Which one of the following is the best choice for emergency treatment of severe dyspnea in an opioid-naïve dying patient:
a. hydromorphone 4 mg IV q 5-10 minutes
b. morphine 1-3 mg IV q 1-2 hours prn
c. transdermal Fentanyl 25 ug q72
d. Oxycontin 15 mg Q12
Answer: b.
Typically, dyspnea can be well managed with small doses in the opioid naïve patient thus small doses of a parenteral opioid is the best choice among these options. The key to treating severe dyspnea is a) picking a drug and dosage that can be administered and dose escalated quickly to achieve the desired effect, and b) safely so that respiratory depression can be avoided. Intravenous opioids have a rapid onset of effect allowing for rapid assessment and decisions about the need for changes. The oral route is too slow to provide needed relief although can be used if no parenteral drugs are available. The dose of hydromorphone in option a. is excessive, equivalent to ~ 20 mg of IV morphine.
Reference NCCN Guideline Pal 11 and Pal 12
See Fast Fact # 27 Dyspnea
