Chronic dyspnea refers to breathlessness lasting > 4-8 weeks and is prevalent in chronic obstructive pulmonary disease (COPD) (56-98%), heart failure (88%), cancer (77%), and end-stage renal disease (ESRD) (11-82%).
Patient self-report is the only reliable indicator of dyspnea.
When dyspnea becomes chronic, sensory input from chemoreceptors and mechanoreceptors become integrated into the neural processing of the brain, making it challenging to fully eradicate.
Controlling the dyspnea-anxiety cycle (breathlessness > anxiety > increased breathlessness) is a key therapeutic goal in chronic dyspnea.
The initial evaluation of chronic dyspnea should address the underlying etiology/chronic illness and correct hypoxemia, if appropriate. For many patients, further optimization of the underlying illness is not achievable, and the therapeutic goal must include symptom control, patient’s capacity improvement, and patient's coping with chronic dyspnea.
Measures should be considered at any stage of disease, not just when life expectancy is short.
Multi-disciplinary regimens usually include:
• Pulmonary rehabilitation: a structured 4-8-week program involving physical and/or occupational therapists to provide education, exercise training, and counseling.
• Patient education, including the psycho-social-spiritual impact of the dyspnea-anxiety cycle.
• Energy conservation techniques.
• Cognitive behavioral therapy.
• Relaxation techniques: diaphragmatic and pursed lip breathing training, guided imagery meditation, and music therapy.
• Acupuncture: limited data suggest a potential role for COPD and cancer.
• Supplemental oxygen (in patients with hypoxemia) and therapeutic room air (a fan to the face).
For intolerable dyspnea that is refractory to non-pharmacologic approaches.
• Opioids: oral (short and extended-release), subcutaneous, and intravenous opioids have long been regarded as the mainstay of pharmacologic treatment for chronic dyspnea.
• Benzodiazepines: there is no convincing evidence for or against the use of benzodiazepines for chronic dyspnea. They could be prescribed for patients with refractory anxiety, which is a significant component to their symptomatology.
See reference for more information.
Adapted from Weinberg R and Ketteren B. Palliative Care Network of Wisconsin. Fast facts and concepts #376. Management of chronic dyspnea. Internet. Accessed on September 22, 2019.