PERT Program

Tip of the Month: December 2004


THE USE OF NEBULIZED MEDICATIONS
FOR THE TREATMENT OF DYSPNEA


Defining Dyspnea and its Impact on Quality of Life

Dyspnea is a subjective experience, often described as shortness of breath, or an unpleasant awareness of breathing. It is not necessarily associated with objective measures of respiratory function such as oxygen saturation or hypoxemia. Some patients with profound dyspnea have no objective measures of impaired respiratory function and some with extensive pulmonary impairments may experience no dyspnea.¹ Dyspnea may or may not be accompanied by a cough.

Dyspnea is both common and distressing in dying patients. Ripamonti and colleagues² reported that more than 70% of hospice patients with advanced cancer or lung disease suffer dyspnea in the last 4 weeks of life. Both dyspnea and cough can negatively affect a patient's daily activities such as bathing, walking, and talking. The patient may become more isolated, dependent on others, and experience spiritual exhaustion.¹


Assessing Dyspnea

The patient's self report is the best indicator of the presence of dyspnea and the amount of distress it causes. To assess dyspnea, staff can use an adapted 0–10 intensity rating scale. (For example, “if 0 is no difficulty breathing and 10 is the most difficulty breathing you can imagine, what number describes your breathing right now?”) This same scale can be used to evaluate treatment efficacy.


Treating Dyspnea

Medical treatment should focus on identifying and treating the underlying cause of dyspnea whenever possible. Treatable conditions such as tumor obstruction, pleural effusion, ascites, infection, and anemia are associated with dyspnea in palliative care patients.³

Common interventions for managing dyspnea include both pharmacological and nondrug treatments.
Examples of nondrug interventions are
  • Positioning the patient (most often this is in an upright position which helps make room for the lungs to expand)
  • Using pillows to prop up the patient
  • Cool air from fans, air conditioning, or an open window
  • Calm, reassuring caregivers
  • Relaxation techniques
  • Pursed lip breathing
Frequently used medications and treatments include
  • Oxygen
  • Steroids
  • Bronchodilators
  • Sedatives
  • Oral and parenteral opioids
  • Anxiolytics and tranquilizers

Nebulized Medications

Opioids

Opioids have been used treat dyspnea since the end of the 19th century, although the mechanisms by which opioids are effective are poorly understood.¹ Today, opioids are a standard treatment of end-stage dyspnea. However, the systemic side effects of opioids, such as sedation, confusion, urinary retention, and constipation, sometimes are unacceptable. Nebulized opioids may relieve dyspnea by acting locally on opioid receptors in the lungs, thereby decreasing systemic side effects.

Despite the potential advantages and effectiveness of nebulized opioids, there are few published studies documenting the effectiveness of this route of administration for end-of-life dyspnea. The studies that have been published are case series in small sample sizes. There are no randomized controlled trials, which are considered the “gold standard” of establishing the efficacy of therapies. Comprehensive reviews of nebulized opioids conclude that there is no evidence to support their use in the treatment of dyspnea.4-6

The reported side effects of nebulized opioids, though rare, include respiratory depression and bronchospasm. Some authors have suggested that fentanyl may be less likely to cause bronchospasm than other nebulized opioids.5

Although there is little research to recommend this route of administration, nebulized opioids are used clinically in specific situations. Anecdotal reports support fewer dyspneic symptoms in patients who use nebulized medications. This is an important factor to consider when collaborating with physicians to provide comfort to residents who are experiencing dyspnea.

At Franciscan Hospice, we use nebulized opioids on an intermittent basis. If a patient expresses a preference for using nebulized medications, then that would be our first choice. Often we use sublingual morphine first to see how this works for the patient, as well as how easily the caregiver can administer this form. We use other opioids if a patient has had (or believes he has had) an allergic reaction from morphine. The patient's historical experience with opioids is important; we do not want to suggest something that causes increased anxiety resulting in increased dyspnea.

Other medications

Most of the literature about nebulized medications for dyspnea concerns opioids. However, other medications also are used. For example, there are case reports regarding the successful use of furosemide in terminally ill patients with dyspnea.7 Nebulized local anesthetics such as lidocaine have been used to treat cough associated with bronchoscopy, and there is anecdotal evidence for their use for persistent cough; however, they should be used with caution because they can cause anaphylactic reactions and impaired gag reflex. Moreover, they can leave a bitter taste.³

The Franciscan Hospice experience with nebulized furosemide (Lasix®) or bupivicaine is limited. In two patients, nebulized medications were ordered after traditional oral medications failed to provide relief. Furosemide was ordered for a patient who was NPO but still desired diuresis. Bupivicaine was ordered for a patient with a persistent cough who did not respond to cough syrups or oral opioids. Both patients died prior to using the medications; however, we felt comfortable offering this route as an alternative when other therapies failed.


