Background: Dyspnea, “breathing discomfort” as described by patients, and respiratory distress, the observed corollary to dyspnea, are common in ICU patients and at end of life (EOL). This symptom is quite distressing and often underestimated by clinical providers. There is limited evidence to support the specific opioid selection and administration for managing dyspnea.1 In 2009 the American Thoracic Society (ATS) published opioid dosage recommendations for treating dyspnea in critical illness.2 Only one published review, in 2022, looked at opioid use for the treatment of dyspnea in palliative care.3
Design and Participants: PRISMA-guided systematic review of studies between 2000-2021 using six databases looking at opioid management for patients at EOL.
Results: Studies included were in terminally ill adult patients with cancer and other diagnoses, all being cared for in hospitals or long-term care facilities. Twenty-three studies were included: the majority were retrospective chart reviews (13), as well as randomized controlled trials (2), non-randomized experimental (3), prospective observational (3), cross sectional (1), and case series (1). Studies included many opioids: morphine, fentanyl, oxycodone, hydromorphone and general opioid use. Routes of administration varied including intravenous, oral, subcutaneous, nebulized, oral transmucosal or a combination. The most common side effect for intravenous continuous morphine was sedation; delirium, hypercapnia, hypotension, malaise and decreased level of consciousness were also reported for this route. Both subjective reporting of dyspnea and objective reporting of respiratory distress were used.
Commentary: There are limited studies looking at the use and documentation of opioids in treating dyspnea in terminally ill patients at the end of life, and the current body of research provides no consensus on the most effective opioid, route and dose for treatment of this distressing symptom in this population. The review does support the limited guidelines regarding opioid use as set forth by the ATS.2 Additionally, recording of the symptom and changes with use of opioid treatment is often lacking. In order to improve management of this symptom, future prospective trials must look at accurate assessment of dyspnea/respiratory distress, as well as opioid tolerance, comorbidities and polypharmacy. Until this consensus exists, opioid use in this setting will continue to be individualized and care should be taken to be vigilant in assessment of this symptom in order to provide the greatest relief to patients.
Bottom Line: Be vigilant and consistent in monitoring for dyspnea/respiratory distress at EOL. Current ATS guidelines can be used as a framework for initiating and titrating opioids, but no consensus exists for treatment and thus patient management must be individualized in order to treat this often-underreported symptom which causes patients and loved ones great distress.
Reviewer: Erin Jane Salvador MD
References:
Campbell ML. How to withdraw mechanical ventilation: a systematic review of the literature. AACN Advanced Critical Care. 2007 Oct 1;18(4):397-403.
Lanken PN, Terry PB, DeLisser HM, Fahy BF, Hansen-Flaschen J, Heffner JE, Levy M, Mularski RA, Osborne ML, Prendergast TJ, Rocker G. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. American journal of respiratory and critical care medicine. 2008 Apr 15;177(8):912-27.
Jennings AL, Davies AN, Higgins JPT, et al. A systematic review of the use of opioids in the management of dyspnoea. Thorax 2002;57(11):939–944; doi: 10.1136/thorax .57.11.939
Source:
Obarzanek L, Wu W, Tutag-Lehr V. Opioid management of dyspnea at end of life: A systematic review. J Palliat Med 2023;26(5):711-726.