Dyspnea may be an issue especially for someone who is actively dying in the ED. Searching for an underlying cause is what Emerg physicians are good at; however it will be important to determine frankly if sedation and comfort measures are the principal measures desired.
- Oxygen may be helpful IF the patient is hypoxic – otherwise O2 mask may just cause distress; nasal prongs may be better tolerated
- Oxygen may be given for patient comfort alone and can be seen as a “symbol of support and care” – however the emphasis should be on NOT titrating to O2 saturation level and avoiding continuous O2 monitoring in this circumstance
- Benzodiazepines (IV/PO lorazepam, midazolam) may be helpful to descrease anxiety
- Opioid-naïve (unlikely): Morphine 1 – 2.5 mg po q6h and 1 mg po q2h prn for breakthrough dyspnea or 0.5-1 mg subcut q6h regularly and 0.5 mg subcut q1h prn for breakthrough dyspnea. Start with small doses and titrate slowly.
- Opioid-tolerant: Increase the patient’s regular dose by 25%
- Furosemide may be considered in patients with end-stage heart failure causing pulmonary edema, however evidence is limited
Also consider your non-pharmacological measures if appropriate. Examples include: using a fan; sitting the patient in an upright position; avoiding exacerbating activities; teaching breathing control or relaxation techniques.