Dyspnea management in palliative care: current approaches and treatment strategies

Abstract

Dyspnea is a common and challenging symptom to manage in palliative care patients. This review discusses the pathophysiology, assessment methods, and current treatment approaches for dyspnea based on the existing literature. Both pharmacological (opioids, benzodiazepines, glucocorticoids) and non-pharmacological (oxygen therapy, respiratory therapy, environmental modifications) treatment strategies are examined in detail, with a discussion on their efficacy and potential side effects. This study is a narrative review compiling the current literature on the topic.

Keywords

• Dyspnea
• palliative care
• symptom management
• multidisciplinary approach

Palyatif bakımda dispne yönetimi: güncel yaklaşımlar ve tedavi stratejileri

Abstract

Dispne, ileri evre hastalıklara sahip hastalarda yaygın ve rahatsız edici bir semptom olup yaşam kalitesini önemli ölçüde olumsuz etkilemektedir. Karmaşık fizyolojik ve psikolojik mekanizmalarla ilişkili olan bu semptomun etkili yönetimi, palyatif bakımda multidisipliner bir yaklaşım gerektirmektedir. Tedavi stratejileri, bireysel hasta ihtiyaçlarına göre uyarlanmış farmakolojik ve non-farmakolojik girişimleri içermektedir. Farmakolojik tedavide opioidler, özellikle morfin, dispne yönetiminde temel tedavi seçeneği olup solunum çabasını azaltarak hastaların rahatlamasına katkı sağlamaktadır. Fentanil ve oksikodon gibi alternatif opioidler belirli vakalarda tercih edilebilmektedir. Ancak sedasyon, solunum depresyonu ve konstipasyon gibi yan etkiler nedeniyle doz titrasyonunun dikkatli yapılması gerekmektedir. Benzodiazepinler, dispne ile ilişkili anksiyete durumunda faydalı olabilir, ancak anksiyete komponenti bulunmayan hastalarda rutin kullanımları önerilmemektedir. Malign hava yolu obstrüksiyonu, lenfanjitik karsinomatozis veya kalp yetmezliği kaynaklı dispnede glukokortikoidler ve diüretikler tedavi seçenekleri arasında yer almaktadır. Non-farmakolojik yaklaşımlar arasında oksijen tedavisi, pulmoner rehabilitasyon ve solunum egzersizleri semptomatik rahatlama açısından önemli rol oynamaktadır. Oksijen tedavisi, hipoksemik hastalarda etkili olup, hipoksemi bulunmayan hastalarda sınırlı yarar sağlamaktadır. Diyafragmatik solunum ve büzük dudak solunumu gibi solunum teknikleri, solunum verimliliğini artırabilir. Non-invaziv mekanik ventilasyon belirli hastalarda düşünülebilse de palyatif bakımda etkinliği konusunda tartışmalar devam etmektedir. Tedaviye dirençli dispne vakalarında, palyatif sedasyon son çare olarak değerlendirilebilmekte olup etik hususlar ve hasta ile bakım verenler arasındaki iletişimin titizlikle yürütülmesi gerekmektedir. Dispnenin etkili yönetimi, farmakolojik ve non-farmakolojik yaklaşımları entegre eden, hasta merkezli ve bireyselleştirilmiş bir strateji gerektirir. Bu doğrultuda, hastaların semptom kontrolünü optimize etmek ve yaşam kalitesini artırmak amacıyla multidisipliner bir yaklaşımın benimsenmesi büyük önem taşımaktadır.

Keywords

• Dispne
• Palyatif Bakım
• Semptom Yönetimi
• Multidisipliner Yaklaşım

References

1. Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4):435-52. doi:10.1164/rccm.201111-2042ST
2. Reisfield GM, Wilson GR. Prognostication in heart failure. J Palliat Med. 2007;10(1):245-246. doi:10.1089/jpm.2006.9987
3. Tokocin O, Çakmak F, İpekci A, et al. Factors affecting the morbidity and mortality of malignancy patients admitted to the emergency department. Phnx Med J. 2019;1(1):8-14. doi:10.38175/phnx.620036
4. Wang D, Creel-Bulos C. A systematic approach to comfort care transitions in the emergency department. J Emerg Med. 2019;56(3):267-274. doi:10.1016/j.jemermed.2018.10.027
5. Akbay MÖ, Oruç Ö, Tunçay E, et al. Akciğer kanserli hastaların ölüm yerleri ve palyatif bakım. Kırıkkale Üni Tıp Derg. 2022;24(3):460-463. doi:10.24938/kutfd.1096735
6. Seow H, Barbera L, Sutradhar R, et al. Trajectory of performance status and symptom scores for patients with cancer during the last six months of life. J Clin Oncol. 2011;20;29(9):1151-1158. doi:10.1200/JCO.2010.30. 7173
7. Currow DC, Smith J, Davidson PM, Newton PJ, Agar MR, Abernethy AP. Do the trajectories of dyspnea differ in prevalence and intensity by diagnosis at the end of life? A consecutive cohort study. J Pain Symptom Manage. 2010;39(4):680-690. doi:10.1016/j.jpainsymman.2009.09.017
8. Guyenet PG, Bayliss DA, Stornetta RL et al. Interdependent feedback regulation of breathing by the carotid bodies and the retrotrapezoid nucleus. J Physiol. 2018;596(15):3029-3042. doi:10.1113/JP274357

