Dyspnoea (breathlessness) management near the end of life in COVID-19 infection

Maria Drummond, Bahaa Alassoud and Professor Bridget Johnston for ScotPalCovid

MEDLINE and EMBASE through Ovid and CINAHL via EBSCO were searched, followed by a Google and Google Scholar search to retrieve English language literature published on managing COVID-19-induced breathlessness near the end of life.

The combination of key words included: COVID-19, Coronavirus, dyspnea, dyspnoea, breathlessness, shortness of breath, end of life, palliative, hospice, terminal, dying

Go to Scottish palliative care guidelines for general palliative and end of life care information (https://www.palliativecareguidelines.scot.nhs.uk/) and the new Scottish Palliative Care COVID-19 guidelines are available here

Figure 1: SIGN 50 Levels of evidence

This image has an empty alt attribute; its file name is image-2.png
  • Of the people who develop COVID-19 and display symptoms, most will have a mild illness. However, a small number will experience breathlessness. Of that cohort, a smaller number will require pharmaceutical and/or medical intervention to manage this. (Xu, et al., 2020 – Level 3)
  • Advancing age, male sex, and pre-existing conditions have been identified as characteristics higher among patients who develop severe symptoms, such as breathlessness, acute respiratory distress syndrome (ARDS) and also death from COVID-19. (Grasselli et al. 2020 ; Yang et al., 2020; Shi et al., 2020; Huang et al., 2020; Xu et al., 2020 – Level 3)
  • When symptoms are severe and critical care is unlikely to lead to a positive outcome for the patient, care should be palliative, with symptom management as the primary treatment aim, to assist the person to die as comfortably as possible. (Arya et al., 2020 – Level 4)
  • Triage is vital during this pandemic to ensure people are cared for in the appropriate environment. Depending on severity of symptoms, those requiring palliative and end of life care will either be cared for in their own homes, a care home, hospice, or hospital. Resource availability, patient wishes, and complexity of care are all part of decision making. The management of breathlessness depends on where they are being cared for, what equipment is available to clinicians and the capacity of caregivers to assist. (Domenico et al., 2020 – Level 4)
  • If nurses are monitoring vital signs, they should focus on temperature, respiratory rhythm, rate, depth, SpO2, respiratory patterns, oxygen saturation. Where possible, monitor water-electrolytes, acid-base balance, and infection indicators of patients to determine the occurrence of complications, such as ARDS, among others. (Xia et al., 2020 – Level 3)
  • Management of breathlessness in people with COVID-19 and dementia is particularly challenging. Clinicians caring for someone with COVID-19 who has dementia should collaborate with social workers, caregivers, and dementia specialists if possible. This is particularly important to manage or prevent delirium from hypoxia. Sedation may be required in this patient group. (Wang et al., 2020 – Level 4; Tanjya et al. 2020 – Level 4)
  • Non-invasive options for mild or moderate respiratory distress may reduce the numbers of patients requiring intubation, mechanical ventilation, and ICU admission in some severely ill patients. However, all forms of oxygen therapy and respiratory support could aerosolise respiratory pathogens. Selection of respiratory support for patients must balance the clinical benefit of the intervention against the risks of nosocomial spread. (Whittle et al. 2020 – Level 4)
  • Non-invasive options include Continuous Positive Airway Pressure (CPAP) or Bi-Level Positive Airway Pressure (BiPAP) which are respiratory support devices that deliver positive airway pressure through tight fitting facial or nasal masks. However, evidence to support their use in managing patients with COVID-19 who are experiencing respiratory distress is inconsistent. They should be used cautiously. Nebuliser therapies should be avoided due to their dispersal of particles. Alternatives, such as metered doses or their use with carefully adapted masks could be considered. (Whittle et al. 2020 – Level 4)
  • If breathlessness accompanies cough, expectoration, chest tightness and cyanosis then oxygen therapy should be commenced if possible. Respiratory support techniques should be selected according to the degree of hypoxia, patient tolerance and the doctor’s advice. Specific, in-depth recommendations about oxygen therapy for elderly people with COVID-19 is available in the full reference: https://onlinelibrary.wiley.com/doi/pdf/10.1002/agm2.12107 (Xia, et al. 2020 – Level 3) and more general oxygen therapy recommendations from: https://onlinelibrary.wiley.com/doi/pdf/10.1002/emp2.12071 (Whittle, et al. 2020 – Level 4)
  • Clinical areas should prepare “palliative medication kits” or “palliative care pandemic pack” specific to patients with COVID-19 who are approaching the end of their lives. These should contain all necessary equipment, medication and prescribing guidelines required to manage the typical symptoms experienced by this patient group, of which breathlessness is one. Clinicians may need to use sedation to alleviate refractory symptoms. (Arya et al. 2020 – Level 4; Ferguson et al. 2020 – Level 4)
  • As deterioration can happen suddenly and rapidly, prescriptions should be prepared in advance that include oral and subcutaneous formulations. It is suggested that morphine and midazolam, are effective at managing breathlessness, and combination of midazolam and levomepromazine should be considered in terminal agitation/restlessness/delirium. (Roland, 2020 – Level 4; Lovell et al. 2020 – Level 3; Chidiac et al. 2020 – level 4; Tanjya et al, 2020 – Level 4; Scottish Palliative Care Guidelines, 2020)
  • Nonpharmacological management of breathlessness includes raising the upper body, letting fresh air into the room and psychological support and reassurance. (Roland, 2020 – Level 4)
  • Clinical areas should stockpile medications to manage breathlessness and the equipment required for its administration, particularly syringe drivers and associated equipment. (Arya et al., 2020 – Level 4; Lovell et al. 2020 – Level 3)
  • Older patients with COVID-19 are at an increased risk of experiencing anxiety and panic. This can then exacerbate breathlessness. Cognitive evaluation, behavioural monitoring and emotional support should be a fundamental part of their care. If clinicians are trained, they can offer Cognitive Behavioural Therapy, positive psychology, and relaxation/meditation to alleviate psychological suffering. (Xia et al. 2020 – Level 3)
  • There is much discussion related to the use of electronic tablet devices to allow family members and loved ones to be “digitally present” with someone who is unwell with COVID-19. However, this should be considered cautiously if the person is at the end of life, as symptoms and presentations may be upsetting and distressing to families. (Tanja et al, 2020 – Level 4)
  • A telephone survey of 16 hospices in Italy emphasised how important palliative and end of life care is in this pandemic. A lack of adequate preparation and equipment to carry out palliative care effectively (or at all) was not only detrimental to patients but was also psychologically distressing to the clinicians involved in their care. (Costantini et al., 2020)

