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Assessment and management of dyspnea in palliative care

INTRODUCTION

Dyspnea is a term used to characterize a subjective experience of breathing discomfort that is comprised of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social, and environmental factors that may induce secondary physiological and behavioral responses [1].

Dyspnea, or breathlessness, encompasses multiple somatic perceptions that are variously described as air hunger, increased effort of breathing, chest tightness, rapid breathing, incomplete exhalation, or a feeling of suffocation. Dyspnea is a multidimensional symptom, consisting of affective as well as physical aspects. Its presence and severity cannot be inferred from physical examination or laboratory investigations – we must ask about it. It can occur in the absence of physical signs (eg, rapid, deep, or labored breathing) or abnormal findings on investigations such as blood gases or chest radiographs.

Palliative care is an interdisciplinary medical specialty that focuses on preventing and relieving suffering and on supporting the best possible quality of life for patients and their families facing life-threatening or other serious illnesses.  The primary tenets of palliative care are symptom management; establishing goals of care that are in keeping with the patient’s values and preferences; consistent and sustained communication between the patient and all those involved in his or her care; psychosocial, spiritual, and practical support both to patients and their family caregivers, and coordination across sites of care. Palliative care aims to relieve suffering in all stages of disease and is not limited to end of life care. Within an integrated model of medical care, palliative care is provided at the same time as curative or life-prolonging treatments. (See "Palliative care: Benefits, services, and models of care".)

This topic focuses on the assessment and care of patients with advanced terminal illness who develop dyspnea. An approach to the diagnosis of dyspnea in adults and the management of specific causes of dyspnea are addressed elsewhere as is the management of cough, stridor, and hemoptysis in palliative care populations. (See "Approach to the patient with dyspnea" and "Symptom-based management of amyotrophic lateral sclerosis", section on 'Respiratory management' and "End of life considerations for heart failure patients", section on 'Dyspnea' and "Management of exacerbations of chronic obstructive pulmonary disease" and "Treatment of acute decompensated heart failure: General considerations" and "Treatment of acute decompensated heart failure: Components of therapy" and "Palliative care: Overview of cough, stridor, and hemoptysis".)

OVERVIEW

Prevalence — Dyspnea is common in patients with advanced life-threatening illness of all types (table 1). It is one of the most common symptoms reported in patients with a terminal cancer in the last six months of life (figure 1). In a systematic review of the prevalence of 11 symptoms in patients with advanced illness from any of five diagnoses (cancer, AIDS, heart disease, chronic obstructive pulmonary disease [COPD] or renal disease), dyspnea was one of only three symptoms to be present in >50 percent of patients from all five groups [2]. Regardless of diagnosis, both the prevalence and severity of dyspnea tend to increase over time, particularly in the last six months of life [3,4].

                                    

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Literature review current through: Jul 2014. | This topic last updated: Jul 11, 2014.
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References
Top
  1. Dyspnea. Mechanisms, assessment, and management: a consensus statement. American Thoracic Society. Am J Respir Crit Care Med 1999; 159:321.
  2. Solano JP, Gomes B, Higginson IJ. A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage 2006; 31:58.
  3. Currow DC, Smith J, Davidson PM, et al. Do the trajectories of dyspnea differ in prevalence and intensity by diagnosis at the end of life? A consecutive cohort study. J Pain Symptom Manage 2010; 39:680.
  4. Seow H, Barbera L, Sutradhar R, et al. Trajectory of performance status and symptom scores for patients with cancer during the last six months of life. J Clin Oncol 2011; 29:1151.
  5. Skilbeck J, Mott L, Page H, et al. Palliative care in chronic obstructive airways disease: a needs assessment. Palliat Med 1998; 12:245.
  6. Roberts DK, Thorne SE, Pearson C. The experience of dyspnea in late-stage cancer. Patients' and nurses' perspectives. Cancer Nurs 1993; 16:310.
  7. Gysels M, Bausewein C, Higginson IJ. Experiences of breathlessness: a systematic review of the qualitative literature. Palliat Support Care 2007; 5:281.
  8. Chochinov HM, Tataryn D, Clinch JJ, Dudgeon D. Will to live in the terminally ill. Lancet 1999; 354:816.
  9. Fainsinger RL, Waller A, Bercovici M, et al. A multicentre international study of sedation for uncontrolled symptoms in terminally ill patients. Palliat Med 2000; 14:257.
