Algorithm for relieving the sensation of suffocation
In their article on palliative care for COVID-19 patients, Anne-Tove Brenne et al. highlight the importance of good communication between different levels of care (5). They emphasise too that high symptom intensity and rapid progression make it difficult to follow standard guidelines for the gradual escalation of drug doses until efficacy is achieved. Palliative medicine experts within the Western Norway Regional Health Authority have therefore collaborated to produce a concise algorithm for alleviating the sensation of suffocation, suitable to carry in a pocket or on a mobile phone. The algorithm is available from the Regional Centre of Excellence for Palliative Care and can be adapted and incorporated into local procedures (6). It is important that the first doctor to see the patient can quickly gain control of the symptoms.
A patient who is fighting for breath can best be helped using medications that reduce the effort required to breath by blocking hypoxia-induced stimulation of respiration, and medications that alleviate the fear of dying. The drugs of choice are therefore morphine (which lowers respiratory rate and effort, and reduces shortness of breath by reducing sensitivity to hypoxia and hypercapnia) and midazolam (which is a sedative, anxiolytic and muscle relaxant) (2, 7, 8). The algorithm for alleviating the sensation of suffocation (6) differs from the current guidelines in that it recommends a high starting dose, greater dose escalation at each step, routine co-administration of morphine and midazolam, and an instruction to consider rapid establishment and use of intravenous access, if not already available. This adjusted regimen is necessary to enable the provision of effective relief, even if doing so may somewhat shorten the life of the patient.
In brief, 5 mg morphine and 2.5 mg midazolam should immediately be administered intravenously
In brief, 5 mg morphine and 2.5 mg midazolam should immediately be administered intravenously. For subcutaneous administration, the starting dose is 10 mg morphine and 5 mg midazolam. Intravenous access and transition to an intravenous regimen should then be considered. For both routes of administration, the dose should be adjusted at specific time intervals in line with the recommendations (6). A low threshold is recommended for contacting local experts in palliative care to plan the subsequent course.
In the absence of evidence for a new clinical condition, we have chosen to reach a consensus on best practice based on available reports. The course of the terminal phase varies greatly across patients, but is characterised by a risk of rapid deterioration (10–20 minutes), even when initial symptoms are of low intensity. Death may occur shortly afterwards, or may follow a terminal phase lasting from hours to a few days, in which further rapid deteriorations may occur (M. Nystad, S. Steine, personal communication). It is crucial that experiences are collated and used as a basis on which to quickly adjust the recommendations. This will enable the healthcare system to offer suitable treatment so that patients do not have to end their lives with the sensation of being suffocated.