MKSAP Quiz: dyspnea in a patient with end-stage COPD
A 72-year-old man is evaluated for dyspnea at rest. He has end-stage COPD and is on a home hospice program. He has weight loss, reduced functional capacity, and muscle atrophy. His medications are ipratropium, salmeterol, fluticasone, albuterol as needed, and prednisone. He is uncomfortable, with chronic air hunger that has gradually increased over the past 2 weeks. Otherwise, his symptoms have been stable without change in cough, sputum production, or fever.
A 72-year-old man is evaluated for dyspnea at rest. He has end-stage COPD and is on a home hospice program. He has weight loss, reduced functional capacity, and muscle atrophy. His medications are ipratropium, salmeterol, fluticasone, albuterol as needed, and prednisone. He is uncomfortable, with chronic air hunger that has gradually increased over the past 2 weeks. Otherwise, his symptoms have been stable without change in cough, sputum production, or fever.
On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 110/84 mm Hg, pulse rate is 102/min, and respiration rate is 30/min; BMI is 17. Breath sounds are decreased. Oxygen saturation on 2 L of oxygen via nasal cannula is 92%. Hematocrit is 36%.
Which of the following is the most appropriate management?
A. Administer a blood transfusion
B. Administer diazepam
C. Administer morphine sulfate
D. Increase oxygen flow
MKSAP Answer and Critique
The correct answer is C: Administer morphine sulfate. This item is available to MKSAP 16 subscribers as item 58 in the Pulmonology and Critical Care Medicine section. More information is available online.
The most appropriate management is to administer morphine sulfate. Dyspnea is one of the most common symptoms encountered in palliative care. It is most often the result of direct cardiothoracic pathology, such as pleural effusions, heart failure, COPD, pulmonary embolism, pneumonia, or lung metastases. Patients with underlying lung disease on bronchodilator therapy should have this therapy continued to maintain comfort. Opioids are effective in reducing dyspnea in patients with underlying cardiopulmonary disease and malignancy. In patients already receiving opioids, using the breakthrough pain dose for dyspnea and increasing this dose by 25% if not fully effective may be helpful. A 5-mg dose of oral morphine given four times daily has been shown to help relieve dyspnea in patients with end-stage heart failure. Low-dose (20-mg) extended-release morphine given daily has been used to relieve dyspnea in patients with advanced COPD.
If severe anemia is uncovered as a cause of dyspnea, a blood transfusion may help relieve symptoms. However, this patient has adequate oxygen carrying capacity, so a blood transfusion is not indicated.
In contrast to opioids, benzodiazepines have not demonstrated consistent benefit in treating dyspnea; however, they may have a special use in patients with dyspnea caused by anxiety.
Oxygen may be useful in relieving dyspnea in terminally ill patients with hypoxemia, but a meta-analysis suggests that it has limited use in symptom relief in patients without hypoxemia. Increasing the flow of oxygen provides no added value in patients already receiving oxygen with adequate oxygenation.
Key Point
- Opioids are effective in reducing dyspnea in patients with end-stage COPD.