All patients should be screened for the presence and severity of dyspnea using an appropriate tool for the patient’s condition (based on their verbal ability and cognitively awareness) and/or diagnosis.
If dyspnea is present hospice should be prepared to offer pharmacologic and non-pharmacologic treatments on site and at the first visit.
If the patient is in respiratory crisis the nurse should stay in the home until the patient is comfortable and the caregiver is comfortable with the care. The need for nursing in home for 2 hours or more may trigger evaluation of need for continuous nursing care. After leaving, the hospice calls the patient at a specific interval post-visit or at bedtime to check in.
Reassessments to evaluate comfort should occur on each visit and when the patient exhibits signs of distress.
Patients in their last days typically become unable to self-report; many are also deeply fatigued and may not wish to respond to a detailed assessment. At this point observation of symptoms and physical indicators and caregiver report should be used to recognize dyspnea (Campbell, 2010).
Educate caregiver on dyspnea, symptoms, what is normal given the patient’s status and how to identify increased discomfort.
Educate the caregiver about what to expect regarding changes in breathing in the last few days.
An on-site visit should be triggered if the patient/caregiver calls more than once regarding dyspnea.
If 2 doses of opioid are not effective, in may mean the dose is not high enough.
Patients who have respiratory symptoms and or live alone are initially called by the on call nurse every evening and weekend in order to develop trust and build relationships. Use a method such as SOS for SOB to help talk someone through the anxiety caused by dyspnea.
Both pharmacologic and non-pharmacologic interventions should be included in the treatment plan. See below for both interventions.
Pharmacological Interventions
A variety of medications are used for dyspnea.For patients with terminal disease and dyspnea, opioids are a first line choice in symptom relief (Viola, 2008; NCI #1, 2014).
Reduce respiratory distress:
Opioid treatment is typically with immediate-release morphine which reduces the respiratory system autonomic response to oxygen need. Opioid dose is titrated to bring relief to the patient (Maxwell, 2007).
Reduce anxiety:
Anxiolytic agents such as the benzodiazepine lorazepam are commonly provided as an adjunct to morphine.
Treatment of cough:
Medications for cough are multifaceted and are determined by the underlying cause of the cough. Opioids suppress cough, antibiotics reduce infections that promote secretions, diuretics reduce fluid in the lungs for patients with heart failure.
Some patients also benefit from medications that numb the throat to reduce cough reflex.
Reduce secretions:
Administration of anticholinergics can reduce secretions that contribute to cough and discomfort.
Anticholinergics may cause dry mouth as a side effect, so are used as needed when secretions are causing patient distress.
Guaifenesin with or without codeine is used to increase viscosity of secretions.
Some hospices offer nebulized saline for patients to loosen thick secretions.
Open airways:
Bronchodilators are used to reduce wheezing
As patients near death they lose the ability to use a metered dose inhaler. Bronchodilators should be provided as aerosol treatments in this case.
Corticosteroids are used as adjuncts to other dyspnea treatments to shrink swelling around tumors and in the airways.
Newer Approaches:
Many hospices have developed techniques for reducing dyspnea that have some evidence but are not yet recommended by guidelines.
Some hospices report good results by using nebulized Lasix (furosemide) in dyspnea management as it reduces the sensation of not getting enough air (Newton 2008).
Although evidence is inconclusive, some hospices report patients’ getting relief from nebulized morphine (NCI #2, 2014). Nebulized medications may be used if the patient cannot get dyspnea relief through other modalities.
*Interventions can be combined or intensified until the patient is comfortable.
Non-Pharmacological Interventions
Environment:
Provide a calming environment based on the patient’s perception of calm.
Try temperature or lighting changes, providing music or controlling the number visitors in the room.
Fan:
Many patients benefit from a fan blowing air at the face.
A wet cloth on the face in addition to the fan stimulates the trigeminal nerve and may provide the sensation of better ability to breath.
Mindful Breathing:
Patients with COPD often feel some relief with pursed lip breathing.
Dyspnea generally is not relieved by breathing techniques when the patient has failing pulmonary function due to terminal COPD or in active dying phase.
Although there is not strong evidence for it, some patients benefit from “pacing” their breathing to synchronize with controlled breathing of a loved one or provider who is acting as a model or coach.
Oxygen:
Oxygen should be provided in the method or flow that achieves comfort for the patient.
Oxygen delivery mode – mask, cannula or tent - should also reflect the patient’s wishes.
Humidified oxygen may prevent dry mouth.
Oxygen is not beneficial for patients near death except where it is reported or observed to decrease patient distress.
Oxygen saturation levels of the blood and oximetry monitoring may predict respiratory distress but do not signify distress; some patients display respiratory comfort even in the face of profound hypoxemia.
Positioning and Comfort:
Many patients are more comfortable upright or in “tripod” sitting position (leaning against a table).
Many patients experience a dry mouth or lips – olive oil or swabs may help with relief.
Reduce Anxiety:
Dyspnea can make the patient anxious and fearful. The increased muscle tension increases oxygen consumption that exacerbates the breathlessness.
The first line approach is to reduce dyspnea, which reduces anxiety.
If the patient remains anxious, she/he may be offered relaxation techniques and medications for the anxiety, in addition to medications specifically targeted to dyspnea and identified here.
Tools
No single tool has been identified as the gold standard (Mularski, Campbell 2010) but there are over 40 validated instruments used to assess for dyspnea and its severity.
Tools for Patients Able to Verbalize Dyspnea
Modified Borg Scale – uses descriptive terms to measure dyspnea with activity.
Edmonton Symptom Assessment System (ESAS) (Wantanabe, 2012; Philip 1998). This is a multi-symptom assessment tool used to evaluate for the presence and severity of several symptoms including dyspnea.
Memorial Symptom Assessment Tool-Short Form (Chang, 2000; Webber, 2011). This tool evaluates for the presence of multiple physical and psychological symptoms including shortness of breath by asking the patient to rate how much the symptoms “distress or bother” them on a scale of 0-4.
Respiratory Distress Observation Scale (RDOS) (Campbell, 2010) – This is an adult observational scale that evaluates indicators of respiratory distress including heart rate, respiratory rate, restlessness, accessory muscle use and other indicators. It has been validated for use by trained caregivers, but not yet for use by caregiver members.
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