Table 8.

Pharmacologic intervention for palliative dyspnea management in the emergency department

Medication	Detail
The recommended medication for dyspnea palliation
Systemic opioid	• The primary medication for palliating refractory dyspnea and dyspnea at the end of life, offered when nonpharmacologic interventions are insufficient to relieve the dyspnea • Administered orally, intravenously (IV), subcutaneously, transmurally, and rectally • Monitoring for sedation and confusion. • The doses for acute dyspnea exacerbations are 50% lower than those treating acute pain. • The opioid titration protocol is “low and slow” IV titration of an immediate-release opioid, until the patient reports or displays relief. • The widely studies and recommendations demonstrate significant reductions in dyspnea with the opioid titration protocol administration without evidence of decreased oxygen saturation or respiratory depression.
Opioid for naive patient	Initial parenteral morphine is 2–5 mg or equivalent, 15–30 min for redosing intervals. Initial oral morphine is 5–15 mg and 60 min for redosing intervals.
Opioid for opioid tolerant patient	A breakthrough dose equivalent to 10%–20% of the previous 24-h opioid dose use (morphine equivalent daily dose: MEDD).
Hydromorphone	Initial IV/subcutaneous dose of 0.2 mg every 5–10 min
Oxycodone	Initial 5 mg orally every 1 h
Benzodiazepine	• The adjunctive addition to the opioid regimen, offered to the patients with anxiety or distress related to dyspnea despite intervention trials • Short-acting benzodiazepines such as midazolam, 2–5 mg every 4 h, may be helpful. In other scenarios, the risk of respiratory depression may further increase due to the benzodiazepines’ adverse effects.
Anticholinergic therapy to dry the death rattle (secretions at the end of life)
Glycopyrrolate	Initial 0.2 mg intravenous bolus every 4–6 h or continuous intravenous/subcutaneous 0.6–1.2 mg/d
Hyoscine BUTYLbromide	Initial 20 mg intravenous bolus every 4–6 h or continuous intravenous/subcutaneous 20–60 mg/d
Hyoscine HYDRObromide	Initial 0.4 mg IV bolus every 4–8 h or continuous intravenous/subcutaneous 1.2–1.6 mg/d. Risk for delirium and agitation

Abbreviations: ED, emergency department; MEDD, morphine equivalent daily dose.

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