  10. Mercadante S, Porzio G, Valle A, et al. Palliative sedation in patients with advanced cancer followed at home: a systematic review. J Pain Symptom Manage 2011; 41:754.
  11. Brown ML, Carrieri V, Dodd MJ. Lung cancer and dyspnea: the patient's perception. Oncol Nurs Forum 1986; 13:19.
  12. Nicolson P, Anderson P. The patient's burden: physical and psychological effects of acute exacerbations of chronic bronchitis. J Antimicrob Chemother 2000; 45:25.
  13. Barnett M. Chronic obstructive pulmonary disease: a phenomenological study of patients' experiences. J Clin Nurs 2005; 14:805.
  14. Maltoni M, Caraceni A, Brunelli C, et al. Prognostic factors in advanced cancer patients: evidence-based clinical recommendations--a study by the Steering Committee of the European Association for Palliative Care. J Clin Oncol 2005; 23:6240.
  15. Viganò A, Dorgan M, Buckingham J, et al. Survival prediction in terminal cancer patients: a systematic review of the medical literature. Palliat Med 2000; 14:363.
  16. Maltoni M, Pirovano M, Scarpi E, et al. Prediction of survival of patients terminally ill with cancer. Results of an Italian prospective multicentric study. Cancer 1995; 75:2613.
  17. Nishimura K, Izumi T, Tsukino M, Oga T. Dyspnea is a better predictor of 5-year survival than airway obstruction in patients with COPD. Chest 2002; 121:1434.
  18. Trajkovic-Vidakovic M, de Graeff A, Voest EE, Teunissen SC. Symptoms tell it all: a systematic review of the value of symptom assessment to predict survival in advanced cancer patients. Crit Rev Oncol Hematol 2012; 84:130.
  19. Bausewein C, Farquhar M, Booth S, et al. Measurement of breathlessness in advanced disease: a systematic review. Respir Med 2007; 101:399.
  20. Mularski RA, Campbell ML, Asch SM, et al. A review of quality of care evaluation for the palliation of dyspnea. Am J Respir Crit Care Med 2010; 181:534.
  21. Bausewein C, Booth S, Higginson IJ. Measurement of dyspnoea in the clinical rather than the research setting. Curr Opin Support Palliat Care 2008; 2:95.
  22. Simon PM, Schwartzstein RM, Weiss JW, et al. Distinguishable types of dyspnea in patients with shortness of breath. Am Rev Respir Dis 1990; 142:1009.
  23. Schwartzstein RM. Language of dyspnea. In: Dyspnea; Mechanisms, measurement and management, 2nd, Mahler DA, O’Donnell DE (Eds), Taylor & Francis Group, Boca Raton, FL 2005. p.115.
  24. Simon ST, Higginson IJ, Benalia H, et al. Episodes of breathlessness: types and patterns - a qualitative study exploring experiences of patients with advanced diseases. Palliat Med 2013; 27:524.
  25. Harver A, Mahler DA, Schwartzstein RM. Use of a descriptor model for prospective diagnosis of dyspnea. Am J Respir Crit Care Med 2000; 161:A705.
  26. Borg GA. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982; 14:377.
  27. McGavin CR, Artvinli M, Naoe H, McHardy GJ. Dyspnoea, disability, and distance walked: comparison of estimates of exercise performance in respiratory disease. Br Med J 1978; 2:241.
  28. O'Driscoll M, Corner J, Bailey C. The experience of breathlessness in lung cancer. Eur J Cancer Care (Engl) 1999; 8:37.
  29. Bailey PH. Death stories: acute exacerbations of chronic obstructive pulmonary disease. Qual Health Res 2001; 11:322.
  30. Portenoy RK, Thaler HT, Kornblith AB, et al. The Memorial Symptom Assessment Scale: an instrument for the evaluation of symptom prevalence, characteristics and distress. Eur J Cancer 1994; 30A:1326.
  31. Campbell ML. Psychometric testing of a respiratory distress observation scale. J Palliat Med 2008; 11:44.
  32. Uronis HE, Shelby RA, Currow DC, et al. Assessment of the psychometric properties of an English version of the cancer dyspnea scale in people with advanced lung cancer. J Pain Symptom Manage 2012; 44:741.
  33. Reddy SK, Parsons HA, Elsayem A, et al. Characteristics and correlates of dyspnea in patients with advanced cancer. J Palliat Med 2009; 12:29.
