Managing Breathing Difficulties During the Dying Process

Pharmacological Management

Opioids are the most effective and widely studied agents for palliation of dyspnea in dying patients, according to the National Comprehensive Cancer Network 1, 2
For opioid-naive patients, the National Comprehensive Cancer Network recommends starting with morphine 2.5-10 mg PO every 2 hours as needed or 1-3 mg IV every 2 hours as needed 3
For patients already on chronic opioids, consider increasing the dose by 25% to manage dyspnea, as suggested by the National Comprehensive Cancer Network 4, 5
Fentanyl (nebulized or subcutaneous) has shown promising results in reducing dyspnea intensity and unpleasantness in several studies, according to the National Comprehensive Cancer Network 4, 5
Benzodiazepines (lorazepam 0.5-1 mg PO every 4 hours as needed) should be added when dyspnea is associated with anxiety or when opioids alone are insufficient, as recommended by the European Respiratory Society 6, 3
Sedation with benzodiazepines or propofol can be considered if dyspnea is not resolved with adequate doses of opioids, according to the World Journal of Emergency Surgery 2
Anticholinergic medications, such as scopolamine, atropine, and glycopyrrolate, help reduce excessive secretions, as suggested by the National Comprehensive Cancer Network 3, 4, 8

Position the patient in an upright sitting position to optimize breathing, as recommended by the World Journal of Emergency Surgery 2
Use of handheld fans directed at the face has been shown to reduce breathlessness in randomized controlled trials, according to the National Comprehensive Cancer Network 8
Increase ambient air flow and maintain cooler room temperatures, as suggested by the World Journal of Emergency Surgery 2
Provide oxygen therapy only for patients with hypoxemia (oxygen saturation <90%), as recommended by the European Respiratory Society 6
Consider time-limited trials of non-invasive ventilation (CPAP, BiPAP) for severe reversible conditions, but recognize that as life expectancy decreases, the role of mechanical ventilation diminishes, according to the National Comprehensive Cancer Network 8, 5

As death approaches, the focus shifts more toward comfort measures and symptom control, as suggested by the National Comprehensive Cancer Network 5
Opioid doses should not be reduced solely for decreased blood pressure, respiration rate, or level of consciousness when necessary for adequate management of dyspnea, according to the National Comprehensive Cancer Network 5
Prepare families for potential changes in breathing patterns, including "agonal breathing" which may occur in the minutes before death, as explained by the American Journal of Respiratory and Critical Care Medicine 7
Explain to families that agonal breathing (slow, irregular, noisy breathing that mimics grunting or gasping) is part of the natural dying process and does not necessarily indicate discomfort, as stated by the American Journal of Respiratory and Critical Care Medicine 7

Provide educational, psychosocial, and emotional support for the patient and family, as recommended by the National Comprehensive Cancer Network 3
Explain the nature of respiratory changes during the dying process to reduce family distress, as suggested by the American Journal of Respiratory and Critical Care Medicine 7

Oxygen therapy may not provide symptomatic benefit in non-hypoxemic patients and should not be routinely administered unless it provides subjective relief, as stated by the National Comprehensive Cancer Network 8
Do not withhold opioids due to concerns about respiratory depression, as the benefits for symptom control outweigh the risks in dying patients, according to the National Comprehensive Cancer Network 5
Recognize that anticholinergic medications for secretion management may cause side effects including dry mouth, urinary retention, and delirium, as suggested by the National Comprehensive Cancer Network 4, 8
Terminal weaning (gradual reduction of ventilator support) rather than abrupt extubation may help avoid noisy breathing due to airway secretions that could distress family members, as recommended by the American Journal of Respiratory and Critical Care Medicine 7