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Palliative cancer care - dyspnoea - Management
When should an opioid be considered?
- Consider using a strong opioid in people who need symptomatic treatment of dyspnoea, especially those with shortness of breath who are near the end of life.
- Continue with non-pharmacological strategies when initiating an opioid. See Simple measures to help dyspnoea.
- For more information see the section on opioids in Prescribing information.
Clarification / Additional information
- Normal-release oral morphine is the usual opioid of choice:
- Routes of administration other than oral may be considered, but use of nebulized opioids is not recommended for symptomatic relief of breathlessness [Jennings et al, 2002; Kvale et al, 2003; Doyle et al, 2004; Brown et al, 2005; Fraser Health, 2006; ICSI, 2007].
- Intermittent opioid dosing is appropriate if dyspnoea is not continuous.
- If the person cannot take oral medication, use a subcutaneous bolus of diamorphine when required or a subcutaneous continuous infusion of diamorphine delivered through a syringe driver [Lothian Palliative Care Guidelines Group, 2004b; Pan-Glasgow Palliative Care Algorithm Group, 2005].
- Concomitant use of an anti-emetic should be considered and treatment with regular laxatives commenced.
Basis for recommendation
- This recommendation is based on palliative care guidelines [Lothian Palliative Care Guidelines Group, 2004b; NHMRC, 2004; ICSI, 2007] and expert opinion from the palliative care literature [Kvale et al, 2003; Doyle et al, 2004; Booth, 2006].
- Opioids can influence a person's perception of dyspnoea, and central mediation of breathing occurs in the brainstem respiratory centre, an area rich with opioid receptors [Booth and Dudgeon, 2006].
- Two systematic reviews using the same data investigated the effectiveness of opioid drugs given by any route in relieving breathlessness in people who are being treated palliatively:
- Eighteen studies were identified, of which nine involved the non-nebulized route of administration and nine the nebulized route. A small but statistically significant positive effect was found when opioids were administered orally or subcutaneously [Jennings et al, 2001; Jennings et al, 2002].
- Evidence was insufficient to conclude whether nebulized opioids were effective or any better than nebulized normal saline.
- A more recent systematic review investigated the effectiveness of nebulized morphine in the management of dyspnoea due to chronic lung disease:
- Results from nine small studies do not support the use of nebulized morphine for treatment of dyspnoea, although several positive case reports have been published [Brown et al, 2005].
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