Consider reversible causes and treat as appropriate:
Studies have shown this is unlikely to help unless the breathlessness is related to relatively acute desaturation, but it may be worth a trial. Consider nasal specula if mask raises anxiety.
Consider humidifying oxygen, which will dry mouth less.
Oximetry, except in the acute situation, is of limited value; use clinical judgment.
May be helpful if bronchospasm is present
Nebulised solution: 250µg in 1mL, 500µg in 2mL
Child less than 1 year: 62.5µg 3 to 4 times daily,
Child 1-5 years: 125-250µg 3 to 4 times daily,
Child 5-12 years: 250-500µg 3 to 4 times daily,
Child over 12 years: 500µg 3 to 4 times daily.
May be helpful if bronchospasm is present.
Aerosol Inhalation:
Child 1 month-18 years: 100-200µg (1-2 puffs) for persistent symptoms up to four times a day.
Nebulised solution: (2.5mg in 2.5mL, 5mg in 2.5mL, 5mg in 1mL)
Neonate: 1.25-2.5mg up to four times daily,
Child 1 month-18 years: 2.5-5mg up to four times daily.
N.B. Salbutamol may make agitation worse, and cause a tremor if over- used.
Reduces anxiety, pain, and pulmonary artery pressure.
Begin with half the analgesic dose, and titrate to effect (see section on pain).
Injection: 10mg in 2mL; 10mg in 5mL.
Injection may be diluted if required, in sodium chloride 0.9% or glucose 5%. Injection can be used for buccal, intranasal, oral or rectal administration.
Oral solution (2.5mg/mL unlicensed), buccal liquid (5 mg/mL Buccolam®) and injection 1mg/mL, 2mg/mL, 5mg/mL (Epistatus® 10mg/mL) are also available from ‘specials’ manufacturers or specialist importing companies (unlicensed). NOTE The buccal and oral formulations available may differ in strength – take care with prescribing.
>1month -18yr: 100µg/kg
Any age: 100µg/kg as a single dose (maximum initial dose 5 mg).
Tastes bitter when given orally but can be mixed with juice or chocolate sauce.
Dosages of 30-50% of terminal seizure control dose can be used to control anxiety and terminal breathlessness.
Contraindications and warnings: caution with pulmonary disease, hepatic and renal dysfunction (reduce dose), severe fluid electrolyte imbalance and congestive cardiac failure. Avoid rapid withdrawal after prolonged treatment.
Licence: licensed for sedation in intensive care and for induction of anaesthesia in children > 7 yr. Other routes and indications not licensed.
Tablets: 1mg (scored), 2.5mg.
Oral suspension only available as ’special’ Injection: 4mg in 1ml, 1ml ampoule
By mouth:
Child < 2 years: 25µg/kg 2–3 times daily,
Child 2–5 years: 500µg 2–3 times daily,
Child 6–10 years: 750µg 3 times daily,
Child 11–14 years: 1mg 3 times daily,
Child 15–18 years: 1–2mg 3 times daily.
Sublingual:
Children of all ages: 25µg/kg as a single dose. Increase to 50µg/kg (maximum 1 mg/dose) if necessary.
Usual adult dose: 500µg – 1mg as a single dose, repeat as required
Well absorbed sublingually (good for panic attacks) and child has control. Injection can also be given sublingually.
Contraindications and warnings: severe pulmonary disease, sleep apnoea, coma, CNS depression. Caution in hepatic and renal failure.
Licence: tablets licensed in children >5yr as premedication. Injection not licensed in children <12yr except for treatment of status epilepticus.
May be helpful in some very rare circumstances such as bronchial obstruction, lymphangitis carcinomatosis, superior vena cava obstruction (SVCO). Should be prescribed with guidance from the specialist palliative medicine team.)
PCM © 2012