9. Santus P, Radovanovic D, Saad M, et al. Acute dyspnea in the emergency department: a clinical review. Intern Emerg Med. 2023;18(5):1491-1507. doi:10.1007/s11739-023-03322-8
10. Ehrman RR, Russell FM, Ansari AH, et al. Can emergency physicians diagnose and correctly classify diastolic dysfunction using bedside echocardiography? Am J Emerg Med. 2015;33(9):1178-1183. doi:10.1016/j.ajem.2015.05.013
11. Herigstad M, Hayen A, Evans E, et al. Dyspnea-related cues engage the prefrontal cortex: evidence from functional brain imaging in COPD. Chest. 2015;148(4):953-961. doi:10.1378/chest.15-0416
12. Guyenet PG, Stornetta RL, Souza GMPR, Abbott SBG, Shi Y, Bayliss DA. The retrotrapezoid nucleus: central chemoreceptor and regulator of breathing automaticity. Trends Neurosci. 2019;42(11):807-824. doi:10. 1016/j.tins.2019.09.002
13. Englehart V, Noonan D, Schneider SM, Thompson J. Implementing the Condensed memorial symptom assessment scale on an inpatient oncology unit. Clin J Oncol Nurs. 2022;;26(1):E1-E6. doi:10.1188/22.CJON.E1-E6
14. Quinn KL, Shurrab M, Gitau K, et al. Association of receipt of palliative care interventions with health care use, quality of life, and symptom burden among adults with chronic noncancer illness: a systematic review and meta-analysis. JAMA. 2020;3;324(14):1439-1450. doi:10.1001/jama.2020.14205
15. Tanaka K, Akechi T, Okuyama T, Nishiwaki Y, Uchitomi Y. Factors correlated with dyspnea in advanced lung cancer patients: organic causes and what else? J Pain Symptom Manage. 2002;23(6):490-500. doi: 10.1016/s0885-3924(02)00400-1
16. Ekström M, Johnson MJ, Schiöler L, Kaasa S, Hjermstad MJ, Currow DC. Who experiences higher and increasing breathlessness in advanced cancer? The longitudinal EPCCS study. Support Care Cancer. 2016;4(9): 3803-3811. doi:10.1007/s00520-016-3207-1
17. Taylor J, Fradgley EA, Clinton-McHarg T, Hall A, Paul CL. Perceived importance of emotional support provided by health care professionals and social networks: should we broaden our focus for the delivery of supportive care? Asia Pac J Clin Oncol. 2023;19(6):681-689. doi:10.1111/ajco.13922
18. Hui D, Bohlke K, Bao T, et al. Management of dyspnea in advanced cancer: ASCO guideline. J Clin Oncol. 2021;39(12):1389-1411. doi:10. 1200/JCO.20.03465
19. Ari M, Akinci Ozyurek B, Yildiz M, et al. Mean platelet volume-to-platelet count ratio (MPR) in acute exacerbations of idiopathic f idiopathic pulmonary fibrosis: a novel biomarker for ICU mortality. Medicina (Kaunas). 2025;61(2):244. doi:10.3390/medicina61020244
20. Akiyama N, Fujisawa T, Morita T, et al. Palliative care for idiopathic pulmonary fibrosis patients: pulmonary physicians' view. J Pain Symptom Manage. 2020;60(5):933-940. doi:10.1016/j.jpainsymman.2020.06.012
21. Jackson CD, Schilthuis AJ, Guice KC, Payne KS, Dabal TD. Know your guidelines 2022 series: the ASCO management of dyspnea in advanced cancer guideline review. South Med J. 2022;115(2):116-117. doi:10.14423/SMJ.0000000000001349
22. Elsayem A, Bruera E. High-dose corticosteroids for the management of dyspnea in patients with tumor obstruction of the upper airway. Support Care Cancer. 2007;15(12):1437-1439. doi:10.1007/s00520-007-0305-0
23. Klimek M. Pulmonary lymphangitis carcinomatosis: systematic review and meta- analysis of case reports, 1970-2018. Postgrad Med. 2019;131(5): 309-318. doi:10.1080/00325481.2019.1595982
24. Lin RJ, Adelman RD, Mehta SS. Dyspnea in palliative care: expanding the role of corticosteroids. J Palliat Med. 2012;15(7):834-837. doi:10.1089/jpm.2011.0260
25. Holland AE, Spathis A, Marsaa K, et al. European Respiratory Society clinical practice guideline on symptom management for adults with serious respiratory illness. Eur Respir J. 2024;63(6):2400335. doi:10.1183/ 13993003.00335-2024
26. van Dam CJ, Algera MH, Olofsen E, et al. Opioid utility function: methods and implications. Ann Palliat Med. 2020;9(2):528-536. doi:10. 21037/apm.2019.10.09
