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Use of opioids for refractory dyspnoea in hospitalised patients with serious illness: a narrative review
  1. Kevin J Karlic1,
  2. Ellen K Hummel2,3,
  3. Nathan Houchens3,4,5,
  4. Jennifer Meddings3,5,6,7,8
  1. 1Department of Internal Medicine, Internal Medicine Residency Program, University of Michigan, Ann Arbor, Michigan, USA
  2. 2Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, Michigan, USA
  3. 3Medicine Service, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  4. 4Department of Internal Medicine, Division of Hospital Medicine, University of Michigan, Ann Arbor, Michigan, USA
  5. 5Patient Safety Enhancement Program, University of Michigan and VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  6. 6Department of Internal Medicine, Division of General Medicine, University of Michigan, Ann Arbor, Michigan, USA
  7. 7Department of Pediatrics and Communicable Diseases, Division of General Pediatrics, University of Michigan, Ann Arbor, Michigan, USA
  8. 8Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
  1. Correspondence to Dr Kevin J Karlic, Department of Internal Medicine, University of Michigan, Ann Arbor, MI 48109-5000, USA; kekarlic{at}


Refractory dyspnoea can be a challenging symptom to manage. Palliative care specialists are not always available for consultation, and while many clinicians may undergo training in palliative care, this education is not universal. Opioids are the most studied and prescribed pharmacological intervention for refractory dyspnoea; however, many clinicians hesitate to prescribe opioids due to regulatory concerns and fear of adverse effects. Current evidence suggests that rates of severe adverse effects, including respiratory depression and hypotension, are low when opioids are administered for refractory dyspnoea. Therefore, systemic, short-acting opioids are a recommended and safe option for the palliation of refractory dyspnoea in patients with serious illness, especially in a hospital setting that facilitates close observation. In this narrative review, we discuss the pathophysiology of dyspnoea; facilitate an evidence-based discussion on the concerns, considerations and complications associated with opioid administration for refractory dyspnoea; and describe one approach to managing refractory dyspnoea.

  • general medicine
  • respiratory medicine
  • palliative care

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  • Contributors All authors contributed equally in the development and preparation of the submitted manuscript. All authors were engaged with performing relevant literary review as well as drafting and submission of the manuscript. Notably, JM, NH and EKH provided expert opinion in their respective areas of practice.

  • Funding JM’s recent research has been supported by AHRQ grants R01HS026912 and R01HS018334 as well as funding from the VA National Center for Patient Safety and the Centers for Disease Prevention and Control. JM’s research has also been supported in recent years by contracts with the Health Research & Education Trust (HRET) involving the prevention of CAUTI, funded by AHRQ and the Centers for Disease Prevention and Control and the Centers for Medicare and Medicaid Services.

  • Competing interests JM was also a recipient of the 2009–2015 National Institutes of Health (NIH) Clinical Loan Repayment Program. JM, EKH and NH are salaried employees of the University of Michigan and the VA Ann Arbor Healthcare System. Notably, there was no funding for development of this review article. Honoraria: JM has reported receiving honoraria from hospitals and professional societies devoted to complication prevention for lectures and teaching related to prevention and value-based purchasing policies involving catheter-associated urinary tract infection and hospital-acquired pressure ulcers. Intellectual Property/Product Development: JM’s research involves development of products to improve patient safety by reducing hospital-acquired complications. Her team has a provisional patent involving one of these products that aims to reduce urinary catheter-associated complications and has recently applied for a patent involving a device to reduce hospital-acquired pressure ulcers. She has no associations with any companies or manufacturers, has no ownership in a commercial entity and receives no royalties.

  • Provenance and peer review Not commissioned; internally peer reviewed.