Management of breathlessness at end of life from new clinical practice covid-19 Guidelines

  • Caregivers should be supported to help reduce any worry or distress related to breathlessness. Furthermore, clinicians should consider the level of support required for caregivers in relation to obtaining and using prescribed medication to manage breathlessness and who they should contact in emergencies. (NIHR Supporting informal carers during the covid-19 pandemic working list, 2020)
  • The use of handheld or portable fans are no longer recommended amid the outbreak of the COVID-19. These measures are linked to cross infection in healthcare facilities, particularly, if the patient is tested positive or suspected to. (Association for Palliative Medicine of Great Britain and Ireland, 2020; Scottish Palliative Care Guidelines, 2020)
  • People with severe COVID-19 symptoms, especially breathlessness can deteriorate quickly. They may require higher starting and maintenance doses of opioids/anxiolytics than usually expected to control the breathlessness and reduce anxiety. However, caution required when administering to elderly patients. (Association for Palliative Medicine of Great Britain and Ireland, 2020; Scottish Palliative Care Guidelines, 2020)
  • Bolus subcutaneous or intravenous doses of as required medication should be considered when commencing syringe drivers due to the delay in medication reaching effective levels when administered via subcutaneous infusion (approximately four hours). (Scottish Palliative Care Guidelines, 2020)

New palliative care guidelines that include management of breathlessness are available from the following links:

Association for Palliative Medicine of Great Britain and Ireland COVID-19 and Palliative, End of Life and Bereavement Care in Secondary Care: https://apmonline.org/wp-content/uploads/2020/03/COVID-19-and-Palliative-End-of-Life-and-Bereavement-Care-22-March-2020.pdf

NICE Covid-19 breathlessness guideline: https://www.nice.org.uk/guidance/ng163/chapter/6-Managing-breathlessness

NIHR Supporting informal carers during the covid-19 pandemic working list: https://elearning.rcgp.org.uk/pluginfile.php/149078/mod_resource/content/5/Supporting%20Informal%20Carers%20During%20The%20C-19%20Pandemic%20V2.pdf

West Midlands Palliative Care Physicians end of life Covid-19 symptom management Guidelines: http://www.wmcares.org.uk/wp-content/uploads/V4-WM-EOLC-DRUG-Guidance-for-Use-in-the-COVID-crisis-1.pdf

Reference List

ARYA, A., BUCHMAN, S., GAGNON, B. & DOWNAR, J. 2020. Pandemic palliative care: beyond ventilators and saving lives. Canadian Medical Association Journal, cmaj.200465.

