As with pain, dyspnea can have many causes. When anemia, bronchospasm, and heart failure have been excluded or treated, the focus should be on symptom control. Oxygen has been shown to be helpful for controlling dyspnea in patients with hypoxia, but may be less convenient and more expensive than opioids. When the dose of opioid is titrated carefully to control the pain and is administered on a regular schedule, with additional doses available for breakthrough dyspnea, the patient can obtain excellent relief without significant respiratory depression (Bruera et al., 1990).

Evidence from 13 studies shows a valuable effect of morphine for dyspnea in advanced lung disease and terminal cancer. However, using nebulized versus oral opioids showed no additional benefit. Good-quality evidence shows that long-acting beta agonists are beneficial in the treatment of dyspnea in chronic obstructive pulmonary disease (Qaseem et al., 2008).

It may also be helpful to provide cool, moving air (open window, fan) and keep an unobstructed line of sight between

1. Has an appropriate starting dose been determined?

2. Is a co-analgesic needed?

3. Is an antiemetic needed?

4. Has a laxative been prescribed?

5. Is the drug regimen written out in sufficient detail?

6. Has the patient been warned about possible side effects that might occur initially?

7. Do the patient and family know what to do if the pain remains uncontrolled?

8. Have arrangements been made for follow-up after 1, 3, and 7 days— either by the physician or by a trained hospice nurse?

9. Does the patient know what to do if he or she needs help or advice before the next follow-up visit?

10. Is the patient confident that the pain will improve considerably, probably within a few days, certainly within 1 or 2 weeks?

Modified from Twycross RG. Symptoms Control in Far Advanced Cancer: Pain Relief, ed 2. London, Pitman, 1993.

Table 5-7 Dosing Data for Co-Analgesics


Drug Class



Bones or soft tissue

Tenderness over bone or joint pain on movement


Ibuprofen, 400mg q4hr

Inexpensive; large pills

Sulindac (Clinoril), 200mg q12hr

Well tolerated; preferred in renal impairment

Naproxen (Naprosyn susp, 125mg/5mL), 15mL q8hr

Liquid preparation

Indomethacin (Indocin, 50-mg caps or susp), q8hr

Suppository; more gastritis?

Piroxicam (Feldene, 20-mg caps), qd

Easiest to swallow; more gastritis?

Choline magnesium trisalicylate (Trilisate susp, 500mg/5mL), 15mL q12hr

No platelet dysfunction; less problem with gastritis; less effective

Celecoxib (Celebrex), 100mg q12hr

Less gastrointestinal toxicity; high cost

Nerve damage or dysesthesia

Burning or shooting pain radiating from plexus or spinal root

Tricyclic antidepressant

Amitriptyline (Elavil), 10-50mg hs

Best studied; sedating; start with low dose

Doxepin (Sinequan), 10-50mg hs

10mg/mL susp available

Trazodone (Desyrel), 25-150mg hs

Less anticholinergic effect; one third as potent as amitriptyline


Carbamazepine (Tegretol), 200mg q6-12hr

Absorbed from rectum, unlike phenytoin

Valproic acid (Depakene), 250mg q8-12hr

Liquid available, can be absorbed rectally

Gabapentin (Neurontin), 100-400mg qd to qid

Often effective but expensive

Smooth muscle spasms

Colic: cramping, abdominal pain bladder spasms


Scopolamine (Transderm-Scop), , 1-2 patches q3d

Transdermal patch

Dicyclomine (Bentyl), 10mg q4-8hr


Oxybutynin (Ditropan), 5-10mg q8hr


Hyoscyamine (Levsin), 0.125mg q4-8hr

Sublingual available


Generalized restlessness and discomfort


Hydroxyzine (Atarax or Vistaril), 10-30mg q4hr

Orally or by subcutaneous infusion

Caps, capsules; NSAID, nonsteroidal anti-inflammatory drug; susp, suspension.

the patient and the outside. Careful consideration should be given to the use of antibiotics for pneumonia in the terminally ill patient. Because dyspnea can be controlled well without antibiotics, the physician must decide whether the antibiotics will improve the quality of life or just prolong the dying.

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