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Breathlessness

 

Guiding Priniciple:

Treat the patient's breathlessness if it is affecting their quality of life.

  • e.g. anxiety, anemia, infection
  • Breathlessness is a subjective discomfort involving the patient’s perceptions and reactions to feeling breathless. It can often be one of the most distressing symptoms of end-stage kidney disease
  • The most common cause for breathlessness in this patient population is pulmonary edema.
  • Start or increase dose of furosemide (Lasix) (loop diuretic).
  • Watch for hypotension and dehydration with decreasing kidney function.
  • Consider combination therapy (low-dose metolazone and high-dose oral furosemide (Lasix)).
  • Metolazone 2.5-5 mg PO in addition to individual‘s furosemide (Lasix) regime up to 120 mg PO BID x 2-5 days, then re-evaluate.
  • Explore with patient contributing and alleviating factors.
  • Sit in an upright position (45°).
  • Position by an open window.
  • Have a fan blow air gently across the face (stimulation of the trigeminal nerve V2 branch has central inhibitory effects on dyspnea).
  • Maintain humidity in room.
  • Pursed lip breathing.
  • Supplemental oxygen: Provide oxygen and titrate to relieve symptoms rather than to achieve a particular oxygen level.
    • Be cautious providing high air flow oxygen to patients with COPD, as the drive for breath depends on their carbon dioxide level.
    • Note: the patient must be hypoxic at rest in order to qualify for coverage at home.
  • Meditation, mindfulness, music and/or relaxation therapy.
  • Provide reassurance.
  • Consider referral to dietitian for consultation on fluid and salt management (for volume overload) (See:  Sodium/Fluid Statement)
  • See: Feeling Short of Breath Patient Handout

Opioids are the most effective drugs for the treatment of breathlessness in end-stage disease. They are safe to use in appropriate doses and are most effective when given orally or by parenteral (subcutaneous or IV) routes. Ensure patient has a laxative regime (See: Constipation Guideline).

Always start with a low dose and titrate slowly to effect.

For shortness of breath that is episodic and primarily associated with a specific activity, consider:

Fentanyl

  • 12.5 mcg subcutaneously/sublingually PRN
  • When used for an opioid naïve patient, start with a low dose on a PRN basis. Due to its fast action, fentanyl works well in cases where breathlessness is predictable. It is a preferred opioid for end stage kidney failure.

For shortness of breath that is more constant or unpredictable in nature, consider:

Hydromorphone (Dilaudid)

  • 0.5 mg PO (0.2 mg subcutaneously) q4h around-the-clock and q1h PRN
  • Due to the accumulation of metabolites, always start with a low dose and monitor closely for signs of toxicity.

If the patient is already taking an opioid for pain , educate the patient and family that it can also be used for the management of breathlessness.

  • Increasing the opioid and/or consider a consult to Palliative Care.
Note: If the patient is in the last days to weeks of life, see the End of Life Breathlessness Algorithm. Open Algorithm PDF

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