Dyspnea is the uncomfortable feeling of being short of breath. By definition, it is a subjective sensation and may or may not be associated with hypoxia. The prevalence of dyspnea in palliative patients is high and the intensity of the sensation tends to worsen towards the end of life. Opioids are the first-line pharmacological therapy, but several other, non-medication-based therapies exist.
Essentials
Establish goals of care in consultation and conversation with the patient, family, and care team.
Dyspnea may not necessarily be due to hypoxia. Improving airflow to the patient with fans can sometimes be as effective as oxygen administration. Paramedics and EMRs should focus on relaxation and other non-pharmacological techniques before escalating to medications.
Sit the patient upright, avoiding compression of the chest and abdomen. Consider positions that allow optimal lung expansion. If the patient cannot tolerate sitting upright, positioning with the affected (i.e., poorly ventilating) lung down may relieve the sensation of breathlessness.
In cancer patients who are dyspneic, consider opioids as a first-line agent.
Oxygen is generally only required in hypoxic patients.
Additional Treatment Information
Subcutaneous morphine can be given to alleviate the sensation of dyspnea.
The dose of subcutaneous morphine is calculated by converting each of the patient’s regular opioid analgesics to a total equivalent daily dose of morphine
If the patient is not prescribed morphine, begin with 2.5 mg SC
Where the total equivalent daily dose of morphine is over 50 mg, 10% of the dose can be converted to and given as a subcutaneous dose
The maximum subcutaneous dose of morphine is 20 mg; consultation should be sought in cases where patients do not experience relief from these doses and conveyance should be considered
Calculated doses of morphine in excess of 10 mg should be discussed with a clinician, either as part of the palliative care team or through CliniCall (1-833-829-4099)
If the patient is unable to have morphine, an equivalent does of fentanyl should be administered
As an example, 2.5 mg of morphine is equivalent to 25 mcg of fentanyl; 20 mg of morphine is equivalent to 200 mcg of fentanyl
Referral Information
All palliative and end-of-life patients can be considered for inclusion in the Palliative Care Clinical Pathway (treat and refer) approach to care. Paramedics must complete required training prior to applying this pathway. EMRs are required to contact CliniCall for consultation to proceed with the ASTaR clinical pathway.
Interventions
First Responder (FR) Interventions
Provide reassurance
Promote non-pharmacological pain management strategies such as repositioning to more upright postures, relaxation, and reassurance
Provide supplemental oxygen in cases of significant breathlessness
Consider the use of alternative strategies to reduce shortness of breath (fans, windows, and improved airflow)
Emergency Medical Responder (EMR) & All License Levels Interventions
Establish goals of care in consultation and conversation with the patient, family, and care team
Complete a comprehensive dyspnea assessment
Provide supplemental oxygen in cases where SpO2 ≤ 94% or differ significantly from patient’s normal oxygen saturation
Apply other methods to provide fresh air when SpO2 measurements do not indicate hypoxia; fans, windows, and improved airflow should be attempted for at least five minutes
Primary Care Paramedic (PCP) Interventions
Assist family with the administration of any medications that are recommended as part of an established care plan
Paramedics can only administer the patient’s own medications where the symptom management plan is clear, they are trained and experienced in the technique of administration, and are operating within BCEHS scope