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Canterbury DHB

Medical Management

Morphine

• Morphine is often useful - the mechanism is not clear.
• Usually lower doses are required than those for pain e.g. 2.5 - 10 mg of elixir 4 hourly or PRN. The dose can be gradually titrated as for pain but comfort rather than resolution of dyspnoea is generally the desired end point.
• Low dose m-Eslon^TM or low dose morphine infusion may be more convenient if a trial of elixir has proved helpful however patients may choose to remain on regular elixir.
• Nebulised morphine has NO demonstrable advantage over morphine elixir.

Benzodiazepines

• Clonazepam oral drops 2.5 mg/ml (1 drop = 0.1 mg) 1-3 drops 4-6 hourly PRN.
• Lorazepam 0.5 - 1 mg PO 4 - 6 hourly.
• Midazolam 10 – 20 mg/24 hours via subcut infusion.
• Midazolam can also be used as a nasal spray. See Intranasal Midazolam Protocol.
• Sedation is sometimes needed and morphine plus a benzodiazepine via subcut infusion is recommended.

Steroids

• Recommended for bronchial obstruction, superior vena cava obstruction (SVCO) and radiation pneumonitis.
• Therapeutic trial can sometimes be worthwhile if cause unclear.
• Either prednisone 20-40 mg mane or dexamethasone 8-12 mg mane – aim to reduce gradually to lowest effective dose.

Ipratropium (Atrovent™) Nebulisers

• Atrovent is useful especially if there is some degree of airway obstruction – not more than 4 hourly.

Topic Code: 11335