  34. Heyse-Moore LH. On Dyspnea in Advanced Cancer, Southampton University, 1993.
  35. Dudgeon DJ, Lertzman M. Dyspnea in the advanced cancer patient. J Pain Symptom Manage 1998; 16:212.
  36. Dudgeon DJ, Lertzman M, Askew GR. Physiological changes and clinical correlations of dyspnea in cancer outpatients. J Pain Symptom Manage 2001; 21:373.
  37. Bruera E, Schmitz B, Pither J, et al. The frequency and correlates of dyspnea in patients with advanced cancer. J Pain Symptom Manage 2000; 19:357.
  38. Tanaka K, Akechi T, Okuyama T, et al. Factors correlated with dyspnea in advanced lung cancer patients: organic causes and what else? J Pain Symptom Manage 2002; 23:490.
  39. Gift AG, Plaut SM, Jacox A. Psychologic and physiologic factors related to dyspnea in subjects with chronic obstructive pulmonary disease. Heart Lung 1986; 15:595.
  40. Carrieri-Kohlman, V. Non-pharmacologic approaches. In: Dyspnoea in advanced disease: A guide to clinical management, Booth, S, Dudgeon, D (Eds), Oxford University Press, New York 2006. p.171.
  41. Zhao I, Yates P. Non-pharmacological interventions for breathlessness management in patients with lung cancer: a systematic review. Palliat Med 2008; 22:693.
  42. Bredin M, Corner J, Krishnasamy M, et al. Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. BMJ 1999; 318:901.
  43. Schwartzstein RM, Lahive K, Pope A, et al. Cold facial stimulation reduces breathlessness induced in normal subjects. Am Rev Respir Dis 1987; 136:58.
  44. Bausewein C, Booth S, Gysels M, et al. Effectiveness of a hand-held fan for breathlessness: a randomised phase II trial. BMC Palliat Care 2010; 9:22.
  45. Galbraith S, Fagan P, Perkins P, et al. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage 2010; 39:831.
  46. Thomas JR, von Gunten CF. Clinical management of dyspnoea. Lancet Oncol 2002; 3:223.
  47. Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev 2008; :CD005623.
  48. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2006; :CD003793.
  49. Puhan M, Scharplatz M, Troosters T, et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2009; :CD005305.
  50. Lanken PN, Terry PB, Delisser HM, et al. An official American Thoracic Society clinical policy statement: palliative care for patients with respiratory diseases and critical illnesses. Am J Respir Crit Care Med 2008; 177:912.
  51. Riesenberg H, Lübbe AS. In-patient rehabilitation of lung cancer patients--a prospective study. Support Care Cancer 2010; 18:877.
  52. Davidson PM, Johnson MJ. Update on the role of palliative oxygen. Curr Opin Support Palliat Care 2011; 5:87.
  53. Qaseem A, Snow V, Shekelle P, et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008; 148:141.
  54. Lorenz KA, Lynn J, Dy SM, et al. Evidence for improving palliative care at the end of life: a systematic review. Ann Intern Med 2008; 148:147.
  55. Cranston JM, Crockett A, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev 2008; :CD004769.
  56. Booth S, Kelly MJ, Cox NP, et al. Does oxygen help dyspnea in patients with cancer? Am J Respir Crit Care Med 1996; 153:1515.
  57. Ahmedzai SH, Laude E, Robertson A, et al. A double-blind, randomised, controlled Phase II trial of Heliox28 gas mixture in lung cancer patients with dyspnoea on exertion. Br J Cancer 2004; 90:366.
  58. Bruera E, de Stoutz N, Velasco-Leiva A, et al. Effects of oxygen on dyspnoea in hypoxaemic terminal-cancer patients. Lancet 1993; 342:13.
  59. Chua TP, Ponikowski PP, Harrington D, et al. Contribution of peripheral chemoreceptors to ventilation and the effects of their suppression on exercise tolerance in chronic heart failure. Heart 1996; 76:483.
  60. Moore DP, Weston AR, Hughes JM, et al. Effects of increased inspired oxygen concentrations on exercise performance in chronic heart failure. Lancet 1992; 339:850.
  61. Restrick LJ, Davies SW, Noone L, Wedzicha JA. Ambulatory oxygen in chronic heart failure. Lancet 1992; 340:1192.
  62. Jones DJ, Paul EA, Bell JH, Wedzicha JA. Ambulatory oxygen therapy in stable kyphoscoliosis. Eur Respir J 1995; 8:819.
