Positioning.

An upright position with the head of the bed as high as possible is generally useful, particularly in COPD [12]. Arms elevated and resting on a pillow on the overbed table with the head of the bed elevated increases vital capacity and may foster dyspnea relief. In some patients with unilateral disease, a side-lying position with the “good” lung up or down improves ventilation or perfusion. Trial-and-error approaches using the individual patient as his/her own control will yield the ideal position. Nurses need to be aware of the “ideal” position for respiratory comfort so other imperatives such as “turn q2” can be overridden.

Oxygen.

Oxygen is useful to treat dyspnea when the patient is hypoxemic (SpO₂ ≤ 85%). Oxygen is better tolerated delivered by nasal cannula; a face mask induces a feeling of suffocation and is aesthetically less desirable as well. Humidification should be added if flow rates exceed 4 l/min to minimize the risk of nasal drying and/or nosebleed. High-flow oxygen (where available) delivers up to 40 l/min; as of this writing, clinical trials are underway to determine if there is a role for high-flow oxygen in the palliation of refractory dyspnea [21].

If the patient is being discharged to home, an oxygen assessment must be performed for insurance to cover the cost of oxygen. The patient must desaturate at rest or with activity to a PaO₂ of less than 55mmHg or SpO₂ of less than 88%. NOTE that if the patient is being discharged with hospice care, this assessment is not usually required, as the hospice agency is the payer and will provide the oxygen based on its own criteria. Oxygen has not been found to be useful in nonhypoxemic dyspnea; no significant or clinically important differences were found when oxygen was compared to medical air [14, 22]. Relief may be achieved from cool air flowing toward the patient’s face. A bedside fan may be useful but is sometimes difficult to operationalize in the hospital due to bioengineering constraints [23, 24].

When the patient is near death and is hypersomnolent or unconscious, with no signs of respiratory distress, oxygen need not be initiated, and if flowing, it can usually be withdrawn, regardless of oxygenation [25]. Withdrawing oxygen during last hours permits a natural death trajectory; continued oxygen in the absence of patient distress may merely prolong dying.

Removing a visible intervention such as oxygen may be disconcerting to the family; alternatively removing oxygen produces an aesthetically pleasing, natural patient appearance. Tactfully explain the rationale for removing this nonbeneficial and burdensome intervention to the family as well as the nursing and respiratory therapy staff. An added benefit of removing oxygen is a quieter environment for the dying patient and family, particularly when humidifiers or masks were in use. Close bedside observation for signs of respiratory distress for several minutes after oxygen withdrawal is indicated. There is no benefit to measuring peripheral oxygen saturation as this is a measure of pulmonary function and not a measure of dyspnea or respiratory distress.

Opioids.

Opioids, morphine, and fentanyl, in oral or parenteral preparations, are the only medications supported by evidence to reduce dyspnea as primary agents [18]. Opioids reduce the effect of hypoxemia or hypercarbia on ventilation [1, 26]. Optimal dosing for dyspnea has not been established, and pharmacovigilance studies are underway [27, 28]. Typical doses of opioids for dyspnea relief are smaller than those used for pain control. Most of the opioid research for treating dyspnea has been conducted with morphine or fentanyl; similar effectiveness with other classes of opioids such as hydromorphone or methadone has not been established. Morphine is the drug of choice for dyspnea relief; fentanyl is safer when the patient has renal impairment.

Severe, unrelieved dyspnea is a palliative care emergency that warrants frequent assessment and rapid titration of opioids (morphine or fentanyl). A recommended titration plan follows. In general, the onset of action of intravenously administered morphine is at 5–10 min with peak effect usually at 15–30 min. Fentanyl has an onset of 1–5 min with a peak effect at 3–5 min. As always in the palliative setting, goals and expected outcomes should be considered when deciding on how quickly to repeat doses. The other consideration is the degree of discomfort displayed by the patient. So, for a patient who is actively dying and in severe distress, a more rapid readministration, for instance, at 5–10 min, may be acceptable and the best approach. For a patient with less severe distress and whose life expectancy is not just minutes to hours, a more conservative approach of redosing at 15–30 min would be prudent. The general pharmacokinetic principle here is that redosing before steady state has been achieved can lead to overdosing. While we never intentionally overdose patients, even in the palliative setting, a high degree of suffering and nearness to death will permit a more “aggressive titration” which is acceptable.

Benzodiazepines.

Benzodiazepines as primary agents for dyspnea were not effective [29]; they may be useful as an adjunct to opioids [19]. Consider adding a benzodiazepine to the dyspnea opioid regimen when the patient requires frequent doses, when the doses are escalating, or when the patient reports or displays anxiety or fear. Starting with lorazepam 1 mg orally or parenterally every 6 h as needed is a reasonable approach. Alprazolam can also be used but is only available orally. Lorazepam tablets easily dissolve and are quite reliably absorbed sublingually and are a good option when there is no IV access and the patient cannot swallow pills easily.

Noninvasive Ventilation.

Noninvasive ventilation (NIV) is an effective treatment for acute respiratory failure [30]. Effectiveness to palliate dyspnea is less well established [31]. In the case of refractory dyspnea with no expectations for disease modification, NIV becomes a relatively permanent treatment; end points need to be determined with the patient. When the patient is near death, and conscious, NIV may be useful to provide some additional time for life closure. When the patient is near death and hypersomnolent or unconscious, there is no patient role for NIV; families may request prolongation to meet the family needs. Stopping points when the patient no longer benefits need to be diplomatically negotiated with the family.

An NIV task force of the Society of Critical Care Medicine made recommendations regarding three categories of patients: (1) NIV with no limits on advanced life support, (2) NIV with “do not intubate” limitations, and (3) NIV with comfort measures only. In Category 1 the expectation is a return to baseline and unassisted breathing; the patient may deteriorate in spite of NIV and accept mechanical ventilation or improve. In Category 2 the goal is also a return to baseline but in this case if the patient declines with NIV or finds NIV intolerable than other palliative treatments for dyspnea are indicated, such as opioids. In Category 3, for which there is little evidence, the goal of NIV is to reduce dyspnea. The end point is improved symptoms; failure to improve symptoms or worsening discomfort from the NIV warrants discontinuation [32].