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Opioids for management of dyspnoea

 

Clinical bottom line

Oral and parenteral opioids, but not nebulised opioids, showed improvements of opioids over placebo for dyspnoea outcomes and exercise tolerance outcomes.


Background

Dyspnoea is a subjective sensation of difficulty in breathing, and is common with advanced disease, including cancer, respiratory, cardiac, and neuromuscular disease. Prevalence of dyspnoea can be 50% or more in patients dying of cancer and cardiac disease, and can be very distressing. Opioids are commonly used to treat dyspnoea in palliative care settings.

Reference


AL Jennings et al. A systematic review of the use of opioids in the management of dyspnoea. Thorax 2002 57: 939-944.


Systematic review

Randomised, placebo-controlled double-blind studies were sought in which opioids (any dose, by any route) were used. Six electronic databases were searched, plus reference lists, reviews, and book chapters, and personal contact with authors and experts. The primary outcome measure was a subjective assessment of dyspnoea.

Results

Eighteen studies were included, all with crossover design, and all studies scored 3 or 4 out of 5 on a commonly used scoring system, indicating that serious bias was unlikely. Studies were small: oral and parental studies had sizes of between 7 and 19 patients (total 116 patients), and those of nebulised opioids had between 8 and 79 patients (total 177 patients). In oral and parenteral studies opioids used were diamorphine, dihydrocodeine, or morphine. In the nebulised studies, only morphine and morphine-6-glucuronide were used.

Oral and parenteral opioids, but not nebulised opioids, showed improvements of opioids over placebo for dyspnoea outcomes and exercise tolerance outcomes. The effect of oral or parenteral opioids amounted to some 8 mm on a 100 mm VAS scale, though several studies used very small doses of opioid.

Comment

The review supports the use of oral and parenteral opioids to treat dyspnoea in patients with advanced disease. There was no reason to suggest that nebulised opioids are any better than nebulised saline.