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Palliative dyspnea — ABIM Board MCQ

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ModerateGeneral Internal MedicinePalliative dyspneaABIM Board

A 68-year-old woman with end-stage fibrotic interstitial lung disease receiving comfort-focused care has severe breathlessness at rest. Her disease-directed treatment, supplemental oxygen for hypoxemia, pulmonary rehabilitation, breathing techniques, and use of a handheld fan have been optimized. She has no fever, increased sputum production, or other evidence of an acute reversible process. She is opioid-naive and has normal kidney function. Anxiety occurs during episodes of breathlessness but is not otherwise present. Which of the following is the most appropriate next treatment?

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Correct answer: B — Begin low-dose immediate-release oral morphine and titrate according to symptom relief and adverse effects

Low-dose systemic morphine is appropriate for severe, refractory dyspnea in advanced interstitial lung disease after reversible causes and disease-directed, oxygen, and nonpharmacologic treatments have been addressed. The dose should be titrated to comfort while monitoring sedation, nausea, and constipation; a bowel regimen is generally added with ongoing opioid therapy. Lorazepam does not directly treat breathlessness and is generally reserved for persistent anxiety that substantially contributes to symptoms after an opioid trial. Evidence supports oral or parenteral rather than nebulized opioids. Noninvasive ventilation is not routinely indicated without ventilatory failure and must remain consistent with the patient's goals. High-dose glucocorticoids are not justified without findings suggesting an acute ILD exacerbation.

Reference: Kalluri M. Chronic breathlessness in fibrotic interstitial lung diseases—patient centered assessment and management in outpatient settings. Annals of Palliative Medicine. 2024;13(4):1056-1075. https://pubmed.ncbi.nlm.nih.gov/20502400/