TERMINAL BREATHLESSNESS (aka DEATH RATTLE)

(As far as we know) this isn't distressing to the patient, but is distressing to the family/friends

Etiology: patient too weak to clear airway secretions

Treatment: scopolamine 0.4-0.6 mg sc q4h prn or 1.5 mg transdermal patch placed behind ear, q3days - dries up secretions and relaxes airway

COUGH

Can lead to insomnia, anorexia, nausea, vomiting, pleuritic or MSK pain

Etiology: bronchospasm, pneumonia, bronchitis, lung CA

Treatment:

• 1) Treat causes
• 2) no smoking in area, humidified air, oral hydration, narcotic cough suppressants. (Expectorants/mucolytics have little or no efficacy)

DYSPNEA

Etiology: anemia, CHF, pleural effusion, bronchospasm, pulmonary infection, COPD, chemo/radiation damage, lung CA/mets

Acute onset: arrhythmia, m.i., embolus

Treatment:

• 1) elevate head of bed, O2 therapy
• 2) According to cause:

• bronchodilators - for bronchospasm or lung Ca
• diuretics

• antibiotics
• steroids - for bronchitis, radiation pneumonitis, lymphangitic mets, SVC obstruction, pulmonary fibrosis (Dexamethasone 4-8mg po tid/qid or Methylprednisolone 16-32 mg po tid/qid)

• 3) Air hunger suppressants (if unresponsive to tx):

• Morphine 5-15 mg q4h or increase 50% if already on morphine
• MS Contin 15-30 mg po q12h
• Hydromorphone 1-4 mg po q4h
• Diazepam 5-10 mg q6-8h
• Chlorpromazine 10-25 mg q4-6h