Management of Anaphylaxis and Dyspnea in Hospice Patients

Immediate Anaphylaxis Management

• The American Heart Association recommends administering intramuscular epinephrine 0.3-0.5 mg immediately for anaphylaxis, as it is life-saving and the only definitive first-line treatment, even in hospice patients 1, 2
• The American Heart Association suggests that the intramuscular route is preferred initially, with 0.3-0.5 mg (0.3-0.5 mL of 1:1000 solution) administered into the lateral thigh for rapid absorption 1, 2
• Epinephrine should be repeated every 5-15 minutes as needed if shortness of breath, bronchospasm, or hypotension persists 1, 2
• The Anaesthesia society recommends administering 100% oxygen immediately via non-rebreather mask or nasal cannula at high flow 4, 2
• Oxygen is essential for patients with prolonged reactions or pre-existing respiratory compromise, according to the Anaesthesia society 4
• The American Heart Association recommends monitoring oxygen saturation continuously with pulse oximetry 2
• If bronchospasm continues after epinephrine, the Anaesthesia society suggests administering nebulized albuterol (salbutamol) 2.5 mg (0.5 mL of 5% solution) 4, 5, 2

Secondary Anaphylaxis Medications

• The Anaesthesia society recommends chlorphenamine 10 mg IV to reduce histamine-mediated symptoms 4, 5, 2
• The Anaesthesia society suggests hydrocortisone 200 mg IV to potentially prevent biphasic reactions (though this won't help acute bronchospasm) 4, 5, 2
• The American Heart Association recommends that these secondary treatments should never delay epinephrine administration 1, 2

Post-Acute Dyspnea Management in Hospice

• The European Society of Cardiology recommends using oral morphine for ongoing dyspnea management once anaphylaxis resolves, as it is the only medication with regulatory approval for chronic breathlessness and has the strongest evidence base 3
• The American Heart Association suggests permanently avoiding all codeine products, as the patient has demonstrated anaphylaxis to this opioid 2
• The European Society of Cardiology recommends starting with oral sustained-release morphine 10 mg once daily (or 5 mg twice daily, or 2.5 mg immediate-release four times daily) 3
• 63% of patients respond to morphine for breathlessness; of responders, 67% benefit at 10 mg/day, 25% require 20 mg/day, and 8% need 30 mg/day, according to the European Society of Cardiology 3
• The European Society of Cardiology suggests that initial response occurs within 24 hours, but full benefit may take up to one week 3
• The maximum dose for breathlessness is 30 mg/24 hours of oral morphine, according to the European Society of Cardiology 3
• If the patient has Stage 4-5 chronic kidney disease (GFR <30 mL/min), the European Society of Cardiology recommends avoiding morphine or using with extreme caution due to accumulation of active metabolites 3
• The European Society of Cardiology suggests considering alternative opioids without renally-excreted active metabolites in significant renal impairment 3
• Using a hand-held fan directed at the face can stimulate facial trigeminal nerve receptors, according to the European Society of Cardiology 3
• Breathing training and relaxation techniques may provide additional benefit, according to the European Society of Cardiology 3
• Oxygen therapy only helps if the patient is hypoxemic; it does not benefit normoxemic patients, according to the European Society of Cardiology 3

Critical Pitfalls to Avoid

• The American Heart Association recommends never delaying epinephrine administration, as it should be given immediately upon suspecting anaphylaxis, not after trying antihistamines or bronchodilators first 1, 2
• The American Heart Association suggests that IV epinephrine should not be used in hospice/home settings without continuous cardiac monitoring - IM route is safer 1, 2
• The American Heart Association recommends that the lateral thigh (vastus lateralis) provides faster absorption than deltoid or subcutaneous routes 1
• The American Heart Association suggests never rechallenging with codeine, as it should be documented as a severe allergy prominently in all medical records 2
• The European Society of Cardiology recommends not assuming all opioids are cross-reactive; morphine has a different structure and is safe to use 3
• The European Society of Cardiology suggests avoiding undertreating dyspnea in hospice patients due to opioid fears - low-dose morphine (10-30 mg/day) for breathlessness does not cause excess mortality 3