Dyspnoea - Paediatric Palliative Care

Description

General and supportive measures

Medicine treatment

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ICD-10 code: R06.0

DESCRIPTION

A subjective feeling of breathlessness, when breathing becomes unpleasant, difficult and tiresome.

GENERAL AND SUPPORTIVE MEASURES

• Find the position in which the patient is most comfortable: upright, semifowlers or prone. In patients with large effusions: position with the bad lung down to allow for maximum aeration of the good lung.
• Treat the underlying cause where appropriate:
  • Pneumonia is a common end of life event in many palliative care patients, with recurrent infections. Discuss with family when it may be appropriate to withhold or withdraw antibiotics.
  • Consider burden versus benefit of repeat drainage of malignant effusions that re-accumulate.
  • Blood transfusions for anaemia, especially at the end of life, have limited benefit.
  • Diuresis for patients with heart or renal failure may provide transient relief.
• Provide supplemental oxygen if beneficial in patients with end-stage disease. Manage the patient and not the saturation monitor. If dyspnoea is not relieved, then discontinue oxygen especially if this keeps patients in hospital.
• Reduce anxiety by addressing psychosocial factors, e.g. parental separation.
• Non-pharmacological interventions such as mindfulness, relaxation techniques, music and controlled breathing exercises can be beneficial.
• Blowing cool air onto the face with a fan or open window may also help relieve dyspnoea.
• Warm the air in the room using a humidifier.
• Keep mouth and lips moist in open mouth breathers.
• Manage secretions:
  • If thick, try loosen with saline nebulisation.
  • Physiotherapy and postural drainage where appropriate.
  • Suction as needed but avoid excessive suctioning.
  • See medication for excessive secretions.

MEDICINE TREATMENT

Morphine

Many fear using morphine for dyspnoea because of its potential to suppress respiration. If used at dyspnoea doses and titrated upwards against dyspnoea and/or pain, this is not a concern and should not be withheld even if the child is not for ventilation.

• Morphine, oral [Immediate release morphine (liquid)].
  • Dyspnoea starting dose for opioid naïve patients is 50% of the pain dose.
  • For patients already on morphine (e.g. for pain) increase their current dose by 30–50%.
  • For moderate dyspnoea, oral:
    • If 0–1 month: 25 mcg/kg/dose 6 hourly.
    • If > 1–12 months: 50 mcg/kg/dose 4 hourly.
    • If > 12 months: 100–200 mcg/kg/dose 4 hourly.
  • For severe dyspnoea, IV or SC:
    • If 0–1 month: 0.01 mg/kg/dose immediately.
    • If > 1–12 months: 0.025 mg/kg/dose immediately.
    • If > 12 months: 0.05–0.1 mg/kg/dose immediately.
    • Repeat in 25 minutes if given IV or 30 minutes if given SC and then start continuous IV or SC infusion.
    • IV/SC infusion starting dose: 10 mcg/kg/hour and titrate upwards in increments of 30 to 50% against dyspnoea.

Midazolam

Route	Dose
Oral	125–250 mcg/kg [maximum: 20 000 mcg (20 mg)] as a single dose.
Buccal/ Intranasal	6 months to 9 years: 50–150 mcg/kg [maximum: 5 mg (5000 mcg)] as a single dose. 10 to 17 years: 1.5–3.5 mg as a single dose
IV or SC injection	1 month to 5 years: Initially 6.25–25 mcg/kg, to be administered over 2–3 minutes; dose can be increased if necessary in small steps to maximum total dose of 3000 mcg/dose (3 mg/dose). 6–11 years: Initially 6.25–25 mcg/kg, to be administered over 2–3 minutes; dose can be increased if necessary in small steps to a maximum total of 3750 mcg (3.75 mg). 12–17 years: Initially 6.25–25 mcg/kg, to be administered over 2–3 minutes; dose can be increased if necessary in small steps to a maximum of 5000 mcg (5 mg).
IV or SC infusion	250–1500 mcg/kg/24 hours as starting dose titrating upwards against symptoms and sedation. (Equates to: 10–60 mg/kg/hour.)

For excessive secretions

• Atropine ophthalmic solution 1%:
  • Starting dose (all ages): 1 drop, sublingual every 6 hours.
  • Increase to 2 drops, sublingual every 6 hours.
  • Stop if mouth becomes too dry.

Note: Following systemic absorption, mydriasis may occur.

• Ensure this agent is discontinued when evaluating patients for brain death with brain stem testing.

Hyoscine butylbromide, SC/IV:

• 1 month to 4 years: 300–500 mcg/kg (maximum: 5 mg/dose) 6– 8 hourly.
• 4–11 years: 5–10 mg 6–8 hourly.
• 12–17 years: 10–20 mg 6–8 hourly.
• Continuous SC infusion:
  • 1 month to 4 years: 1.5 mg/kg/24 hours (maximum: 15 mg/day).
  • 5–11 years: 30 mg over 24 hours.
  • 12–17 years: Up to 60–80 mg over 24 hours.
  • Higher doses may be needed: doses used in adults range from 10–120 mg/24 hours (maximum: 300 mg/day).

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Standard Treatment Guidelines And Essential Medicines List For South Africa, Hospital Level, Paediatrics, 2023 Edition

Chapter: 21. Palliative Care,  21.1 Symptom Control,  21.1.2 Respiratory Symptoms,  21.1.2.1 Dyspnoea