Opioid therapy for emergency management of severe acute breathlessness in palliative care
Opioids are a key part of the multifaceted management of severe acute breathlessness; see Principles of emergency management of severe acute breathlessness in palliative care. Examples of clinical scenarios in which opioid therapy might be used for emergency management of severe acute breathlessness gives examples of clinical scenarios in which opioid therapy might be used for the emergency management of severe acute breathlessness.
Do not use nebulised opioids to treat breathlessness—there is no evidence of benefitBarnes, 2016.
For patients with palliative care needs who have severe acute breathlessness and are being treated in a monitored acute care setting (eg an emergency department or intensive care unit)1, use:
1morphine 1 to 2.5 mg intravenously, repeated at 5-minute intervals as required; seek specialist advice if 3 doses do not improve breathlessness morphine
OR
1morphine 2.5 to 5 mg subcutaneously, repeated at 10-minute intervals as required; seek specialist advice if 3 doses do not improve breathlessness. morphine
The primary aim of opioid therapy is to decrease breathlessness. Studies show that when appropriate doses of opioids are used, they do not cause respiratory depression or shorten lifeBarnes, 2016Gallagher, 2010; however, use caution with short interval opioid dosing because toxicity such as drowsiness can occur. See also Opioid adverse effects in palliative care and Opioid-induced ventilatory impairment in palliative care.
For patients with palliative care needs who have severe acute breathlessness and are not being treated in a monitored acute care setting (eg patient is being treated in an inpatient ward or community aged care), lower opioid doses are used and the time between doses is increased to reduce the risk of toxicity. Use:
1morphine immediate-release 2 to 5 mg orally, 1-hourly as required23; seek specialist advice if 3 doses do not improve breathlessness morphine
OR
1morphine 1 to 2.5 mg subcutaneously, 1-hourly as required; seek specialist advice if 3 doses do not improve breathlessness. morphine
The ceiling effect for opioids in breathlessness is approximately 30 mg oral morphine equivalent in 24 hours; beyond this dose, adverse effects usually outweigh any additional improvement.
For patients who already take a regular opioid for another indication (eg pain), the above doses of morphine (or equivalent dose of another opioid) can be used; however, if these doses are ineffective, consider increasing to the dose the patient uses for breakthrough pain. A higher maximum total daily dose (ie greater than 30 mg oral morphine equivalent) may be required in patients who take a regular opioid for another indication. Seek specialist advice if the patient’s cumulative total daily opioid dose is higher than 100 mg oral morphine equivalent.
Case study 1
A middle-aged patient with severe COPD presents to hospital by ambulance with severe acute breathlessness, on a background of increased cough and fever. The breathlessness remains severe despite salbutamol administration and appropriate oxygen titration.
Arterial blood gas measurement shows hypoxic and hypercapnic respiratory failure, and it is agreed to start noninvasive ventilation. The patient and treating team agree that invasive ventilation or cardiopulmonary resuscitation are not appropriate. A chest X-ray is clear. Oral antibiotics, prednisolone and regular salbutamol are started for an infective exacerbation of COPD.
While these acute investigations are being performed, and management decisions are discussed, consider using an opioid to help manage severe acute breathlessness.
Case study 2
An older patient with advanced head and neck cancer presents to the emergency department with breathlessness and stridor. While the patient, their oncologist and the ENT surgeon discuss active treatment options to manage the airway and cancer, nebulised adrenaline and a corticosteroid may be used to manage the obstruction; an opioid can be considered to help manage severe acute breathlessness.