Dyspnoea

Dyspnoea in CKD can be due to renal and/or non-renal causes. Common aetiologies include:

• Renal: Anaemia, Fluid overload
• Non-renal
  – Chronic lung disease eg COPD, pulmonary fibrosis
  – Cardiac eg primary congestive cardiac failure, diastolic dysfunction, and unstable angina
  – Anxiety
  – General deconditioning

Management

Correct underlying aetiology if possible. Treat co-morbid anxiety. Non-pharmacological measures are the mainstay of treatment.

• Check iron, B12, folate and replace as required. For iron replete patients, consider EPO if Hb <100g/L. For non-dialysis patients with Hb<100g/L, treat anaemia to symptoms rather than biochemical targets.
• Fluid overload. May be both renal and cardiac causes
  – Restrictions to sodium and water intake
  – Loop diuretics (frusemide or bumetanide): may require higher doses to achieve diuretic effect. Will need electrolyte monitoring.
  – Consider intravenous diuretics in resistant cases, as gastrointestinal oedema may affect oral drug absorption.

Non-pharmacological management

• Hand held fan.
• Gentle physical exercise to improve conditioning.
• Energy conservation strategies.

Oxygen

Oxygen therapy has not been shown to be better than placebo in patients with normal oxygen saturation.

Consider palliative oxygen in hypoxic patients.

Pharmacological management

Opioids are first-line treatment. Hydromorphone: start with 0.25mg-0.5mg po tds, and up-titrate by 0.25mg to effect (max 4mg over 24 hours)

Benzodiazepines can be added to opioids.
– Lorazepam 0.5mg sublingually bd to tds. Uptitrate by 0.5mg to 1mg tds.
– In acute cases, midazolam 2.5-5mg subcut can be used in addition to opioids

Download as PDF