  63. Mahler DA, Selecky PA, Harrod CG, et al. American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease. Chest 2010; 137:674.
  64. Philip J, Gold M, Milner A, et al. A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. J Pain Symptom Manage 2006; 32:541.
  65. Bruera E, Schoeller T, MacEachern T. Symptomatic benefit of supplemental oxygen in hypoxemic patients with terminal cancer: the use of the N of 1 randomized controlled trial. J Pain Symptom Manage 1992; 7:365.
  66. Swinburn CR, Mould H, Stone TN, et al. Symptomatic benefit of supplemental oxygen in hypoxemic patients with chronic lung disease. Am Rev Respir Dis 1991; 143:913.
  67. Alvisi V, Mirkovic T, Nesme P, et al. Acute effects of hyperoxia on dyspnea in hypoxemia patients with chronic airway obstruction at rest. Chest 2003; 123:1038.
  68. Liss HP, Grant BJ. The effect of nasal flow on breathlessness in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1988; 137:1285.
  69. Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet 2010; 376:784.
  70. Bruera E, Sweeney C, Willey J, et al. A randomized controlled trial of supplemental oxygen versus air in cancer patients with dyspnea. Palliat Med 2003; 17:659.
  71. Yeow ME, Mehta RS, White DB, Szmuilowicz E. Using noninvasive ventilation at the end of life #230. J Palliat Med 2010; 13:1149.
  72. Freichels TA. Palliative ventilatory support: use of noninvasive positive pressure ventilation in terminal respiratory insufficiency. Am J Crit Care 1994; 3:6.
  73. Azoulay E, Kouatchet A, Jaber S, et al. Noninvasive mechanical ventilation in patients having declined tracheal intubation. Intensive Care Med 2013; 39:292.
  74. Sinuff T, Cook DJ, Keenan SP, et al. Noninvasive ventilation for acute respiratory failure near the end of life. Crit Care Med 2008; 36:789.
  75. Ehlenbach WJ, Curtis JR. Noninvasive ventilation for patients near the end of life: what do we know and what do we need to know? Crit Care Med 2008; 36:1003.
  76. Nava S, Ferrer M, Esquinas A, et al. Palliative use of non-invasive ventilation in end-of-life patients with solid tumours: a randomised feasibility trial. Lancet Oncol 2013; 14:219.
  77. Levy M, Tanios MA, Nelson D, et al. Outcomes of patients with do-not-intubate orders treated with noninvasive ventilation. Crit Care Med 2004; 32:2002.
  78. Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation reverses acute respiratory failure in select "do-not-intubate" patients. Crit Care Med 2005; 33:1976.
  79. Yeow ME, Szmuilowicz E. Practical aspects of using noninvasive positive pressure ventilation at the end of life #231. J Palliat Med 2010; 13:1150.
  80. Murgu S, Langer S, Colt H. Bronchoscopic intervention obviates the need for continued mechanical ventilation in patients with airway obstruction and respiratory failure from inoperable non-small-cell lung cancer. Respiration 2012; 84:55.
  81. Kazi AA, Flowers WJ, Barrett JM, et al. Ethical issues in laryngology: tracheal stenting as palliative care. Laryngoscope 2014; 124:1663.
  82. Bandyopadhyay D, Induru RR. Role of palliative tracheobronchial stenting in hospice patients: boon or bane? Am J Hosp Palliat Care 2011; 28:445.
  83. Laude EA, Duffy NC, Baveystock C, et al. The effect of helium and oxygen on exercise performance in chronic obstructive pulmonary disease: a randomized crossover trial. Am J Respir Crit Care Med 2006; 173:865.
  84. Chiappa GR, Queiroga F Jr, Meda E, et al. Heliox improves oxygen delivery and utilization during dynamic exercise in patients with chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2009; 179:1004.
  85. D'Angelo E, Santus P, Civitillo MF, et al. Expiratory flow-limitation and heliox breathing in resting and exercising COPD patients. Respir Physiol Neurobiol 2009; 169:291.
  86. Lewith GT, Prescott P, Davis CL. Can a standardized acupuncture technique palliate disabling breathlessness: a single-blind, placebo-controlled crossover study. Chest 2004; 125:1783.
  87. Filshie J, Penn K, Ashley S, Davis CL. Acupuncture for the relief of cancer-related breathlessness. Palliat Med 1996; 10:145.
