmonary function, as well as the patient's current and past opioid use. 

Most palliative care experts recommend that for palliative treatment of severe dyspnea in an opioid-naive patient, initial therapy should be morphine sulfate (2.5-5.0 mg orally) as a single dose. If tolerated, the dose can be administered every four hours. An additional dose can be available every hour in between scheduled doses for as-needed relief of severe dyspnea. 

Oxycodone or hydromorphone in equianalgesic doses are alternatives to morphine. Nebulized opioids are not recommended, given the current evidence.

Table 1. Key Medications for Palliation of Dyspnea
Opioids
  • Morphine is usual first choice.
  • Oxycodone or hydromorphone are alternatives.
Oxygen
  • Administer by nasal cannula (see Table 2). 
Benzodiazepines
  • Consider when significant anxiety contributes to dyspnea.           

Clinicians considering opioid therapy for palliation of dyspnea often express concern about inducing respiratory depression. In a recent systematic analysis, there was no evidence of clinically relevant respiratory adverse events from low-dose opioids used to treat chronic breathlessness. When opioids are appropriately dosed and slowly titrated along with good clinical care and appropriate monitoring, they are useful for palliative treatment of refractory dyspnea. 

Oxygen  Oxygen clearly benefits patients with hypoxemia, but in the absence of hypoxemia, the role of palliative oxygen in the treatment of dyspnea is controversial. A recent double-blind randomized controlled trial of oxygen vs. room air (both given by nasal cannula) was conducted; 62% of participants had COPD. This study concluded that room air is as effective as oxygen for relieving dyspnea in those without hypoxia (< 90% oxygen saturation at rest), and most of the improvement occurred within the first 72 hours of therapy. It was hypothesized that both interventions provide movement of air over the face and nose, and that air movement may lead to better symptom control. There is an important psychosocial component to dyspnea, however, and if the patient or family desires oxygen, a therapeutic trial of oxygen is appropriate (Table 2).

Table 2. Key Points about the Use of Oxygen for Palliative Care in Advanced COPD 
  • Oxygen can provide relief of dyspnea for patients who have hypoxemia. Use humidified oxygen via nasal prongs at rate of 1-7 liters/min, aiming for oxygen saturation ≥90% if tolerated. 
  • Consider a brief trial of oxygen, even when a patient is not hypoxemic, if oxygen is requested by patient or family.
  • Using a fan that blows cool air across the face may be an effective alternative to oxygen therapy.

Benzodiazepines  Because of the complex interaction between anxiety, panic, and the perception of dyspnea, anxiolytics are often added to opioids as an adjuvant therapy for dyspnea. A recent Cochrane review found insufficient data to support routine use of benzodiazepines in the palliative therapy of advanced COPD. However, benzodiazepines may be considered second- or third-line options when opioids and non-pharmacologic treatments do not provide adequate control of breathlessness, especially at the end of life, for patients who are very anxious and distressed. 

Non-Pharmacological Management

Non-pharmacologic interventions for breathlessness in advanced lung disease are listed in Table 3. Interventions need to be tailored to the patient, for the stage of disease and disease trajectory. Some therapies require a high level of motivation, support, and expertise. There are recent reviews of acupuncture and cognitive behavioral therapies for COPD patients, and although they include only small numbers of studies and patients, they report encouraging results.

Table 3. Non-Pharmacological Interventions for Breathlessness in Patients with Advanced COPD
Room Environment and Positioning
  • Cool room with low humidity, free of dust or smoke.
  • Breeze from open window or fan, directed towards face.
  • Sitting upright in bed or chair.
Breathing
  • Pursed-lip diaphragmatic breathing: close mouth, inhale slowly through nose, purse lips as if whistling, exhale slowly.
Physical Therapy/Acupuncture and Cognitive Behavioral Therapy (CBT)
  • General muscle strengthening
  • Walking aids to conserve strength
  • Neuromuscular electrical stimulation.
  • Acupuncture may improve dyspnea and health quality of life. 
  • CBT can be effective in treating and preventing panic attacks and decreasing perceived dyspnea.

References and Resources

  • Abernathy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnea:  A double-blind, randomized controlled trial.  Lancet 2010; 376; 784-93. 
  • Barnes H, McDonald J, Smallwood N, Manser R. Opioids for the palliation of refractory breathlessness in adults with advanced disease and terminal illness. Cochrane Database of Systematic Reviews 2016, Issue 3, Art No.: CD011008.
  • Booth S, Moffat C, Burkin J et al. Nonpharmacologic interventions for breathlessness. Curr Opin Support Palliat Care 2011; 5: 77-86.
  • Coyle M, Shergis J, et al. Acupuncture Therapies for chronic obstructive pulmonary disease: a systematic review of randomized, controlled trials. Altern Ther Health Med 2014; 20(6): 10-23.
  • Ekstrom M, Bajwah S, Bland JM et al. One Evidence Base; Three stories: Do Opioids Relieve Chronic Breathlessness? Thorax 2018; 73: 88-90.
  • Simon ST, Higgins IJ, Booth S, et al. Benzodiazepines for the relief of breathlessness in advanced malignant and nonmalignant diseases in adults. Cochrane Database System Rev 2010: CD007354.
  • Verberkt CA, Van den Beuken-van Everdingen MHJ, Schols JMGA, Datla S et. al. Respiratory adverse effects of opioids for breathlessness: a systematic review and meta-analysis. Eur Respir J 2017; 50: 1701153.