Contents:
Pharmaceutical intervention
NOTE: Maximise treatment for underlying disease and liaise with appropriate specialist team.
- There is no robust evidence base for the use of Palliative oxygen to relieve breathlessness.
- There is also limited value if oxygen saturation is already >90% prior to starting oxygen therapy.
- If prescribing oxygen 1-2 litres per minute would be usual flow rate, via nasal cannula.
- In palliative care routine monitoring with blood gases is not usually required but use oxygen with caution in patients who are known or have the potential to retain CO2.
Steroid treatment may be helpful in patients with COPD, who have previously responded to this treatment. Short term steroid treatment can also be of benefit to patients with malignant obstructive disease (large volume lung tumours or mediastinal lymphadenopathy) prior to treatment with palliative radiotherapy, and in inflammatory malignant lung disease.
Consider the following doses:
- Oral prednisolone for exacerbations of known COPD; (30mg od for 5 days).
- 8-16mg Dexamethasone daily for obstructing lung tumours/ lymphadenopathy – prior to radiotherapy.
- Steroids may be worth considering as a therapeutic trial in patients with lymphangitis (typically dexamethasone 16mg per day).
- High dose dexamethasone (16mg daily) can also be used to relieve stridor due to malignant upper airway obstruction (ONLY PRESCRIBE ABOVE 16mg AFTER SEEKING SPECIALIST ADVICE).
In patients with viscous respiratory secretions consider the use of:
- Saline Nebulisers (0.9% Sodium Chloride) 2.5mls PRN up to every 4 hrs
- Carbocisteine 375mg tablets or oral liquid 250mg/5mls
- Dose 750mg TDS initially to aid sputum clearance.
- Maintenance dose 750mg BD
There are several options for the management of respiratory secretions in the dying patient. Please see West Midlands Palliative Care Guidelines and refer to your local formulary/EOLC guideline for first choice of drug.
In patients with airways obstruction or who have wheeze on clinical examination consider the use of an inhaled bronchodilator, preferably via a spacer device.
Salbutamol inhaler 100-200mcg via Spacer if necessary.
- If patient with breathlessness has low mood and anxiety symptoms please consider commencing an anti-depressant.
- Short acting benzodiazepines may be useful for those patient with marked anxiety/panic attacks associated with episodes of breathlessness.
- There is less evidence for the efficacy of benzodiazepine vs opioid therapy in relieving breathlessness.
- Consider prescribing the following:
- Lorazepam (scored 1mg blue tablet – Genus brand) 0.5mg sublingual 4–6 hourly PRN
- Diazepam 2mg–5 mg o.n. regularly for patients with ongoing debilitating anxiety
Management of chronic breathlessness with opioids
Before starting opioids please consider the following:
- Patient has optimised pharmacological management of underlying condition
- All non-pharmacological management steps have been optimised (see Step 2)
- Consider COPD or heart failure therapy, sputum management, oxygen assessment (if appropriate),
- Ask the question ‘Have I missed anything?’
Opioids can be considered for patients with chronic breathlessness who meet the following criteria
- Patient has persistent breathlessness at rest or on minimal exertion (MRC grade 5)
- Patient has a life limiting diagnosis which is the underlying cause for their breathlessness
Prescribing opioids for chronic breathlessness:
First line treatment recommendation is for REGULAR OPIOID THERAPY
• Morphine sulfate modified release tablets (MST) 5mg BD
OR
• Morphine sulfate 10mg/5mls oral solution – dose 2mg (1ml) QDS
In patients with Renal/Hepatic impairment; Frail Elderly patients or any patient in whom a slower titration is advisable recommendation is:
• Morphine Sulfate 10mg/5mls oral solution – dose 1mg (0.5ml) bd and careful titration according to clinical response
Note:
Opioids cause constipation and may cause nausea therefore it is important to co-prescribe
- Laxative medication
- Antiemetic for PRN use
Disclaimer
These Guidelines are intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.
Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.
Whilst SPAGG takes every care to compile accurate information , we cannot guarantee its correctness and completeness, and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.