Short acting opioids decrease the sensation of breathlessness. Start with 5mg of oral morphine sulphate solution on an as required basis (2.5mg if patient is particularly frail or there is concern about renal function). Remember to co-prescribe a laxative and anti emetic. Long acting opioids probably have a similar effect, but there is less evidence for their effectiveness.
Anxiolytics may help when there is considerable anxiety exacerbating the breathlessness. Possible drugs that can be used include diazepam 2-5mg three times a day, lorazepam 0.5 – 1mg twice a day, buspirone 5mg twice a day (although its effect may take up to two weeks).
Nebulised saline may improve the sensation of breathlessness although will have no effect on lung function. Use 2.5 –5ml of normal saline for injection in a standard nebuliser.
Nebulised broncho-dilators may help if there is associated bronchospasm, as identified by an inspiratory wheeze on auscultation. Salbutamol 2.5 –5mg as often as two hourly may be needed, but the patient may find the subsequent tremor unacceptable.
Oral high dose steroids may help where there is evidence of lymphangitis or broncho-spasm. Consider dexamethasone 8mg in a single daily dose in the morning. If effective, titrate dose down to the minimum dose that controls symptoms in the subsequent two weeks (usually 2-6mg). Use appropriate GI protection with either a proton pump inhibitor or misoprostol in at risk patients.
Oxygen has a limited role to play in the dyspnoea of advanced lung cancer, but if a patient has been shown to be hypoxaemic by pulse oximetry, the judicious use of oxygen at flow rates between 2 –4 l/min may be of benefit. In some cases of lymphangitis, higher flow rates may be needed to maintain oxygenation.
