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Thursday, January 12, 2012

Opiates good therapy for air hunger

There's nothing worse than the feeling you can't catch your breath, or dyspnea, or air hunger.  I can attest that the worst pain you acn endure is worse than not being able to breathe.  And when dyspnea becomes severe and chronic, one of the best remedies available are opiates (a.k.a. narcotics).

This was a remedy that was first applied to asthmatics back in the 19th century.  It relieved the anxiety and the feeling of air hunger.  Asthma was beleived to be a nervous disorder back then, so many experts believed opiates worked by easing the mind and, thus, easing the breathing.

However, morphine was also known to slow down the respiratory rate.  Giving too much of the substance would run the risk of knocking out one's respiratory drive and, perhaps, even cause death. 

These doctors were correct that morphine worked for asthma and dyspnea, yet wrong in their explanation.  According to "(opiates) decrease brainstem responsiveness to carbon dioxide (the primary mechanism of opioid induced respiratory depression) and lessen the reflex vasoconstriction caused by increased blood PCO2 levels so that the perception of dyspnea is reduced."

Opiates, thus, reduce dyspnea by vasodilation and decreased peripheral vascular resistance (blood pressure).  This may cause hypotension and increased hystamine release. It also may decrease gastrointestinal motility (another thing to watch out for).

Opiates are also good mild bronchodilators, so they are another option when everything else is failing.  Mainly, opiates are an option for your end stage lung disease patients who are chronically and severely dyspneic.  The medicine can be given systemically, yet another option is to nebulizer the medicine to get an immediate response in the lungs with minimal systemic effect.

When nebulized -- yes opiates can be nebulized -- medical professionals must wear appropriate masks to prevent inhalation of opoids. They can be given as needed or continuous infusion. As needed is probably better because it allows you to prevent over sedation.

The following are your opoid options:

1.  Morphine:  The therapeutic dose of nebulized morphine is 5 mg of the 0.1% solution every 4 hours as needed.  Studies have shown (click here) that opiates (nebulized or other) decrease shortness of breath, allow for a greater feeling of relaxation, and increase exercise tolerance. No significant difference was reported with doses higher than 5 mg. However, since morphine can cause bronchoconstriction, promote histamine release, and depress respirations, it should be used with caution. It also can cause hypotension, so it's ideal for anxious patients in respiratory disterss with high blood pressure.

It can also be provided orally, under the tongue (sublingually), injection into an IV, or even given by continuous infusion (although this option is generally reserved for post operative pain).   Here's a scientific article about Morphine for dyspnea, and here's a post from asthmatic Breathin Stephen who uses Morphine for his dyspnea.

2.  Hydromophone (Dilaudid):  A dose of 4mg every four hours may be mixed with normal saline and given via nebulizer in patients who are allergic or intollerent to Morphine sulfate to treat dyspnea. Some patients have benefited from 1 mg nebulized dilaudid every four hours, and some required as much as 20mg to receive benefits. Symptom relief was generally felt within 15 minutes and most patients suffered no adverse effects.
Nebulized dilaudid sometimes works better for those suffering from dyspnea due to fewer side effects than the pill form of opiates.  One common side effect is headaches.

3.  Fenatanyl (Dublimaze):  Can also be nebulized and given for dyspnea relief. A dose of 25 micrograms in 2cc normal saline is the usual dose. Eighty one percent of patients in one study noted relief within 5 minutes, and relief lasted up to an hour. Oxygen saturations and respiratory rate also improved. So it can be used as an alternate for those patients allergic to or intollerent to morphine sulfate. Optimum dose and duration of benefits are unknown at this time. Unlike Morphine, it does not have the side effect of histamine release. It is expensive however.

4.  Codeine:  A dose of 15 mg nebulized codeine can be given to patients for dyspnea relief is they have an allergy or intollerence to morphine sulphate (source

5.  Meperedine (Demerol):  Not a very good analgesic. It's highly addictive, may cause hallucinations, and buildup can lead to ceizures.

6.  Hydrocodone: No information available for treating dyspnea.

7.  Oxycodone (Oxycontin):  No information available for treating dyspnea.

8.  Anileridine (Leritine):  New analgesic no longer available in the United States. Is available in Europe. Similar to Demerol but chemicals are altered slightly to give it a stronger analgesic effect. It's available as a tablet or injection, yet 25mg can be aerosolized in a nebulizer for treating dyspnea.
For more information about respiratory medicine check out my medicine lexicon.


Anonymous said...

Morphine works great I had complications after thoracic surgery requiring an emergency chest tube. I ended up with restrictive lung disease,pleural thickening ,pleural effusion. Felt like was running a marathon just to have a short conversation it was really scary. Was taking oxy for pain but was switched to morphine for pain. The day I stareted to morphine was the day I could have a conversation again. Yes I still get out of breath bc I'm not cured but not half as bad before the morphine.. :)

Barb said...

I have horrible air hunger. I started taking percocets on a regular bases and not as needed. I also sleep with oxygen. I have realized that the air hunger has stopped! I also increased alprazolm to one during the day and one at night. So. If you have air hunger it could be a side effect or just the need to relax.