Respiratory Distress in Hospice – Helping your Loved One


If you or your loved one is experiencing difficulty with breathing, there are several approaches to minimize these symptoms.

To better understand how to treat shortness of breath, it is important to understand the main functions of the respiratory system, and how they are affected by serious illness or disease.   When evaluating problems with breathing, observe how well someone’s lungs are expanding and contracting, this is referred to as ventilation.  You can visibly see someone is having a hard time breathing, because they will start to using muscles of the abdomen and upper chest to help with ventilation.  Often times, the increased respiratory effort is associated with an increased rate of breathing.

The other critical function of our lungs is the exchange of oxygen for carbon dioxide, referred to as perfusion.  If someone has fluid in their lungs, this interferes with that oxygen exchange.  When the body senses a drop in oxygen levels, people can experience some anxiety as it signals a stress response.  Symptoms of shortness of breath are related to either ventilation or perfusion, and often times a combination of both.

We can measure how well blood is being oxygenated, by assessing capillary flow in the nailbeds with a pulse oximeter.  This little device is handy, but should not solely be relied on to determine someone’s wellness.  A person could be having a ventilation problem, and their oxygen level might be normal, which is between 92-100%.  Familiarizing yourself on how to calculate a respiratory rate can help a caregiver identify shortness of breath.  In order to figure out the rate, count how many breaths are being taken in one full minute.  If a normal respiration rate is usually between 16-20 breaths per minute, then over 40 breaths in one minute is considered respiratory distress.  A rapid rate of breathing is exhausting, and can be uncomfortable for your loved one.  With the assistance of hospice, there is a way for you to help.

What are the most common reasons for Shortness of Breath?

Chronic Lung Disease

Very commonly we treat patients in hospice with a diagnosis of Chronic Obstructive Pulmonary Disease  (COPD), which encompasses varying degrees of  Emphysema, Chronic Bronchitis, and Asthma.  Specific medications are given to these patients to quiet their immune response, like steroids in oral and inhalation forms.   Cancers of the lung and a disease called Pulmonary Fibrosis are also treated in a similar manner.  There is a very high risk for respiratory infections and pneumonia, and these patients are commonly treated with antibiotics, when they experience worsening of shortness of breath.

Anemia

Our blood is rich in red blood cells, which transport a mineral called Iron.  This mineral has a specific function in the blood, because it attracts and binds to oxygen molecules.  The oxygen is then delivered to all of the cells in our body.  If someone were to have a shortage of red blood cells, they might experience some shortness of breath, as a result of a deficiency of Iron.  Anemia is defined as a decreased red blood cell count, and in severe cases may require a blood transfusion to replace that blood that has been lost.   In hospice, blood transfusions are generally considered aggressive treatment and life support.  It may be worth consideration, if the reason for the blood loss is not corrected,  repeated need for blood transfusions could potentially prolong suffering.  It is not unusual for patient to take an iron supplement to help with anemia,  under their supervision of a doctor.  Bleeding issues can be a culprit for anemia in many situations, but it can also be related to disease processes like: Chronic Kidney Disease, Celiac disease, or a Vitamin B-12 deficiency.

Pulmonary Edema

Pulmonary edema  is a condition that is commonly referred to as “fluid in the lungs”.  Sometimes these patients will experience some swelling in their arms and legs as well, and this means that they have too much fluid in their bloodstream. The fluid is being forced into the tissues, because it has nowhere else to go.  This fluid will also seep into the lungs, making it difficult to breathe.  Most frequently this caused by a weakened heart, failing kidneys, or cancers of the lung.  Your hospice doctor may prescribe some “water pills” called diuretics, in an effort to help the body remove some of the excess fluid in the bloodstream.   Another consideration in decreasing symptoms of shortness of breath, related to pulmonary edema, is to potentially restrict the amount of the fluid that someone might be drinking.  Fluid restrictions can really benefit this type of patient, and I would encourage you to discuss this with your hospice nurse.

Choking

Shortness of breath can be triggered in the event of choking, or accidently getting food or liquids into the lungs while eating.  In hospice, it is not uncommon for patients to have a weakened ability to swallow.  These patients are at a very high risk for this particular problem, referred to as aspiration.  You may start to notice that drinking fluids will force someone to cough, and this could be an indicator of a condition called dysphagia.  If you or your loved one starts to demonstrate problems with swallowing, there are some preventative measures to consider.  Initially, changing the consistency of food to a softer diet,   and using a special powder to thicken the consistency of liquids. Your hospice nurse will guide you on how to prevent complications related to potential aspiration or choking.

Overall, the sensation of air hunger can produce anxiety, and sometimes panic.  It can be quite noticeable when someone’s Oxygen levels in the blood drop below normal.  Chronic states of oxygen deprivation can lead to increased episodes of confusion and fatigue over time. If the symptoms are treated appropriately, shortness of breath can be managed quite effectively.  Hospice patients can continue to maintain some quality of life, despite their difficulties with breathing.

