Dyspnea in Cancer

1. See Also
   1. Dyspnea
2. Management: General
   1. Direct symptomatic treatment at Dyspnea not Tachypnea
   2. 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
      2. Maximize patient comfort
         1. Patient in sitting position
         2. Postural drainage
         3. Massage
         4. Distraction by reading or music
         5. No disagreements in front of patient
   3. 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
   4. 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
3. Management: Pharmacologic (Empiric)
   1. Opioids (intermittent dose to avoid excessive Sedation)
      1. Mild Dyspnea
         1. Hydrocodone 5 mg PO q4 hours
         2. Tylenol #3 or codeine 30 mg, 1 capsule PO q4 hours
      2. Severe Dyspnea
         1. Morphine 5 mg, titrate up to 15 mg PO q4 hours
         2. Oxycodone 5 mg, titrate to 10 mg PO q4 hours
         3. Hydromorphone 0.5 to 2 mg PO titrate dose q4 hours
         4. Extended use of fixed dose Opioids used for pain
            1. Give 50% of base dose hourly during Dyspnea
      3. 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
4. Management: Increased Respiratory 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
5. References
   1. Dudgeon (1998) J Pain Symptom Manage 16:212-9
   2. Mosenthal (2002) J Am Coll Surg 194:381
   3. Reuben (1986) Chest 89:234-6
   4. Ross (2001) Am Fam Physician 64(6):1019-26