Waikato DHB Palliative Care Guidelines

6. Dyspnoea

6.1 Morphine 6.2 Benzodiazepines 6.3 Steroids 6.4 Oxygen 6.5 Non-pharmacological treatments

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• Check for reversible causes (e.g. LVF, COAD, asthma, pleural or pericardial effusion, mechanical airway obstruction etc).
• Saline nebulisers can help with tenacious sputum.
• A fan can be helpful in providing a flow of air.
• If indicated a bronchodilator may be useful.
• Rationalize activities.

6.1 Morphine

Morphine is very useful in the management of dyspnoea.

Usually lower doses are required than those for pain e.g. 2.5 - 10mg of elixir 4 hourly or PRN. The dose can be gradually titrated as for pain but comfort rather than resolution of dyspnoea is generally the desired end point.

If a trial of elixir has proved helpful a low dose of M-Eslon™ or low dose morphine infusion may be more convenient however, patients may choose to remain on regular elixir.

Nebulised morphine has NO demonstrable advantage over morphine elixir.

6.2 Benzodiazepines

Clonazepam oral drops 2.5mg/ml (1 drop = 0.1mg) 1-3 drops 4-6 hourly PRN.

Lorazepam 0.5 - 1mg PO 4 - 6 hourly.

Midazolam 10 – 20mg/24hours via subcut infusion. Available by special authority - see Pharmac website or check with the hospital pharmacist (relevant specialist only).

Sedation is sometimes needed and morphine plus a benzodiazepine via subcut infusion is recommended.

6.3 Steroids

Recommended for bronchial obstruction, superior vena cava obstruction (SVCO), radiation pneumonitis and lymphangitis carcinomatosis.

Therapeutic trial can sometimes be worthwhile if cause unclear.

Either prednisone 20-40mg mane or dexamethasone 8-12mg mane – depending on cause and then aim to reduce gradually to lowest effective dose.

6.4 Oxygen

The use of oxygen in a non-cyanotic patient is controversial but there is extensive anecdotal evidence to warrant a trial if other measures have failed.

 

6.5 Non-pharmacological treatments

Very important consideration.

Physiotherapy, occupational therapy, counselling, relaxation and music therapy all have a role in the management of dyspnoea.

Information last reviewed: June 2009	Please foward any enquiries about this document to haggars@waikatodhb.govt.nz
Next review date: July 2010	For Palliative Care advice, please call 8691 or the specialist on-call.

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