How is difficulty with breathing managed in the hospice patient?

Oxygen

Most hospice patients will need some level respiratory support, and it is pretty standard that patients are issued an oxygen concentrator at the start of hospice care.  These machines plug into the wall, and pull room air into them, and then produce an air flow with concentrated oxygen.  Most people will wear a small piece of plastic tubing that delivers oxygen through the nose, called a nasal cannula.  There is a way to adjust the flow rate, which is referred to as the Liter flow.  The maximum benefit of oxygen support through a nasal cannula is 4 Liters per minute, and many will find that this intervention provides a lot of comfort.   It is very important to note that Oxygen is flammable, and to keep away from any type of open flames or heat sources.   Your hospice nurse will guide you on the use of supplemental oxygen, and when it may be appropriate for you or your loved one.

Nebulizers

This is a delivery method for various inhalant medications that can be useful in treating shortness of breath.  A nebulizer is an air compressor, tubing is attached, with a chamber for medication, and a mouthpiece or mask.  This medication is inhaled in a mist form, and a treatment usually takes a about 15-20 minutes to deliver all of the medication.  Albuterol or Duoneb are commonly used in a nebulizer, and this is the preferred treatment for symptoms of wheezing or airway constriction.  The hospice doctor may prescribe breathing treatments, and your hospice nurse will guide you on the appropriate administration of these medications.

Positioning

The function of breathing is easier when someone’s is head elevated, and some may prefer to sit completely upright.  An electric hospital bed may be beneficial for someone struggling with orthopnea, because the position of the head of the bed can adjusted for comfort.  It is not unusual for people to have a difficult time sleeping in a lying down position, and they will frequently find themselves napping in their recliner.

Suctioning

Hospice will provide you with a small suction machine.  Take precaution to only suction in the cheek area, and remain clear of the back of the throat.  As the vacuum container begins to collect fluid, the suction will become less effective, so be sure to empty the contents of canister as needed.  This can be a helpful piece of equipment to have on hand, if there is a need to clear someone’s airway, in the example of choking.  It is a comfort measure to be able provide suction if necessary.  Your hospice nurse can set the suction machine up for you, and demonstrate on how to administer oral suction, when it is appropriate.

Environment

One factor that is often over looked is the general climate of the room.  An oxygen concentrator will generate some heat, especially when it is running constantly.  Sometimes it may need to be removed from the room, and an extension set of tubing can be obtained very easily.  When someone is very short of breath, making sure the room is cool can be helpful.  Even placing a fan nearby to circulate the air, may decrease anxiety.

Medications

 The hospice doctor may prescribe a variety of different medications, and your hospice nurse will guide you on how they are used most effectively.  The following are some of the more common medications used to treat particular symptoms that may contribute to shortness of breath.

Infection- Antibiotics that may be prescribed to treat respiratory infections: Levofloxacin aka Levaquin, Azithromycin aka Z-pak, or Clindamycin aka Cleocin.

Congestion- In an effort to thin mucus in the chest,  an expectorant medication containing the generic Guaifenesin is generally prescribed.  Common brand names of this medication are Robitusson and Mucinex, and this can be very beneficial.

Coughing- When a productive cough is frequent or severe, and causing pain to the chest wall, a suppressant is often recommended.  Medications with Dextromorphan (DM), Benzonatate, or Codeine can may be prescribed by your hospice doctor.

Shortness of Breath-  Steroids can be helpful in treating this symptom, and are usually seen commonly as: Dexamethasone or Prednisone ( which is frequently administered in a  Medrol Dose Pack).  Benzodiazepines are also helpful with anxiety, especially when related to  moderate shortness of breath.  This medication can be found in the comfort pack, most commonly used in form of Ativan aka Lorazepam.  For severe shortness of breath, it is highly recommended that morphine be considered. In hospice, Roxanol is a common brand name for morphine, which is in a liquid form, given orally under the tongue, known to be fast and effective.  In the event that morphine may be necessary to control severe difficulty with breathing, your hospice nurse will be by your side to provide guidance.

Severe Congestion- There may be incidence of a severe productive cough, and we refer to this as respiratory secretions.  The hospice doctor may prescribe an Anticholinergic medication like: Atropine Sulfate, Levsin, and Scopolamine.  The medications have a complex action, but simply stated, they reduce the amount of secretions that are being produced.  These medications should be used with caution, and with guidance from your hospice nurse.

