I can count the times I’ve run into air hunger at the end of life as a visiting RN Case Manager for going on five years on one hand. Over the years, I’ve managed patients with pulmonary fibrosis, lung cancers (diverse types), breast cancer, COPD, congestive heart failure, B-cell lymphoma, leukemia, and other diseases that can impact one person’s ability to breathe correctly. Air hunger is rare in my firsthand experiences, but it can happen.
Air hunger often sounds like the person is gasping for breath without regard to the actual respiratory rate (how fast they are breathing); it can also sound like stridor (YouTube videos below where you can hear the difference).
Let me share with you how I’ve managed air hunger in the past with the understanding that only a medical provider can prescribe/order medications (as a hospice RN, I recommend to the provider what I believe will work, and the provider will either accept, modify, or reject my recommendation):
Prevention
Review existing medications and non-pharmaceutical methods currently being used.
Ensure that a small portable fan (where the fan base is not much larger than an adult’s hand) is used for most of the day, with the fan pointed at the left or right cheek of the person on the low to moderate setting.
Ensure the environment is cool without being uncomfortable for the person with minimum to low humidity.
Review switching from inhalers of any type to nebulized albuterol sulfate or nebulized ipratropium bromide and albuterol sulfate (duo nebs), keeping in mind frequent education about rinsing the patient’s mouth after inhaler/nebulizer sessions when steroids are involved. The typical nebulized medications are every 6 hours as needed. Still, I’ve had cases where the doctor allowed every 2 hours as needed, and this thought process and action can be greatly beneficial to the patient to prevent air hunger.
Consider a maintenance steroid such as dexamethasone 2 mg to 4 mg daily to BID. Always encourage swallowing, and if the patient takes their meds in any food or chews their medications, remember to have them rinse their mouth afterward to attempt to prevent thrush.
Consider routine and PRN lorazepam and liquid morphine (often referred to as Roxanol).
Management of Air Hunger
If severe, 20 mg Roxanol + 1 mg Haldol + 1.0 mg Lorazepam should be given every 10 to 15 minutes until comfortable, keeping in mind that the typical maximum daily dose for Lorazepam is 10 to 14 mg.
If new onset or otherwise mild, take 10 to 20 mg of Roxanol every one to two hours and 0.5 mg to 1 mg of Lorazepam every four to six hours.
Maintain all items in the prevention category as appropriate (case by case basis).
The need for external oxygen via nasal cannula or distinct types of face masks is often questioned when it comes to preventing air hunger, and the utilization of such will depend on the disease process (i.e., pulmonary fibrosis), the extent of the disease process along with related diseases (i.e., pulmonary fibrosis and lung cancer). Often, if someone is on oxygenation at the start or end of life, they will either maintain the same liter flow vs. frequent changes as going higher or lower does not guarantee comfort; it is on a case-by-case basis. If you are the patient or caregiver and want to try changes… please only do one liter up or down at a time and wait at least sixty minutes for any change; if it is worse, return to the previous setting quickly.
Always remember to contact your palliative care provider/hospice provider 24/7. This article and other articles I write are not intended to be medical advice but a tool for you to work with your provider team to help you.
Conclusion
In conclusion, managing air hunger at the end of life is crucial to comfort terminally ill patients. Non-pharmacological interventions such as using a small portable fan, ensuring a cool environment, and reviewing existing medications play a significant role in prevention. Additionally, considering nebulized medications, maintenance steroids, and routine and PRN medications like lorazepam and liquid morphine can help prevent and manage air hunger. When air hunger occurs, a combination of medicines, including Roxanol, Haldol, and Lorazepam, can be administered based on the severity of the symptoms. Though not universally helpful, oxygen therapy can also be considered based on the disease process. Remembering that a medical provider should discuss and prescribe these interventions is essential. Contact your palliative care provider or hospice team for personalized guidance and support.
