Table 7.
Nonpharmacologic intervention for palliative dyspnea management in the emergency department
| Nonpharmacologic Intervention | Detail |
|---|---|
| Airflow interventions | A fan blowing air toward the patient’s face (trigeminal nerve distribution). |
| Supplemental oxygen | Standard therapy for patients with symptomatic acute hypoxemia on room air (SpO2 ≤ 90%). In other scenarios, a therapeutic trial may be based on symptom relief, which could be helpful in terms of airflow. |
| Nasal cannula | Patients generally prefer nasal cannula administration to a mask, as is commonly seen in the agitation of imminently dying patients due to the mask. Standard supplemental oxygen is typically delivered through a nasal cannula at 2–6 LPM. |
| High-flow nasal cannula (HFNC) | • Alleviating dyspnea by increasing oxygenation, improving ventilation with nasopharyngeal washout, stimulation of the trigeminal nerves, augmentation of positive airway pressure, reduction of work of breathing, and heating and humidifying of the inhaled gas • Offered when the patient has severe hypoxemia and the goal is concordant. HFNC could also be used as a time-limited therapeutic trial intervention. • Set the temperature 34°C to 37°C. The flow rate usually starts at 45–50 LPM but may decrease to 20 LPM or increase gradually up to 80 LPM of heated and humidified oxygen, depending on the patient’s comfort. |
| Noninvasive ventilation (NIV) | • Alleviating dyspnea by increased oxygenation, improved ventilation by providing positive end-expiratory pressure, and augmenting respiratory muscles. • More likely to be beneficial for patients with hypercapnic respiratory failure and concordant goals. NIV could also be used as a time-limited therapeutic trial intervention. • The contraindications include facial trauma, a reduced level of consciousness, severe vomiting, the inability to clear secretions, and severe claustrophobia. • The potential adverse events include skin breakdown, muffled communication, claustrophobia, and the inability to eat. Approximately 7% of patients have discontinued due to intolerance. |
| Positioning | • The head and chest are elevated while in the sitting position, possibly with arms elevated on pillows or a bedside table. • A side-lying position with the “good” lung up or down is helpful for increasing perfusion and/or ventilation. |
| Bedside breathing exercises | • Abdominal breathing: when inhaling, focus on filling the lungs completely and feel the stomach move outward away. While exhaling, feel the stomach fall slowly and the lungs empty. • Pursed-lip breathing: exhale from the mouth as twice long as inhale. Breathe in through the nose (eg, count 1–2). Pucker the lips and breathe out slowly through the mouth (eg, count 1–2-3–4). |
| Bedside relaxation techniques | Mindfulness, meditation, guided imagery, and distraction strategies (eg, music, pictures, reading by oneself or a caregiver) |
| Discontinuing parenteral fluids | In the imminently dying patients |
Abbreviations: ED, emergency department; LPM, liter per minutes; SpO2, peripheral capillary oxygen saturation.
Data from [Weissman DE. Dyspnea at End-of-Life. Palliative Care Network of Wisconsin. 2015. Available at: www.mypcnow.org/fast-fact/dyspnea-at-end-of-life/. Accessed March 2023.] [Ahmed A, Graber MA. Approach to the adult with dyspnea in the emergency department. UpToDate 2022. Available at: https://www.uptodate.com/contents/approach-to-the-adult-with-dyspnea-in-the-emergency-department. Accessed March 2023.] [Hui D, Bohlke K, Bao T, et al. Management of Dyspnea in Advanced Cancer: ASCO Guideline. J Clin Oncol. 2021;39(12):1389–1411. https://doi.org/10.1200/JCO.20.03465] [Mularski RA, Reinke LF, Carrieri-Kohlman V, et al. An official American Thoracic Society workshop report: assessment and palliative management of dyspnea crisis. Ann Am Thorac Soc. 2013;10(5):S98-S106. https://doi.org/10.1513/AnnalsATS.201306-169ST] [Quest TE, Lamba S. Palliative for adults in the ED: Concepts, presenting complaints, and symptom management. UpToDate 2022. Available at: https://www.uptodate.com/contents/palliative-care-for-adults-in-the-ed-concepts-presenting-complaints-and-symptom-management. Accessed March 2023.]