Provide Reassurance

Now that you have done what your hospice nurse has advised you to do, you wait for the interventions to work. Trust the medications with confidence. Trust that you have the ability to make your loved one feel much better, with just a little direction.  Something as simple as holding someone’s hand can provide a lot of emotional support.  You can also encourage a breathing technique called pursed lip breathing, when someone inhales through their nose, and exhales through their lips in a puckered position, like you are sucking through a straw.  Your hospice nurse will guide you in the management of respiratory symptoms, under the direction of the hospice doctor.  There are several things that can be done to ensure that you or your loved one will be comfortable, especially when there may be some difficulty with breathing.

I hope this was helpful.  Please feel free to ask a question or leave a comment.

 




12 Comments

  • Smcfadden May 22, 2017 at 2:25 am

    Thank you for the timely post about shortness of breath, my Mother suffered from congestive heart failure and was on oxygen for several months before her death. I’m sure this information will be helpful to those caregivers dealing with loved ones having difficulty breathing.

    Reply
    • Heather Williams RN CHPN May 22, 2017 at 3:09 am

      I am sorry for your mother and her problems with congestive heart failure,and my condolences for your loss. That can be challenging to manage that particular disease process. Thank you for taking the time to read my article.
      Take Care,
      Heather

      Reply
  • Charles May 22, 2017 at 5:47 pm

    My sister grew up with asthma, and she frequently had to use an inhaler. She started suffering from that from early childhood.

    Breathing problems are scary. I think not being able to breathe would be very scary. When my sister first had problems with asthma, she panicked.

    My parents panicked too, because they didn’t know what to do. Your article is insightful and informative.

    Reply
    • Heather Williams RN CHPN May 23, 2017 at 2:40 am

      Asthma is a very serious childhood disease, and can be life threatening. Thank you for the nice comment, I am glad that you found the information useful.
      Take Care,
      Heather

      Reply
  • Farhan May 22, 2017 at 10:57 pm

    I suffered from childhood asthma many years ago, so I definitely understand the panic that people feel when they experience shortness of breath. Thankfully, none of my old folks have any breathing problems at this point.

    I wish I had come across this article much earlier. There is so much useful information here. Just wondering, do many young people also suffer from shortness of breath? Or does it just affect the old?

    Thanks for the information!

    Reply
    • Heather Williams RN CHPN May 23, 2017 at 2:38 am

      Anyone can suffer from shortness of breath, and for people that are not in hospice, should seek urgent/emergent treatment for sure. Kiddos and asthma when they has attacks, that is some scary stuff, and then there is peanut allergies and other types of allergic reactions which will restrict the airway. There are physicians that specialize soley in the treatement Children and Adult Pulmonary Disease. Hope that helps.
      Take Care,
      Heather

      Reply
  • Kendrick May 22, 2017 at 11:29 pm

    Hey,
    This is a nice post on shortness of breath. I remember my granddad experienced shortness of breath.

    I thought that he was just tired from doing physical activity. It is good to know there are methods to help minimize the symptoms for other people who may need the help.

    Thanks for the information.

    Reply
  • Irma May 23, 2017 at 6:45 pm

    Thank you for this information.

    My 86 year old mother has recently been diagnosed with COPD and she has used several kinds of “puffers”. I think it has more to do with allergies, as she also suffers from IBS, and so has had to change up the food that she eats to get relief.

    When I had asthma in my mid 20’s (It came on during a time of high stress), I found that spring hay fever made my symptoms worse. As well, even after I stopped taking meds because my symptoms pretty much went away, I did have the odd time when I had the tightness of chest and wheezing, usually after I ate something “odd”, like food at a buffet or potluck.

    Do you think that allergies are connected to asthma?

    Reply
    • Heather Williams RN CHPN May 23, 2017 at 8:41 pm

      Yes, asthma is an overactive immune system, when the lungs detect a possible threat, the airway goes bananas and tries to close up. The immune response of Asthma can be triggered by allergens, exercise, stress, changes in climate and weather. Food allergies in severe form can also trigger an airway constriction as well, called anaphylaxis, can all be life treatening and quite serious. Hope that helps.
      Take Care,
      Heather

      Reply
  • Jackie June 9, 2017 at 2:12 pm

    My Aunt, who is almost 90, just recently had a stroke. After the stroke her breathing was impaired so much that she had to be put on an oxygen machine. I’m not sure why the stroke brought this on, but I think she had breathing issues way back. It’s very scary for her because not only are her legs not working so well (from the stroke) but the oxygen tubes from the machine get tangled up in her feet when she tries to get to the bathroom. Your article was very informative and I’m glad I found it today. She’s not yet in hospice, but i feel it’s the next step. Bless you, for the work you do!

    Reply
    • Heather Williams RN CHPN June 12, 2017 at 3:26 pm

      Thank you very much. I am sorry to hear about your aunt. I hope she is getting the care that she needs. Many blessing to you and your family.
      Take Care, Heather

      Reply

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