II. Signs

  1. Tachypnea
  2. Increased work of breathing
  3. Grunting

IV. Management: General

  1. Direct symptomatic treatment at Dyspnea not Tachypnea
  2. Provide aggressive palliative Resuscitation to get a patient to maximal possible comfort
    1. DNR does not mean less care
    2. Assign 1:1 nursing
  3. Employ General Measures
    1. Maximize environmental air-flow
      1. Fans for better air circulation
      2. Cool room as tolerated
      3. Humidifier
      4. Oxygen as tolerated
        1. May start with oxygen mask or Nasal Cannula but remove if uncomfortable
        2. Consider cutting off Nasal Cannula probes and family member holds near patient
      5. Noninvasive Positive Pressure Ventilation (Bipap, humidified high flow nasal oxygen)
        1. May be tried if patient wishes, and discontinued if uncomfortable or not effective
    2. Maximize patient comfort
      1. Patient in sitting position
      2. Seat family in chairs near bed
      3. Postural drainage
      4. Massage
      5. Distraction by reading or music
      6. No disagreements in front of patient
      7. Turn off monitors
  4. Consider treatment for most common reversible causes
    1. Bronchospasm
    2. Bronchial obstruction
    3. Pleural Effusion
    4. Pericardial Effusion
    5. Hypoxia
    6. Anemia
      1. Transfusion
      2. Erythropoietin 10,000 units for 2 weeks
  5. Consider treatment for other underlying causes
    1. Pleural Effusion
    2. Pericardial Effusion
    3. Congestive Heart Failure
    4. Pulmonary Embolus
    5. Chronic Obstructive Pulmonary Disease
    6. Anxiety Disorder
    7. Infection
    8. Superior Vena Cava Syndrome
      1. Radiation Therapy
      2. High dose Corticosteroids
    9. Lymphangitic cancer spread
      1. Short-term high dose Corticosteroids
  6. Involve other teams as available
    1. Palliative Care
    2. Social services
    3. Chaplain

V. Management: Pharmacologic (Empiric)

  1. Opioids
    1. Mechanism
      1. Reduces sense of Air Hunger in Dyspnea
      2. When appropriately dosed, does not compromise respiratory status or hasten death
    2. Approach
      1. Intermittent dose to avoid excessive Sedation
      2. Start at low dose with short dosing interval as needed and titrate to effect
    3. Mild Dyspnea
      1. Hydrocodone 5 mg orally every 4 hours
    4. Severe Dyspnea
      1. Morphine 5 mg, titrate up to 15 mg orally every 4 hours
      2. Oxycodone 5 mg, titrate to 10 mg orally every 4 hours
      3. Hydromorphone 0.5 to 2 mg orally titrate dose every 4 hours
      4. Extended use of fixed dose Opioids used for pain
        1. Give 50% of base dose hourly during Dyspnea
    5. Critically ill patient
      1. Morphine or Fentanyl
      2. Bolus dose, then continuous Opioid infusion
  2. Adjunctive Measures
    1. Benzodiazepines for anxiety reduction
    2. Dexamethasone 2-4 mg twice daily
    3. Fan directed toward face
  3. Unhelpful measures
    1. Oxygen does not relieve Dyspnea in non-hypoxic patients
    2. Avoid nebulized Opiates

VI. Management: Increased Respiratory Secretions

  1. With loss of consciousness, patient's respirations become gurgling
    1. Does not appear to cause patient discomfort, but often distressing to patients
    2. Attempt to reposition patient and reassure patient
  2. Measures that may dry secretions
    1. Atropine eye drops 1% one to two drops orally or under Tongue every 8 hours (titrate to effect)
    2. Glycopyrolate 1 mg orally or 0.2 mg SQ or IV every 4-8 hours
    3. Hyoscyamine (Levsin) 0.125 to 0.5 mg orally, sublingual or IV every 4 hours as needed
    4. Scopolamine patch reapplied every 48 to 72 hours

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