Examples of Nebulized Medications Used in Hospice and Palliative Care

Opioids
  1. Small Volume Nebulized (SVN) Morphine: 5–10mg with 2.5ml saline (unit dose) every 4 hours prn dyspnea, can use along with albuterol unit dose.

  2. Hydromorphone (Dilaudid®): 2mg in 2.5ml saline every 4 hours prn shortness of breath. May use with albuterol unit dose.

  3. Fentanyl Citrate: 25 micrograms in 2ml of saline every 2–3 hours, prn dyspnea.
Other Agents
  1. Furosemide (Lasix®): 20–40 mg in 2.5ml saline once or twice daily, prn dyspnea caused by fluid retention.

  2. Mucomyst®: 1–2ml of 20% solution via small volume nebulizer every 4 hours, prn thick mucous.

  3. Bupivicaine (Marcaine®): 0.25%, 1–2 mls every 4–6 hours, prn cough; begin with 1 ml every 6 hours, titrate to relief of cough, no eating or drinking for 30 minutes to 1 hour after the treatment.

Tips for Working with Patients receiving Nebulized Medications

When using nebulized medications, remember the following:

  • Teach the resident not to hyperventilate and to breathe deeply during the nebulizer treatments.

  • Have the resident sit up during the treatments to ensure full expansion of the chest.

  • If holding the nebulizer is fatiguing for the resident, enlist the help of family members to assist.

  • Avoid the use of facemasks for nebulized treatments, as these tend to give the resident a feeling of suffocation and cause trapping of aerosolized droplets in and on the nose.

  • Observe the patient's technique for using the nebulizer. Instruct the patient to place the mouthpiece between his or her teeth, with the lips closed around it. Also instruct the patient to keep his or her tongue below the mouthpiece.8


Summary

Further research with larger samples of patients is needed to explore the effects of these nebulized medications. However, clinicians can assess the appropriateness of providing nebulized medications for symptom relief in their individual patients. This decision is based on the patient's and family's goals, and the efficacy or lack thereof from other forms of treatment. Providing comfort to our patients and families is the goal each of us strives for in hospice and palliative care.



This month's Tip was provided by Pam Ketzner, RN, MN, CHPN, Educator, and Michael Lindgren, RPh, Pharmacist, from Franciscan Hospice, Tacoma, WA.



References


  1. Coyne, P.J. (2003). The use of nebulized fentanyl for the management of dyspnea. Clinical Journal of Oncology Nursing, 7, 334-335.
  2. Ripamonti C, Fulfaro F, Bruera E. Dyspnoea in patients with advanced cancer: incidence, causes and treatments. Cancer Treat Rev. 1998;24(1):69-80.
  3. National Cancer Institute (2004). Dyspnea and coughing in patients with advanced cancer. Available at: http://www.nci.nih.gov/cancertopics/pdq/supportivecare/cardiopulmonary/HealthProfessional/page2, Accessed December 16, 2004.
  4. Jennings, A.L., Davies, A.N., Higgins, J.P., Gibbs, J.S., & Broadley, K.E. (2002). A systematic review of the use of opioids in the management of dyspnoea. Thorax, 57, 939-44
  5. Johnson, D. (2004). Nebulized opioids for dyspnea: fact or fiction? Retrieved November 23, 2004 from Available at: www.jasonprogram.org/nebulized_opioids.htm
  6. Joyce, M., McSweeney, M., Carrieri-Kohlman, V., & Hawkins, J. (2004). The use of nebulized opioids in the management of dyspnea: evidence synthesis. Oncology Nursing Form 31, 551-559.
  7. Kohara, H., Ueoka, H., Aoe, K., Maeda, T., Takeyama, H., Saito, R., Shima, Y., Uchitomi, Y. (2003). Effect of nebulized furosemide in terminally ill cancer patients with dyspnea. Journal of Pain and Symptom Management, 26, 962-7
  8. Krames On Demand (2004). Using a nebulizer. http://www.kramesondemand.com/HealthSheet.aspx?id=82459&ContentTypeId=3 Accessed December 21, 2004.