  88. Suzuki M, Muro S, Ando Y, et al. A randomized, placebo-controlled trial of acupuncture in patients with chronic obstructive pulmonary disease (COPD): the COPD-acupuncture trial (CAT). Arch Intern Med 2012; 172:878.
  89. Zebraski SE, Kochenash SM, Raffa RB. Lung opioid receptors: pharmacology and possible target for nebulized morphine in dyspnea. Life Sci 2000; 66:2221.
  90. Ben-Aharon I, Gafter-Gvili A, Paul M, et al. Interventions for alleviating cancer-related dyspnea: a systematic review. J Clin Oncol 2008; 26:2396.
  91. Abernethy AP, Currow DC, Frith P, et al. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ 2003; 327:523.
  92. Booth S, Moosavi SH, Higginson IJ. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy. Nat Clin Pract Oncol 2008; 5:90.
  93. Viola R, Kiteley C, Lloyd NS, et al. The management of dyspnea in cancer patients: a systematic review. Support Care Cancer 2008; 16:329.
  94. Charles MA, Reymond L, Israel F. Relief of incident dyspnea in palliative cancer patients: a pilot, randomized, controlled trial comparing nebulized hydromorphone, systemic hydromorphone, and nebulized saline. J Pain Symptom Manage 2008; 36:29.
  95. Rice KL, Kronenberg RS, Hedemark LL, Niewoehner DE. Effects of chronic administration of codeine and promethazine on breathlessness and exercise tolerance in patients with chronic airflow obstruction. Br J Dis Chest 1987; 81:287.
  96. Johnson MA, Woodcock AA, Geddes DM. Dihydrocodeine for breathlessness in "pink puffers". Br Med J (Clin Res Ed) 1983; 286:675.
  97. Chua TP, Harrington D, Ponikowski P, et al. Effects of dihydrocodeine on chemosensitivity and exercise tolerance in patients with chronic heart failure. J Am Coll Cardiol 1997; 29:147.
  98. Bar-Or D, Marx JA, Good J. Breathlessness, alcohol, and opiates. N Engl J Med 1982; 306:1363.
  99. Woodcock AA, Gross ER, Gellert A, et al. Effects of dihydrocodeine, alcohol, and caffeine on breathlessness and exercise tolerance in patients with chronic obstructive lung disease and normal blood gases. N Engl J Med 1981; 305:1611.
  100. Eiser N, Denman WT, West C, Luce P. Oral diamorphine: lack of effect on dyspnoea and exercise tolerance in the "pink puffer" syndrome. Eur Respir J 1991; 4:926.
  101. Gauna AA, Kang SK, Triano ML, et al. Oral transmucosal fentanyl citrate for dyspnea in terminally ill patients: an observational case series. J Palliat Med 2008; 11:643.
  102. Hui D, Xu A, Frisbee-Hume S, et al. Effects of prophylactic subcutaneous fentanyl on exercise-induced breakthrough dyspnea in cancer patients: a preliminary double-blind, randomized, controlled trial. J Pain Symptom Manage 2014; 47:209.
  103. Rocker G, Horton R, Currow D, et al. Palliation of dyspnoea in advanced COPD: revisiting a role for opioids. Thorax 2009; 64:910.
  104. Currow DC, McDonald C, Oaten S, et al. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance study. J Pain Symptom Manage 2011; 42:388.
  105. Clemens KE, Quednau I, Klaschik E. Use of oxygen and opioids in the palliation of dyspnoea in hypoxic and non-hypoxic palliative care patients: a prospective study. Support Care Cancer 2009; 17:367.
  106. Clemens KE, Quednau I, Klaschik E. Is there a higher risk of respiratory depression in opioid-naïve palliative care patients during symptomatic therapy of dyspnea with strong opioids? J Palliat Med 2008; 11:204.
  107. Clemens KE, Klaschik E. Effect of hydromorphone on ventilation in palliative care patients with dyspnea. Support Care Cancer 2008; 16:93.
  108. Light RW, Muro JR, Sato RI, et al. Effects of oral morphine on breathlessness and exercise tolerance in patients with chronic obstructive pulmonary disease. Am Rev Respir Dis 1989; 139:126.
  109. Hallenbeck J. Pathophysiologies of dyspnea explained: why might opioids relieve dyspnea and not hasten death? J Palliat Med 2012; 15:848.
  110. Zeppetella G. Nebulized morphine in the palliation of dyspnoea. Palliat Med 1997; 11:267.
  111. Coyne P, Viswanathan R, Smith TJ. Fentanyl by nebulizer reduces dyspnea (abstract). Proc Am Soc Clin Oncol 2001; 20:402a.
