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:


  • 12.5 mcg subcutaneously/sublingually/intravenously q1h 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 - 1.0 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

Warning, this site doesn't support the web browser version you are using.

Thus, certain functions may be missing or appear to be broken. Please considering updating your browser to improve your web experience.