What is Dyspnea?

Definition

A multidimensional, subjective perception of being unable to catch your breath or having difficulty breathing.

Understanding its causes, prevention, and treatment will help most people find Relief.

Causes

• COPD
• Asthma
• Restrictive lung disease
• Bronchospasm
• Airway obstruction
• Aspiration
• Excessive Respiratory Secretions
• Medication allergic reaction
• Chemotherapy induced cardiopulmonary toxicity
• Radiation therapy induced pulmonary fibrosis
• Radiation therapy induced pericarditis
• Psychological
• Anxiety
• Anemia
• Infections
• Pulmonary embolism
• Fluid overload
• Cardiac arrhythmia
• Cardiac arrest (MI)
• Congestive heart failure
• Ischemic heart disease
• Ascities
• Hepatomegaly
• Neuromuscular disease (ALS, MS, paralysis)

Acute: arrhythmia, embolus, LV failure, MI

Gradual: pleural infection, effusion, tumor growth, anemia

Sporadic: anxiety, arrhythmia

Assessment

History

• Onset, acute or chronic dyspnea
• Is dyspnea affected by positioning
• Precipitating/relieving factors
• Timing
• What diseases/illness does this person have that may cause the dyspnea
• Medications
• Response to medications, interventions
• Allergy history
• Associated symptoms (cough, fever)
• Anxiety
• Social
• Spiritual concerns
• Impact on functionality
• Quality of life.

Physical Exam

• Appearance of patient
• Cardiopulmonary system
• Abnormal heart or lung sounds
• Abnormal breathing pattern
• Jugular venous pressure
• Use of accessory muscles
• Skin turgor/color

Non Pharmacological Interventions

Environmental changes-eliminate irritants; provide cool air, oscillating fan, or damp cloth on face, proximity of needed articles to reduce exertion, cool mist humidifier

• Positioning for chest expansion-upright
• Energy conservation techniques
• Pursed lip breathing
• Physical therapy
• Massage therapy
• Relaxation & distraction therapies
• Therapeutic touch
• Music, Guided imagery, Prayer
• Patient/family education to alleviate fear/anxiety
• Active listening and emotional support

Pharmacological Interventions

Pharmacological Treatment of Dyspnea

Pharmacological treatment should be based on relieving cause of dyspnea whenever possible.

Oxygen via nasal cannula-(use cautiously in patients with obstructive disease)

Morphine sulfate 5-15 mg po q 3 h as needed for dyspnea

• If adverse CNS side effects from oral morphine consider nebulized preservative free morphine 5-15 mg q 4 h prn with or without albuterol
  
• Discuss with PFCC/SSN/team regarding respiratory therapist consult

Obstructive Disease/Bronchospasm

• Albuterol (Proventil®) via inhaler 1-2 puffs q 4-6 h and prn
• Ipratropium (Atrovent®) 1-2 puffs TID-QID consider using a spacer device with inhalers
• If ineffective, consider same medications via nebulizer
• Consider risk versus benefit of steroid therapy via inhaler or oral dosing

Congestive Heart Failure (CHF)/Pulmonary Edema

• Lasix (Furosemide) 20-40 mg po X 1 and reassess
• If continued consider potassium supplementation of 10 mEq/20 mg of furosemide

Evaluate and document symptom at each visit until resolved. Evaluate discontinuing medications as symptoms resolve.

Collaborate with psychosocial and spiritual professionals to confirm that symptoms are managed with the most effective combination of non pharmacological and pharmacological interventions

References

Clinical Practice Guidelines: The Hospice of the Florida Suncoast (2008).

Dudgeon D. Dyspnea, Death Rattle and Cough. In: Ferrell B & Coyle N, eds Textbook of Palliative Nursing 2nd ed, pp 249 – 255. Oxford University Press, 2006.

Grauer P, Shuster J & McCrate-Protus B. (2008). Palliative Care Consultant: A reference guide for palliative care 3RDed. Kendall/Hunt publishing Co.

Kuebler KK, Davis MP & Moore CD. (2005). Palliative Practices: An Interdisciplinary Approach. Elsevier/Mosby: Missouri.

Chan KS, Sham MMK, Tse DMW & Thorsen AB. Palliative Medicine in Malignant Respiratory Disease In: Doyle D, Hanks G, Cherny N, Calman K eds Oxford Textbook Palliative Medicine. 3rd ed. pp. 587 – 618, Oxford University, 2005.

Story P, Knight CF & Schonwetter RS. Pocket Guide to Hospice/Palliative Medicine. American Academy of Hospice and Palliative Medicine, 2003.

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