Dyspnea, Management of (Palliative Care)

Guideline Dyspnoea Management

Guideline Responsibilities and Authorisation

Department Responsible for Guideline Palliative Care

Document Facilitator Name Lana Ferguson & Peter Kirk

Document Facilitator Title Advanced trainee (registrar) & consultant, palliative care

Document Owner Name Peter Kirk

Document Owner Title Clinical Director

Disclaimer: This document has been developed by Waikato District Health Board specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at their own risk and Waikato District Health Board assumes no responsibility whatsoever.

Guideline Review History

Version Updated by Date Updated Description of Changes

Contents

Causes of dyspnoea

Non-pharmacological management of dyspnoea

Pharmacological management of dyspnoea

Management of acute respiratory distress or severe dyspnoea at the end of life

Doc ID: 5893 Version: 01 Issue Date: 02 MAY 2018 Review Date: 02 MAY 2021 Facilitator Title: Registrar Department: Palliative Care IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING Page 1 of 7

Guideline Dyspnoea Management

1. Overview Dyspnoea is an unpleasant subjective experience of breathlessness or breathing discomfort. It is often multifactorial, particularly in the setting of malignancy. There may be significant psychological, emotional or social factors influencing a patient’s perception of dyspnoea (see figure 1). Dyspnoea is not always associated with tachypnoea or hypoxaemia. Reversible causes of dyspnoea should be identified and treated as part of dyspnoea management.

1.1 Purpose To provide guidance in the management of dyspnoea in palliative care patients.

1.2 Scope All waikato DHB medical staff involved in the clinical care of palliative patients will be aware of and familiar with guidelines.

1.3 Patient / client group Palliative care patients with breathlessness and/or breathing difficulties.

Guideline Dyspnoea Management

2. Clinical Management

2.1 Causes of dyspnoea Concept of total dyspnoea Total dyspnoea, analogous to the concept of total pain, describes the interplay between factors that influence a patient’s experience of dyspnoea as shown in the diagram below. It is useful to consider this when assessing dyspnoea in a palliative patient.

Figure 1

Reversible causes of dyspnoea Cause Management options Infection Antimicrobials Pleural effusion Pleural drainage, pleurodesis Pulmonary oedema Diuresis (+/- optimisation of heart failure therapy) Pulmonary embolism Anticoagulation Lymphangitis Corticosteroids Superior vena cava obstruction Corticosteroids, radiation, stenting Airway obstruction Corticosteroids, radiation, stenting Anaemia Transfusion Pain Adequate analgesia

Guideline Dyspnoea Management

2.4.2 Management of dyspnoea – non-pharmacological • Air flow - the use of fan or open windows allowing air movement can improve the sensations of dyspnoea • Patient and family/whanau education:

o Encourage activity within tolerance level and awareness of activities which may trigger dyspnoea.

o Ensure patient and family/whanau know how and when to use medications • Pulmonary rehabilitation (non-malignant disease) • Anxiety reduction and distraction techniques • Breathing techniques – referral to physiotherapist may be helpful • Positioning

2.4.3 Management of dyspnoea – pharmacological Opioids • Low dose opioids are the mainstay of dyspnoea management. • Opioids reduce the sensation of dyspnoea in both malignant and non-malignant disease.

• Appropriate use of opioids do not lead to CO2 retention. • Respiratory depression associated with opioids is very rare when opioids are appropriately titrated.

Opioid dosing in MILD dyspnoea: 1. Opioid naïve patients:

• Morphine elixir 1-2 mg PO Q1H PRN • Encourage pre-emptive use, i.e. 20-30 minutes pre-activity. • May benefit from background opioid starting but rarely need >40 mg/day morphine for dyspnoea alone. • Consider starting m-Eslon 10mg BD if requiring frequent PRN doses of morphine elixir for resting dyspnoea.

2. Patients already on background opioids for analgesia: • Use 1/10th of their total daily morphine dose PRN Q1H as a starting dose and titrate to effect. • E.g. in patient on m-Eslon 50mg BD, prescribe 10mg morphine immediate release Q1H PRN for dyspnoea

Guideline Dyspnoea Management

Benzodiazepines • Useful in dyspnoea that is associated with anxiety. • Benzodiazepines should NOT be used if there is NO anxiety component. • There is no evidence that benzodiazepines directly reduce breathlessness. • In the context of severe anxiety or history of previous anxiety disorder, patients may benefit from background selective serotonin reuptake inhibitors (SSRI) or serotonin and norepinephrine inhibitors (SNRI) however this should be discussed with psychiatry. • Benzodiazepines should be used on a PRN basis however some patients may benefit from regular or background dosing (NB: tolerance)

1. Benzodiazepine PRN dosing: • Midazolam 1.25-2.5 mg subcut Q1H PRN for anxiety associated with dyspnoea • Lorazepam 0.5 mg PO TDS PRN for anxiety associated with dyspnoea 2. Benzodiazepine regular dosing: • Lorazepam 0.5 mg PO BD • Clonazepam (tablets not drops) 0.25-0.5 mg BD

Oxygen There is no role for supplemental oxygen in the non-hypoxic patient. If oxygen is used, particularly at high flow and for long periods of time, it should be humidified to prevent drying of mucous membranes.