Chidiac, C., Feuer, D., Naismith, J., Flatley, M., & Preston, N. (2020). Emergency Palliative Care Planning and Support in a COVID-19 Pandemic. Journal of Palliative Medicine. doi:10.1089/jpm.2020.0195

COSTANTINI, M., SLEEMAN, K. E., PERUSELLI, C. & HIGGINSON, I. J. 2020. Response and role of palliative care during the COVID-19 pandemic: a national telephone survey of hospices in Italy. medRxiv, 2020.03.18.20038448.

DOMENICO, B. G., CLAUDIA, G., MONIKA, O. & RAIF, J. 2020. COVID-19: Decision making and palliative care Swiss Medical Weekly, 150.

Ferguson, L., & Barham, D. (2020). Palliative Care Pandemic Pack: a Specialist Palliative Care Service response to planning the COVID-19 pandemic. J Pain Symptom Manage. doi:10.1016/j.jpainsymman.2020.03.026

HUANG, Y., YANG, R., XU, Y. & GONG, P. 2020. Clinical characteristics of 36 non-survivors with COVID-19 in Wuhan, China. medRxiv, 2020.02.27.20029009.

Grasselli, G., Zangrillo, A., Zanella, A., Antonelli, M., Cabrini, L., Castelli, A., . . . Network, f. t. C.-L. I. (2020). Baseline Characteristics and Outcomes of 1591 Patients Infected With SARS-CoV-2 Admitted to ICUs of the Lombardy Region, Italy. JAMA. doi:10.1001/jama.2020.5394

ROLAND, K. M., MINDER 2020. COVID-19 pandemic: Palliative care for elderly and frail patients at home and in residential and nursing homes. Swiss Medical Weekly, 150.

SHI, Y., YU, X., ZHAO, H., WANG, H., ZHAO, R. & SHENG, J. 2020. Host susceptibility to severe COVID-19 and establishment of a host risk score: findings of 487 cases outside Wuhan. Crit Care, 24, 108.

Tanja, F. S., Nancy, P., Keller, N., & Claudia, G. (2020). Conservative management of Covid-19 patients – emergency palliative care in action. J Pain Symptom Manage. doi:10.1016/j.jpainsymman.2020.03.030

WANG, H., LI, T., BARBARINO, P., GAUTHIER, S., BRODATY, H., MOLINUEVO, J. L., XIE, H., SUN, Y., YU, E., TANG, Y., WEIDNER, W. & YU, X. 2020. Dementia care during COVID-19. The Lancet.

WHITTLE, J. S., PAVLOV, I., SACCHETTI, A. D., ATWOOD, C. & ROSENBERG, M. S. 2020. Respiratory Support for Adult Patients with COVID-19. Journal of the American College of Emergency Physicians Open, n/a.

XIA, W., CHAO, S., HUI-XIU, H., ZI-XIN, W., HUI, W., HUA, P., JIAN-HONG, Q. & LAN, G. 2020. Expert consensus on the nursing management of critically ill elderly patients with coronavirus disease 2019. AGING MEDICINE, n/a.

XU, X.-W., WU, X.-X., JIANG, X.-G., XU, K.-J., YING, L.-J., MA, C.-L., LI, S.-B., WANG, H.-Y., ZHANG, S., GAO, H.-N., SHENG, J.-F., CAI, H.-L., QIU, Y.-Q. & LI, L.-J. 2020. Clinical findings in a group of patients infected with the 2019 novel coronavirus (SARS-Cov-2) outside of Wuhan, China: retrospective case series. BMJ, 368, m606.

YANG, X., YU, Y., XU, J., SHU, H., XIA, J. A., LIU, H., WU, Y., ZHANG, L., YU, Z., FANG, M., YU, T., WANG, Y., PAN, S., ZOU, X., YUAN, S. & SHANG, Y. 2020. Clinical course and outcomes of critically ill patients with SARS-CoV-2 pneumonia in Wuhan, China: a single-centered, retrospective, observational study. The Lancet Respiratory Medicine.

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out /  Change )

Google photo

You are commenting using your Google account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )

Connecting to %s

Create your website at WordPress.com
Get started
%d bloggers like this: