Clemens, K.E., & Klaschik, E. (2008). Effect of hydromorphone on ventilation in palliative care patients with dyspnea. Supportive Care in Cancer, 16(1), 93-99.

The objective of this study was to assess the safety and effectiveness of hydromorphone for the improvement of ventilation and intensity of dyspnea in palliative care patients.

Baseline intensity of dyspnea was recorded at rest and during exertion during a light physical activity. Baseline data, including arterial pressure of carbon dioxide (tcPaCO₂), peripheral oxygen saturation (SaO₂), and pulse frequency (PF) were measured continuously via a noninvasive calibrated digital sensor (i.e., the SenTec Digital Monitor) attached to the patients’ earlobe. They then were initiated on orally administered hydromorphone every four hours and titrated to at least 50% dyspnea reduction. Rescue doses of one-sixth of the calculated daily dose were made available for relief of breakthrough dyspnea.

• The sample was comprised of 14 patients.
• The patients ranged in age from 40–84 years.
• The median age was 64 years.
• Six of the patients were female, and eight of the patients were male.
• The diagnosis documented was advanced terminal cancer.
• Admission diagnoses included lung (7), breast (3), pancreatic (1), colorectal (2), and ovarian (1) carcinoma.
• At admission, all participants reported moderate to severe dyspnea (as indicated by self-reported scores of greater than 3 out of 10 on a numeric rating scale), recorded at rest and on exertion during performance of light physical activity.
• Seven of the 14 patients were not opiate naïve.

The single-site study was conducted in an inpatient setting on a palliative care unit at the Center for Palliative Medicine in Germany.

Patients were undergoing end-of-life and palliative care.

The study was a prospective, nonrandomized trial.

• Respiratory rate
• Subjective rating on intensity of dyspnea numeric rating scale where 0 indicates no dyspnea, 1–3 indicates mild dyspnea, 4–7 indicates moderate dyspnea, and greater than 7 indicates severe dyspnea
• Peripheral oxygen saturation (SaO₂)
• Transcutaneous arterial pressure of carbon dioxide (tcaCO₂)
• Pulse frequency

• Oral hydromorphone was found to significantly decrease dyspnea 120 minutes after use (p < 0.001).
• No increase in tcaCO₂ or decrease in SaO₂ were observed that would suggest respiratory depression.
• Mean respiratory rate decreased from 38.8 breaths (SD = 4.9 breaths) per minute to 34.6 breaths (SD = 4.2 breaths) per minute after 30 minutes and 29 breaths (SD = 3.1 breaths) per minute by 120 minutes.

Use of oral hydromorphone potentially could reduce dyspnea with minimal risk of respiratory depression to patients with advanced or terminal cancer.

• The study had a small sample size, with less than 30 participants.
• This was done for only 120 minutes at a single point in time–longer term efficacy is not clear.
• The level of significance for time to symptom relief was not reported, but effects on severity of dyspnea were apparent as early as 30 minutes after beginning treatment.

Use of hydromorphone in the palliative care setting may serve as an effective treatment alternative for patients with renal impairment or intolerance to morphine in the management of dyspnea and work of ventilation. Hydromorphone may reduce dyspnea even in patients who already are receiving opiates for other symptoms.