I can count the times I've run into at the end of life as a visiting 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 properly. is exceedingly 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

  1. existing medications and non-pharmaceutical methods currently being used.
  2. Ensure that a small portable fan (where the fan base is not that much larger than the hand of an adult) is being 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.
  3. Ensure the environment is cool without being uncomfortable for the person with minimum to low humidity.
  4. switching from inhalers of any type to either nebulized albuterol sulfate to 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, but 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.
  5. 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 afterwards to attempt to prevent thrush.
  6. Consider routine and PRN lorazepam and liquid morphine (often referred to as Roxanol).

Management if Air Hunger Occurs

  1. If severe: 20 mg Roxanol + 1 mg Haldol + 1.0 mg Lorazepam given every 10 to 15 minutes until comfortable AND keeping in mind the typical maximum daily dose for Lorazepam is 10 to 14 mg.
  2. If new onset or otherwise mild: 10 to 20 mg Roxanol every one to two hours, 0.5 mg to 1 mg Lorazepam every four to six hours.
  3. 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 of 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; and if it is worse, go back to the previous setting quickly.

Always remember to reach out to your provider/hospice provider 24×7 as this article and 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 a crucial aspect of providing comfort to terminally ill patients. 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 medications, including Roxanol, Haldol, and Lorazepam, can be administered based on the severity of the symptoms. , though not universally helpful, can also be considered based on the disease process. It's important to remember that these interventions should be discussed and prescribed by a medical provider. Always reach out to your provider or hospice team for personalized guidance and support.

Resources

The Importance of Caregiver Journaling

Reporting Changes of Condition to Hospice

Providing Comfort During the Last Days of Life with Barbara Karnes RN (YouTube Video)

Preparing the patient, family, and caregivers for a “Good Death”

Velocity of Changes in Condition as an Indicator of Approaching Death (often helpful to answer how soon? or when?)

The Dying Process and the End of Life

The Last Hours of Life

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Gone from My Sight: The Dying Experience

The Eleventh Hour: A Caring Guideline for the Hours to Minutes Before Death

By Your Side , A Guide for Caring for the Dying at Home

Sounds of Air Hunger may sound like gasping for breath
https://www.youtube.com/watch?v=gcio26KP7LA&t=17s

Sounds of Air Hunger may sound like stridor
https://youtu.be/vDdJo0RPKa8?t=29

Other End-of-life Breathing Patterns that by themselves do not indicate Air Hunger

Cheyne Stokes
https://www.youtube.com/watch?v=VkuxP7iChYY

Kussmaul Breathing Pattern
https://www.youtube.com/watch?v=raEKXVfuWTo

Sounds of Breathing Patterns (Cheyne Stokes, Kussmaul's, Biot's)
https://www.youtube.com/watch?v=ViGjOiPE2mY

Managing Dyspnea at End of Life
https://www.med.unc.edu/pcare/wp-content/uploads/sites/503/2017/11/managing-dyspnea-in-end-of-life-care.pdf

Eldercare Locator: a nationwide service that connects older Americans and their caregivers with trustworthy local support resources

As an Amazon Associate, I earn from qualifying purchases. The amount generated from these “qualifying purchases” helps to maintain this site.

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