Non-Pain Symptoms
Respiratory:
Dyspnea
Dyspnea is the subjective sensation of shortness of breath. It is important to remember that objective findings such as tachypnea or oxygen desaturation are not usually correlated with the patient's perception of breathlessness.
Causes: The are many causes for dyspnea including:
- Pain
- Fatigue
- Anxiety
- Infection
- Acidosis
- Fluid overload
- Anemia
- Pulmonary disease/dysfunction
- bronchospasm
- metastasis
- pulmonary embolism
- pleural effusion
- Cardiac failure
- Muscle weakness
- Thick secretions
Treatment:
Non pharmacological :
- Comfort measures as positioning, loose clothing, use of a fan and improving the room air circulation are so useful.
- If anxiety is a coexisting factor, a calm attitude and relaxation measures are strongly recommended.
Pharmacological
- Treatment depends on the etiology, the patient clinical status and disease progression.
- There are three important approaches in palliative care: oxygen, opioids and anxiolytics.
Oxygen
- The role of oxygen is controversial. Many children with dyspnea in their terminal phase may not find oxygen helpful and may become agitated by the mask or nasal prongs.
- The goal must be to improve the subjective perception of breathlessness and not the alteration of the oxygen saturation.
- The interaction between the child and the parents should be always taken in consideration. Quite often it is very important for the parents “to do something”, even when that may not be medically beneficial(3).
Morphine
Mechanisms of morphine to treat dyspnea involve several mechanisms(4):
- Acts on the CO2 receptors in the respiratory center of the medulla. Hypercapnia is part of the sense of breathlessness and morphine reduces the sensitivity to CO2.
- Produces a sedative (narcosis) effect that can be beneficial in patients with dyspnea.
- There are opioid receptors in the alveoli, so that is a possible site of local action.
- Morphine has a vasodilatory effect and in patients with heart failure and dyspnea may help to provide relief.
Morphine can be commenced at a low dose (half of the usual starting dose) and increased as required to reduce symptoms(5).
Commonly used doses:
- Morphine IV/SC 10 mcg/kg/hr plus 10 mcg/kg bolus every 5-10 min.
- Morphine PO 0.2 mg/kg q 4 h plus 0.1-0.2 mg/kg q 1 h PRN.
Benzodiazepines
Commonly used in combination with opioids and the dose should be titrated to obtain the desired effect.
Benzodiacepines are a group of drugs that reduce anxiety, sedate and improve sleep and relax muscles(5).
Commonly used doses:
- Midazolam IV/SC 1 mcg/kg/min plus 60 mcg /kg q 15 min PRN.
- Midazolam buccal 0.1-0.3 mg/kg q 4 h PRN. May be repeated after 15 min.
- Max 3 doses.