2.4.4 Management of acute respiratory distress or severe dyspnoea at the end of life. Opioid dosing in SEVERE dyspnoea: • This should be managed in consultation with a palliative specialist • If significant dyspnoea is anticipated at the end of life, crisis medication should be available (pre-filled syringes in home setting) as follows:

o Morphine 5 mg subcut Q15 minutes, titrated to effect. o Midazolam 2.5-5 mg subcut Q15 minutes, titrated to effect. Midazolam can be used as an adjunct to dyspnoea management in this setting. Opioids remain the first-line management.

Guideline Dyspnoea Management

• It may be appropriate to start a continuous subcutaneous infusion (CSCI) to manage dyspnoea.

CSCI medication and dosing in respiratory distress or severe end of life dyspnoea: 1. Opioid naïve patients • Morphine 10mg, midazolam 10mg via CSCI over 24hrs, this should be reviewed regularly and adjusted based on PRN usage every 24hrs. • Ensure PRN doses are available:

o Morphine 2.5mg subcut Q1H PRN o Midazolam 1.25 – 2.5 mg Q1H PRN for anxiety associated with dyspnoea • Estimated glomerular filtration rate (eGFR) <15ml/min – suggest substituting morphine for fentanyl 100-150 microg over 24hrs

o Fentanyl 12.5-25 microg subcut Q1H PRN 2. Patients already on background opioids for analgesia: In patient already on opioids for pain – consult with palliative specialist for advice Palliative sedation may be appropriate in severe/refractory dyspnoea, but should NOT be undertaken without the guidance of a palliative specialist.

3. Audit Indicators

3.1 Indicators • Patients with dyspnoea should be prescribed PRN opioids to manage symptoms. • Benzodiazepines should only be used in those patients that experience anxiety associated with dyspnoea.

4. Evidence Base

4.1 Associated Waikato DHB Documents • Waikato DHB Medicines Management policy (Ref. 0138) • Waikato DHB Medicines Management Infusion and Related Therapies Skills Verification guideline (Ref. 1340) • Waikato DHB Care of the Dying guideline (Ref. 4966) • Waikato DHB Care of the Deceased / Tūpāpaku policy (Ref. 0133) • Waikato DHB Resuscitation policy (Ref. 1970) • Waikato DHB Tikanga Recommended Best Practice guidelines (under review)

Guideline Dyspnoea Management

• Waikato DHB Inpatient Pain Service Adult Pain Management Handbook

4.2 References • Kennedy B, Dyson T, Macpherson N & Roberts D. 2016. Fraser Health. Hospice Palliative Care Program; Symptom Guidelines. Available from: [www. http://www.fraserhealth.ca/health-professionals/professional-resources/hospice- palliative-care/] • Kamal AH, Maguire JM, Wheeler JL, Currow DC, Abernethy AP. Dyspnoea review for the palliative care professional: assessment, burdens, and etiologies. Journal of palliative medicine. 2011;14(10):1167-72. • Simon ST, Higginson IJ, Booth S, Harding R & Bausewein C. Cochrane Review. Non- Pharmacological interventions for dyspnoea in advanced stages of malignant & non- malignant disease. 2011. • Cabezón-Gutiérrez L, Khosravi-Shahi P, Custodio-Cabello S, Muñiz-González F, del Puerto Cano-Aguirre M, Alonso-Viteri S. Opioids for management of episodic breathlessness or dyspnoea in patients with advanced disease. Supportive Care in Cancer. 2016 Sep 1;24(9):4045-55. • Grundy, K. 2016. Canterbury district health board palliative care guidelines. Available from: [www.cdhb.palliativecare.org.nz] • Watson M, Armstrong P & Back I. Palliative Adult Network Guidelines. 4th edition. Surrey, Sussex & Wales. London Cancer Alliance, RM Partners; 2016. • Abernathy AP, McDonal CF, Frith PA, Clark K, Herndon JE, Marcello J, Young IH Bull J, Wilcock A, Booth S, Wheeler JL, Tulsky JA, Crockett AJ & Currow DC. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double blind, randomised controlled trial. 2010. Lancet vol 376 sept.