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Nov.30.2021

Dyspnea Management (Home Health Care) - CE

ALERT

Use the high-Fowler position only if the patient is responsive, hemodynamically stable, and has an unobstructed airway.

Opioids may cause depressed respiratory rate and depth. Because opioids are metabolized in the liver, with any impaired liver function, the amount of opioid—particularly morphine—that is released into the bloodstream may be lacking or may vary.undefined#ref4">4

OVERVIEW

Dyspnea, characterized by subjective breathlessness,3 is a common symptom in patients with terminal cancer, and in many cases, it is not managed well. Dyspnea is a complex symptom involving physiologic and psychologic factors that can occur in conjunction with many disease processes, especially in patients who have a life-limiting illness.2 Dyspnea may also be associated with respiratory and cardiac conditions (e.g., airway obstruction, chronic heart failure, chronic obstructive pulmonary disease [COPD], and respiratory infection). With progression of the underlying disease processes, dyspnea worsens and usually peaks in the last week of life (requiring additional home visits to better manage symptoms).5 As life expectancy decreases, the need for opioids and benzodiazepines likely will increase. Examination may reveal tachypnea, inspiratory retractions, accessory muscle use, nasal flaring, and cyanosis. Auscultation may reveal normal or diminished breath sounds, inspiratory stridor, expiratory wheezing, and crackles.

Common causes of dyspnea include:

  • Anemia
  • Ascites
  • Asthma
  • Common medications (e.g., pioglitazone, amiodarone, captopril, indomethacin, interferons, atorvastatin, loxapine, leuprorelin acetate, oral mesalamine, naproxen, nitrofurantoin, amlodipine, ticagrelor, zidovudine)
  • COPD
  • Effects of therapy (e.g., etoposide phosphate, methotrexate, paclitaxel)
  • Heart failure
  • Metabolic acidosis
  • Pleural effusion
  • Pulmonary hypertension
  • Respiratory infections
  • Tumor load

Differential diagnoses include:

  • Airway obstruction
  • Anemia
  • Chest trauma
  • Collapsed lung
  • Congestive heart failure
  • Disorders of the airway, including emphysema and asthma
  • Flail chest
  • Lung (pulmonary) sarcoidosis
  • Metastatic cancer
  • Pleural effusion
  • Pneumonia
  • Pneumothorax
  • Primary lung cancer
  • Pulmonary embolism
  • Superior vena cava syndrome

