MKSAP: 72-year-old man with dyspnea at rest

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians.

A 72-year-old man is evaluated for dyspnea at rest. He has end-stage COPD and is on a home hospice program. He has weight loss, reduced functional capacity, and muscle atrophy. His medications are ipratropium, salmeterol, fluticasone, albuterol as needed, and prednisone. He is uncomfortable, with chronic air hunger that has gradually increased over the past 2 weeks. Otherwise, his symptoms have been stable without change in cough, sputum production, or fever. Following a physical exam, what is the most appropriate management?

On physical examination, temperature is 37.0 °C (98.6 °F), blood pressure is 110/84 mm Hg, pulse rate is 102/min, and respiration rate is 30/min; BMI is 17. Breath sounds are decreased. Oxygen saturation on 2 L of oxygen via nasal cannula is 92%. Hematocrit is 36%.

Which of the following is the most appropriate management?

A: Administer a blood transfusion
B: Administer diazepam
C: Administer morphine sulfate
D: Increase oxygen flow

MKSAP Answer and Critique

The correct answer is C: Administer morphine sulfate.

The most appropriate management is to administer morphine sulfate. Dyspnea is one of the most common symptoms encountered in palliative care. It is most often the result of direct cardiothoracic pathology, such as pleural effusions, heart failure, COPD, pulmonary embolism, pneumonia, or lung metastases. Patients with underlying lung disease on bronchodilator therapy should have this therapy continued to maintain comfort. Opioids are effective in reducing dyspnea in patients with underlying cardiopulmonary disease and malignancy. In patients already receiving opioids, using the breakthrough pain dose for dyspnea and increasing this dose by 25% if not fully effective may be helpful. A 5-mg dose of oral morphine given four times daily has been shown to help relieve dyspnea in patients with end-stage heart failure. Low-dose (20-mg) extended-release morphine given daily has been used to relieve dyspnea in patients with advanced COPD.

If severe anemia is uncovered as a cause of dyspnea, a blood transfusion may help relieve symptoms. However, this patient has adequate oxygen carrying capacity, so a blood transfusion is not indicated.

In contrast to opioids, benzodiazepines have not demonstrated consistent benefit in treating dyspnea; however, they may have a special use in patients with dyspnea caused by anxiety.

Oxygen may be useful in relieving dyspnea in terminally ill patients with hypoxemia, but a meta-analysis suggests that it has limited use in symptom relief in patients without hypoxemia. Increasing the flow of oxygen provides no added value in patients already receiving oxygen with adequate oxygenation.

Key Point

  • Opioids are effective in reducing dyspnea in patients with end-stage COPD.

This content is excerpted from MKSAP 16 with permission from the American College of Physicians (ACP). Use is restricted in the same manner as that defined in the MKSAP 16 Digital license agreement. This material should never be used as a substitute for clinical judgment and does not represent an official position of ACP. All content is licensed to on an “AS IS” basis without any warranty of any nature. The publisher, ACP, shall not be liable for any damage or loss of any kind arising out of or resulting from use of content, regardless of whether such liability is based in tort, contract or otherwise.

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