Opioids (and benzodiazepines) are the mainstays of drug therapy for dyspnea in palliative care. Opioids are the best drug to alleviate symptoms of dyspnea and usually effective in small doses.
For the opioid naïve patient, low doses of oral (5-15 mg) or parenteral morphine (2-5 mg), will usually provide relief. A reasonable initial order would be: Morphine 2-5 mg IV or SQ q 10 min prn dyspnea
- For patients on chronic opioids: Higher doses will be needed, increase fixed schedule opioid by up to 50%.
- If dyspnea is acute and severe, parenteral is the route of choice: 2-5 mg IV every 5-10 minutes until relief.
- In the inpatient setting, a continuous opioid infusion titrated to sedation or a PCA that patients, nurses, or families can administer, will provide timeliest relief.
- Nebulized morphine has been reported to provide benefit in uncontrolled case reports, however, controlled trials have not demonstrated any benefit compared to placebo, confirming the low bioavailability of nebulized opioids.