27. Vozoris NT, Wang X, Fischer HD, et al. Incident opioid drug use and adverse respiratory outcomes among older adults with COPD. Eur Respir J. 2016;48(3):683-693. doi:10.1183/13993003.01967-2015
28. Verberkt CA, van den Beuken-van Everdingen MHJ, Schols JMGA, et al. Respiratory adverse effects of opioids for breathlessness: a systematic review and meta-analysis. Eur Respir J. 2017;50(5):1701153. doi:10.1183/ 13993003.01153-2017
29. Bateman JT, Saunders SE, Levitt ES. Understanding and countering opioid- induced respiratory depression. Br J Pharmacol. 2023;180(7):813-828. doi:10.1111/bph.15580
30. Fong S, Richman-Eisenstat J, Kalluri M. Buccal hydromorphone syrup for managing dyspnea in idiopathic pulmonary fibrosis. Am J Hosp Palliat Care. 2021;38(8):1046-1052. doi:10.1177/1049909120969126
31. Mori M, Yamaguchi T, Suzuki K, et al. Do types of opioids matter for terminal cancer dyspnea? A preliminary multicenter cohort study. J Pain Symptom Manage. 2023;66(2):e177-e184. doi:10.1016/j.jpainsymman. 2023.04.009
32. Kreutzwiser D, Tawfic QA. Methadone for pain management: a pharmacotherapeutic review. CNS Drugs. 2020;34(8):827-839. doi:10. 1007/s40263-020-00743-3
33. Ragaban F, Purohit O, Del Fabbro E. Methadone in cancer-related neuropathic pain: a narrative review. Curr Oncol. 2024;31(12):7613-7624. doi:10.3390/curroncol31120561
34. Simon ST, Higginson IJ, Booth S, Harding R, Weingärtner V, Bausewein C. Benzodiazepines for the relief of breathlessness in advanced malignant and non- malignant diseases in adults. Cochrane Database Syst Rev. 2016;10(10):CD007354. doi:10.1002/14651858.CD007354.pub3
35. Simon ST, Mori M, Ekström M, Pralong A, Yamaguchi T, Hui D. Should benzodiazepines be used for reducing dyspnea in patients with advanced illnesses? J Pain Symptom Manage. 2023;65(3):e219-e223. doi:10.1016/j.jpainsymman.2022.11.018
36. Hui D, Yennurajalingam S. The role of corticosteroids in the palliation of dyspnea in cancer patients: an evidence-based review. Curr Opin Support Palliat Care. 2023;17(4):270-276. doi:10.1097/SPC. 0000000000000677
37. Hess MW. Oxygen therapy in COPD. Respir Care. 2023;68(7):998-1012. doi:10.4187/respcare.10876
38. Cranston JM, Crockett A, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev. 2008;16(3):CD004769. doi:10. 1002/14651858.CD004769.pub2
39. Comellini V, Pacilli AMG, Nava S. Benefits of non-invasive ventilation in acute hypercapnic respiratory failure. Respirology. 2019;24(4):308-317. doi:10.1111/resp.13469
40. Kızılgöz D, Akın Kabalak P, Kavurgacı S, İnal Cengiz T, Yılmaz Ü. The success of non-invasive mechanical ventilation in lung cancer patients with respiratory failure. Int J Clin Pract. 2021;75(10):e14712. doi:10. 1111/ijcp.14712
41. Cascella M, Monaco F, Vittori A, Elshazly M, Carlucci A, Piazza O. Bridging knowledge gaps: a bibliometric analysis of non-invasive ventilation in palliative care studies. J Anesth Analg Crit Care. 2024; 4(1):5. doi:10.1186/s44158-024-00140-y
42. Diaz de Teran T, Barbagelata E, Cilloniz C, et al. Non-invasive ventilation in palliative care: a systematic review. Minerva Med. 2019;110(6):555-563. doi:10.23736/S0026-4806.19.06273-6
43. Ari M, Ozdemir T, Yildiz M, et al. Factors affecting the length of hospital stay in hypercapnic respiratory failure. Diagnostics (Basel). 2024;15(1):14. doi:10.3390/diagnostics15010014
44. Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2):1602426. doi:10.1183/13993003.02426-2016
45. Yeow ME, Szmuilowicz E. Practical aspects of using noninvasive positive pressure ventilation at the end of life #231. J Palliat Med. 2010; 13(9):1150-1151. doi:10.1089/jpm.2010.9787
46. Mularski RA, Reinke LF, Carrieri-Kohlman V, et al. An official American Thoracic Society workshop report: assessment and palliative management of dyspnea crisis. Ann Am Thorac Soc. 2013;10(5):S98-106. doi:10.1513/AnnalsATS.201306-169ST
47. Surges SM, Brunsch H, Jaspers B, et al. Revised European Association for Palliative Care (EAPC) recommended framework on palliative sedation: an international Delphi study. Palliat Med. 2024;38(2):213-228. doi:10.1177/02692163231220225