Janet Campion, MD, Sue Cassidy, ANP-BC, ACHPN, Laura Harrison, GNP-BC, ACHPN,
Linda Snyder, MD, College of Medicine, University of Arizona
TIPS FOR PALLIATIVE CARE OF DYSPNEA IN PATIENTS WITH ADVANCED COPD
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."
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.
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.
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
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
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-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
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.