Correct reversible causes first
Opioids are the medications of choice for dyspnea in advanced disease.
Adjuvants and other therapies should always be considered.
Essential opioid principles
There are 12 essentials to know when prescribing opioids:
- Opioids are the medication of choice for both pain and dyspnea in advanced disease.
- Patients with addiction should have pain/dyspnea treated — use buprenorphine, adjuvant medications, limited breakthroughs, small amount dispensed frequently.
- Opioids are safe in cardiopulmonary disease, but start low go slow.
- Persistent symptoms require regular dosing, i.e. short-acting opioid q4 hours.
- Not all opioids are the same, and inter-individual analgesia/side effects vary widely.
- Opioids with few or no active metabolites are preferred for those with renal failure or frailty.
- Always order breakthrough with regular dosing: 10% of total daily opioid dose q1h prn. Recalculate breakthrough dose when regular dose is changed.
- If 3 or more breakthroughs used in the last 24 hours, increase the regular dose.
- Titrate dose to the best symptom control with the fewest side effects.
- When you prescribe an opioid, prescribe a laxative.
- If side effects are intolerable, consider rotating opioid.
- Educate patient/family about control of symptoms and opioid safety.
Talk tip: “Controlling shortness of breath helps you to have better quality of life.”
Talk tip: “These medications can always be increased if you have more shortness of breath. They do not lose effectiveness over time.”
Talk tip: “Our goal is to prevent shortness of breath, so take the medication as directed, even if you don’t have shortness of breath at the time.”
Opioid Equianalgesic Table
Name | PO dose |
|---|---|
Tylenol #3 (codeine 30mg/acetaminophen 325mg) | 2 tablets |
Morphine | 10mg |
Hydromorphone | 2mg |
Oxycodone | 7.5mg |
Fentanyl – see note below |
Morphine to fentanyl
Fentanyl 25mcg/hr patch =
50mg morphine/day orally
Fentanyl 25mcg/hr patch =
100mg morphine/day orally in CRF and frail older adult.
Lowest dose patch=12mcg/hr, but can remove half of backing and dose is 6mcg/hr
Breakthrough dose
Calculate breakthrough dose based on morphine equivalents of the patch.
Opioid dosing
Opioid | Starting p.o. dose | Oral/ SC dose | Starting p.o dose frail, older/CRF | Active metabolites |
|---|---|---|---|---|
Tylenol 3 | avoid | 2 tabs/ n/a | avoid | +++ |
Morphine | 5-10 mg q4h | 10mg/5mg | 2.5-5mg q4hr | +++ |
Hydromorphone | 1-2mg q4h | 2mg/1mg | .5-1mg q4h | ++ |
Oxycodone | 5-10mg q4h | 7.5mg/ n/a | 2.5-5mg q4h | 0 |
Fentanyl transdermal | see footnote | see footnote | see footnote | 0 |
Methadone (consult POCT) | 2-5mg q8h | 1mg/0.5mg | 1mg q12h | 0 |
Footnotes
Opioid naive: patient has NOT had 5 days of continuous opioid exposure (i.e. short-acting q4hr po,sc; long-acting q12hr; transdermal)
Fentanyl transdermal patch NOT recommended for opioid-naive patients. Previous opioid must be continued for first 12 hours of Fentanyl patch as onset delayed. See Opioid Equianalgesic Table for conversion from morphine to Fentanyl.
Morphine conversion factor:see opioid rotation
Methadone: Variable half life and dosing.Consult palliative care if not familiar with this medication.
Buprenorphine: see Opioid Equianalgesic Table under Pain
Opioid Calculations
Calculating breakthrough dose
10% of the total daily regular opioid dose q1h prn
Example
Morphine 50mg q4hr total daily dose 50×6=300mg. 300/10=30mg q1hr prn
Review + calc new dose
Add 24 hour/total regular dose+total breakthroughs used=total daily opioid dose. Divide this by dosing intervals. This is new regular dose. Recalculate breakthrough dose.
Example
Hydromorphone 12mg q4h, with 4 breakthroughs of 8mg q1h
Total daily opioid dose
(12×6)+(4×8)=104mg
New dosing
104/6=16mg q4hr with breakthrough of of 10mg q1hr prn
Switching to sustained release (SR)
Titrate short-acting to optimal dose
Total daily dose
Add total regular dose+breakthroughs (if used)
Total daily dose /2
Opioid SR q12hours
Note about younger patients
They metabolize rapidly and may require q8dosing.
Opioid Titration
goal is to achieve best relief of symptom with fewest side effects
titration rate depends on half-life of opioid, its formulation, and the metabolism and excretion abilities of patient
frail older adults – go slow on titration
titration maximums: every 24hr for short acting, every 2 days for long-acting, every 2-3 days for fentanyl transdermal, every week for buprenorphine transdermal
Opioid rotation
Add total regular dose+ breakthroughs (if used)=total daily dose. Total daily dose X morphine conversion factor=total daily morphine equivalents.