  112. Coyne PJ, Viswanathan R, Smith TJ. Nebulized fentanyl citrate improves patients' perception of breathing, respiratory rate, and oxygen saturation in dyspnea. J Pain Symptom Manage 2002; 23:157.
  113. Sarhill N, Walsh D, Khawam E, et al. Nebulized hydromorphone for dyspnea in hospice care of advanced cancer. Am J Hosp Palliat Care 2000; 17:389.
  114. Polosa R, Simidchiev A, Walters EH. Nebulised morphine for severe interstitial lung disease. Cochrane Database Syst Rev 2002; :CD002872.
  115. Davis C. The role of nebulised drugs in palliating respiratory symptoms from mlaignant disease. Eur J Palliat Care 1995; 2:9.
  116. Bruera E, Sala R, Spruyt O, et al. Nebulized versus subcutaneous morphine for patients with cancer dyspnea: a preliminary study. J Pain Symptom Manage 2005; 29:613.
  117. Jensen D, Alsuhail A, Viola R, et al. Inhaled fentanyl citrate improves exercise endurance during high-intensity constant work rate cycle exercise in chronic obstructive pulmonary disease. J Pain Symptom Manage 2012; 43:706.
  118. Woodcock AA, Gross ER, Geddes DM. Drug treatment of breathlessness: contrasting effects of diazepam and promethazine in pink puffers. Br Med J (Clin Res Ed) 1981; 283:343.
  119. Light RW, Stansbury DW, Webster JS. Effect of 30 mg of morphine alone or with promethazine or prochlorperazine on the exercise capacity of patients with COPD. Chest 1996; 109:975.
  120. Simon ST, Higginson IJ, Booth S, et al. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev 2010; :CD007354.
  121. Clemens KE, Klaschik E. Dyspnoea associated with anxiety--symptomatic therapy with opioids in combination with lorazepam and its effect on ventilation in palliative care patients. Support Care Cancer 2011; 19:2027.
  122. Navigante AH, Castro MA, Cerchietti LC. Morphine versus midazolam as upfront therapy to control dyspnea perception in cancer patients while its underlying cause is sought or treated. J Pain Symptom Manage 2010; 39:820.
  123. Navigante AH, Cerchietti LC, Castro MA, et al. Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer. J Pain Symptom Manage 2006; 31:38.
  124. Congleton J, Muers MF. The incidence of airflow obstruction in bronchial carcinoma, its relation to breathlessness, and response to bronchodilator therapy. Respir Med 1995; 89:291.
  125. Newton PJ, Davidson PM, Macdonald P, et al. Nebulized furosemide for the management of dyspnea: does the evidence support its use? J Pain Symptom Manage 2008; 36:424.
  126. Nishino T, Ide T, Sudo T, Sato J. Inhaled furosemide greatly alleviates the sensation of experimentally induced dyspnea. Am J Respir Crit Care Med 2000; 161:1963.
  127. Kohara H, Ueoka H, Aoe K, et al. Effect of nebulized furosemide in terminally ill cancer patients with dyspnea. J Pain Symptom Manage 2003; 26:962.
  128. Shimoyama N, Shimoyama M. Nebulized furosemide as a novel treatment for dyspnea in terminal cancer patients. J Pain Symptom Manage 2002; 23:73.
  129. Wilcock A, Walton A, Manderson C, et al. Randomised, placebo controlled trial of nebulised furosemide for breathlessness in patients with cancer. Thorax 2008; 63:872.
  130. Elsayem A, Bruera E. High-dose corticosteroids for the management of dyspnea in patients with tumor obstruction of the upper airway. Support Care Cancer 2007; 15:1437.
  131. Storck K, Crispens M, Brader K. Squamous cell carcinoma of the cervix presenting as lymphangitic carcinomatosis: a case report and review of the literature. Gynecol Oncol 2004; 94:825.
  132. Lin RJ, Adelman RD, Mehta SS. Dyspnea in palliative care: expanding the role of corticosteroids. J Palliat Med 2012; 15:834.
  133. Consensus statement on the management of dyspnea in patients with advanced lung or heart disease from the American College of Chest Physicians available online at http://www.chestnet.org/accp/consensus-statements/american-college-chest-physicians-consensus-statement-management-dyspnea-patien (Accessed on March 23, 2011).