Pharmacologic interventions include those that may relieve contributing factors, such as bronchodilators, benzodiazepines, and diuretics, as well as those that may provide direct symptom relief, such as opioids (particularly morphine), steroids, and oxygen.4 Nonpharmacologic interventions include use of a fan or ambient air, decreased room temperature, sitting upright, breathing exercises, proper positioning, and relaxation techniques.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Instruct the patient, family, and caregivers regarding the potential side effects and adverse reactions to the medication.
  • Teach the patient, family, and caregivers how to order supplies, as needed.
  • Teach the patient, family, and caregivers how to keep a dyspnea diary.
  • Instruct the patient, family, and caregivers on emergency measures.
  • Instruct the patient, family, and caregivers when to contact the practitioner.
  • Instruct the patient to report changes in respiratory rate and sputum production.
  • Instruct the patient to report fever.
  • Teach the patient pursed lip breathing, relaxation techniques, diaphragmatic breathing, and inspiratory muscle training.
  • Instruct the patient, family, and caregivers on the importance of regular exercise and good nutrition.
  • Instruct the patient, family, and caregivers on oxygen use and safety in the home.
  • Teach energy conservation and pacing.
  • Advise the patient, family, and caregivers to eliminate smoking and pet dander in the home when possible. Smoking and pet dander in the home may exacerbate dyspnea.
  • Advise the patient, family, and caregivers to change the air filters in house heating and air-conditioning systems as directed.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene and don gloves. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
  2. Introduce yourself to the patient, family, and caregivers.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
  5. Verify the practitioner’s order and assess the patient for pain.
  6. Prepare an area in a clean, convenient location and assemble the necessary supplies.
  7. Assess the patient for a history of:1
    1. Smoking
    2. Lifetime occupational exposure to toxins
    3. Medications and compliance
    4. Recent hospitalizations or travel
    5. Orthopnea
    6. Exercise tolerance
      Rationale: Dyspnea is multidimensional and multifactorial.3
  8. Perform a physical examination and assess for objective signs and symptoms of dyspnea.
    1. Respiratory rate and rhythm
    2. Skin color, including cyanosis of extremities
    3. Engorged neck veins
    4. Barrel chest
    5. Nasal flaring
    6. Clubbing of fingers
    7. Decreased chest expansion
    8. Use of accessory muscles
    9. Breath sounds, paradoxical breathing, hyperventilation, expiratory wheezes (COPD), silent chest (airway stenosis)
    10. Ability to change body position and keep oxygen cannula or mask in place
    11. Tolerance of body position changes and oxygen cannula or mask
    12. Vital signs with oxygen saturation reading
  9. Obtain blood work for laboratory assessments if ordered. Review and report laboratory values to the practitioner.
  10. Assess the patient’s dyspnea. Use a standardized disease-specific assessment tool when appropriate.
    1. Frequency
    2. Timing
    3. Aggravating and alleviating factors
    4. Impact on activity
    5. Impact of emotions (e.g., anxiety, depression, anger)
    6. Diagnostics (e.g., peak flow)
  11. Place the patient in a high-Fowler position while in bed or in a tripod position (sitting on edge of bed, with feet dangling and arms resting on over-bed table).
  12. Perform nonpharmacologic interventions.
    Rationale: Providing nonpharmacologic interventions in conjunction with pharmacologic interventions may improve dyspnea management.
    1. Increase ambient airflow to the patient’s face with use of a fan.
      Rationale: Increasing airflow to the patient’s face stimulates the trigeminal nerve and inhibits dyspnea.
    2. Promote relaxation and stress reduction.
    3. Provide a walking aid.
    4. Perform breathing retraining.
  13. Perform oral hygiene.
    Rationale: Oral hygiene enhances olfactory sensations.
  14. Obtain a practitioner’s order for respiratory parameters and interventions.
    1. Apply oxygen via nasal cannula or nonrebreather mask and titrate per the practitioner’s order.
      Notify the practitioner if dyspnea does not improve with oxygen use. If oxygen is ineffective, obtain a practitioner’s order to discontinue it because of the potential for adverse reactions from continued therapy.
    2. Administer any medications ordered by the practitioner, including bronchodilators and opioids.
    3. Administer atropine, scopolamine, or hyoscyamine for excessive secretions, if ordered.
  15. If the patient does not respond to interventions or is in respiratory distress and a Do Not Resuscitate order is not present in the home, activate emergency medical services.
  16. Discard or store supplies, remove PPE, and perform hand hygiene.
  17. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Patient has positive response to interventions.
  • Patient shows decrease of respiratory distress.
  • Patient can tolerate or cooperate with oxygen facial cannula or mask.
  • Patient experiences no adverse reactions.
  • Patient and family are competent and knowledgeable in handling of oxygen-related equipment.

UNEXPECTED OUTCOMES

  • Cardiopulmonary arrest occurs.
  • Patient shows signs of respiratory distress or failure.
  • Patient is unable to tolerate or cooperate with oxygen facial cannula or mask.
  • Patient has adverse reactions to morphine sulfate, including hypotension, decreased respiratory rate, constipation, dizziness, nausea, vomiting, sweating, dysphoria or euphoria, or mental status changes.

DOCUMENTATION

  • Total red blood cell count, hemoglobin and hematocrit levels, and SpO2
  • Physical examination findings
  • Evaluation of respiration (peak flow or handheld spirometry)
  • Education
  • Patient’s progress toward goals
  • Assessment of pain, treatment if necessary, and reassessment
  • Worsening symptoms
  • Communication with practitioner and orders received
  • Patient assessment
  • Unexpected outcomes and related interventions
  • Patient’s response to interventions

REFERENCES

  1. Barbera, A.R., Jones, M.P. (2016). Dyspnea in the elderly. Emergency Medicine Clinics of North America, 34(3), 543-558. doi:10.1016/j.emc.2016.04.007
  2. Birkholz, L., Haney, T. (2018). Using a dyspnea assessment tool to improve care at the end of life. Journal of Hospice and Palliative Care, 20(3), 219-227. doi:10.1097/NJH.0000000000000432 (Level VI)
  3. Campbell, M.L. (2017). Dyspnea. Critical Care Nursing Clinics of North America, 29(4), 461-470. doi:10.1016/j.cnc.2017.08.006
  4. Pisani, L. and others. (2018). Management of dyspnea in the terminally ill. Chest, 154(4), 925-934. doi:10.1016/j.chest.2018.04.003
  5. World Health Organization (WHO). (2021). Chronic obstructive pulmonary disease (COPD). Retrieved September 18, 2021, from https://www.who.int/en/news-room/fact-sheets/detail/chronic-obstructive-pulmonary-disease-(copd) (Level VII)

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports

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