Total daily new opioid dose
Daily morphine equivalents/conversion factor to new opioid: reduce 25-50% in case of tolerance to previous opioid. Divide by dosing interval.
Morphine conversion factor
- morphine 10mg
- hydromorphone 2mg
- oxycodone 7.5mg
- Tylenol #3 – 2 tabs
Example
Tylenol 3 12tabs/day=60mg morphine equivalents per day=12mg of hydromorphone per day=9mg hydromorphone per day (reduced for tolerance)=1.5 mg hydromorphone po q4hr, hydromorphone 1mg q1hr prn for breakthrough.
Oral to parenteral
Depending on the opioid, may have to rotate to either hydromorphone or morphine for sc.
Total daily oral dose
Add up regular oral doses + breakthroughs (if used). Total daily oral dose/2=total parenteral dose.
Example
Morphine SR 120mg po q12hx2=240mg total daily morphine dose po=120mg total parenteral morphine dose=20mg s.c. q4h regular, morphine 12mg sc q1hr prn for breakthrough.
Opioid side effects
Sedation
Tolerance develops in 2-5 days. If not, rotate opioid. If symptom controlled, reduce dose.
Talk tip: “You may be drowsy for the first two days, but it should clear.”
Nausea
Common in first week
metoclopramide
- 10mg qid
haloperidol
- 0.5mg bid
Rotate opioid if persists.
Constipation
Constipation always occurs with opioid use.
Stimulant laxative (senna) +/- osmotic laxative (PEG, lactulose).
Opioid-induced neurotoxicity
Spectrum of neurotoxicity starting with reduced LOC, myoclonus, hallucinations, delirium and rarely seizures.
Rotate opioid, consider hydration, treat concurrent infection.
Pruritus
Consider rotation if persists.
Respiratory depression secondary to opioids
Rare with appropriate dosing. Respiratory depression due to opioids = increased pCO2 + decreased pO2 + low respiratory rate. Assess O2 saturation, respiratory rate and signs of hypoventilation. Differential diagnosis: sedation from drugs (benzodiazepines or neuroleptics), hypoglycemia, head trauma, exhaustion, actively dying.
Treatment
Mild – moderate: reduce/review dosing of all sedating medications
Severe: Risk of severe pain, aspiration and opioid withdrawal with full dose naloxone. Dilute dose naloxone: dilute 1ml (0.4mg/ml) naloxone in 9ml saline, slow IV push (0.5-1ml q2min) S.C. or I.M. if I.V. access not available. Goal of naloxone is to improve ventilation. Partial reversal of respiratory disturbance by naloxone does not confirm opioid as the primary cause particularly if problems develop during stable opioid dosing.
Adjuvants
Methotrimeprazine
- 5-10mg po/sc tid
- frail older adults: 2.5-5mg po/sc tid
Benzodiazepines
- consider only if strong anxiety component
- may cause delirium in frail older adults
Ketamine: Consult PC
Ketamine is a bronchodilator and is sometimes used as adjuvant or in refractory.
Oxygen via nasal prongs not routinely used in management of dyspnea due to advanced disease, as dyspnea results from lung problems, respiratory muscle weakness and metabolic issues.
Anti-anxiety
- if strong anxiety component, consider mirtazepine
Other therapies
Fan
- stimulates trigeminal V2 branch and reduces dyspnea
- direct gentle breeze across face
Calm presence
- a calm provider is essential
- family distress can exacerbate dyspnea
- meditation/relaxation may help
Position
- 45-60 degrees upright, arms away from sides
Use of oxygen in dyspnea of advanced disease
Oxygen via nasal prongs not routinely used in management of dyspnea of advanced disease, unless patient is hypoxic and trial of use provides symptomatic benefit. Dyspnea has many causes including lung problems, respiratory muscle weakness and metabolic issues that may not result in hypoxia.
BiPAP and High Flow Nasal Canula
Both options are bridge to recovery for reversible causes of hypoxia or special circumstances e.g. buying time for dying patient to achieve urgent goal e.g. visit of family
Non-invasive positive pressure ventilation (NPPV, often called ‘BiPAP’) used in patients with respiratory failure from COPD, CHF, and other disorders. NPPV decreases work of breathing and allows respiratory muscle rest during inspiration. BiPap – has adequate PEEP (high flow O2 doesn’t) can use to buy time.
High Flow Nasal Canula (HFNC): more precise and higher FiO2 delivery. HFNC can create continuous positive airway pressure, albeit less than NIV. Oxygen can be administered from 21% to 100%. May improve dyspnea, oxygen saturation, and respiratory rate comparably to NIV or O2 via nasal prongs. HFNC used as adjuvant therapy or in those intolerant to non-invasive ventilation who may recover or wish to buy time.
Talk tip: “Many people are fearful of dying when they feel short of breath. Do you feel like this?”
Patient will benefit from a plan for severe dyspnea episodes and discussion that they will not die gasping for breath as dyspnea can be managed.
Contact us: severe dyspnea in advanced illness is an emergency.