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CLINICAL Q&A
The Use of Nebulized Fentanyl
for the Management of Dyspnea
Patrick J. Coyne, MSN, APRN, BC
Q
uestion: I have heard about the use
of nebulized fentanyl for the man-
agement of dyspnea in patients
with cancer but have not found anything in
the literature about this topic. Could you
please discuss this topic and provide some
references?
nswer: Dyspnea (breathlessness),
A an unpleasant awareness of breath-
ing, is a subjective experience. This
symptom is all too common, with reports of
more than 70% of patients with advanced
cancer experiencing this symptom (Ripa-
monti, 1999). Unfortunately, the mechanisms
that lead to dyspnea are not well understood.
Patients self-report of dyspnea is the best in-
dicator of its presence and level of distress.
Respiratory rate and oxygenation saturation
level are not reliable indicators of the pres-
ence of dyspnea. Patients tend to experience
a chronic course, punctuated by episodes of
acute shortness of breath. Dyspnea has physi-
cal and affective components, which may
worsen anxiety and frighten patients. When
dyspnea persists, patients often decrease their
daily activities. Social isolation, dependence
on others, and physiologic, psychological,
social, and spiritual exhaustion may result
(Coyne, Lyne, & Watson, 2002).
Patients previous experiences with dys-
pnea influence their perception of breath-
lessness. Some patients have described dys-
pnea as breathing through a straw.
Healthcare providers sometimes under-
recognize the impact of this symptom be-
cause of its subjective nature.
Concurrent treatments, including non-
pharmacologic and pharmacologic thera-
pies, should be initiated on a case-by-case
basis. Oxygen therapy is recommended for
dyspneic patients at the end stage of disease
(Bruera, deStoutz, Valasco-Leiva, Scho-
eller, & Hanson, 1993). Other nonpharma-
cologic treatments for dyspnea include po-
sitioning for comfort. Propping patients up
on pillows in a forward sitting position may
improve air exchange. Cool air blown by
fans or air from an open window or air con-
334
ditioner also may be helpful. The presence
of calm and reassuring family members and
caregivers as well as the use of soothing, re-
laxing music and pursed-lip breathing can
reduce anxiety, slow respiratory rate, and re-
duce dyspnea. Guided imagery and medita-
tion, massage, and prayer are other therapies
that can promote comfort and relaxation
(American Association of Colleges of Nurs-
ing [AACN] & City of Hope Medical Cen-
ter [COH], 2002).
Pharmacologic treatment of dyspnea in-
cludes the use of combinations of opioids,
anxiolytics, sedatives, tranquilizers, and an-
ticholinergic medications (AACN & COH,
2002; Newshan & Sherman, 1999). How-
ever, traditional bronchodilators, mucolytic
agents, and anxiolytics often are suboptimal
in treating dyspnea related to malignancy.
In addition, adrenergic agonists and theo-
phylline may cause increased anxiety and
agitation and worsen patients breathing sta-
tus (Storey, 1994).
Opioids have been used effectively for
more than a century to relieve breathless-
ness, but their mechanism is not clearly un-
derstood (Coyne, Viswanathan, & Smith,
2002). Starting opioids early in treatment
will facilitate development of tolerance to
respiratory effects and allow titration to
comfort levels that will reduce anxiety and
distress (Twycross, 1994). Nebulizer opi-
oids using morphine, although a promising
concept, has shown no benefit in controlled
trials (Davis, Penn, AHern, Daniels, &
Slevin, 1996; Runo & Ely, 2001). Nebulizer
furosemide has been shown to protect
against bronchospasms, which may be an
etiology of dyspnea (Bianco, Vaghi,
Robuschi, & Pasargiklian, 1998). Early pi-
lot studies utilizing nebulizer fentanyl ap-
pear promising, perhaps because of this
opioids lipophilic properties (Coyne,
Viswanathan, et al.). Research regarding this
intervention presently is ongoing. Because
as much as 70% of the opioid is not absorbed
systemically, few, if any, side effects are
seen (Coyne, Viswanathan, et al.).
In the Medical College of Virginia Hos-
pitals and Virginia Commonwealth Univer-
sity, nebulizer fentanyl is an intervention
used with any patient experiencing ongoing
dyspnea regardless of its etiology. The stan-
dard dose used in this facility is 25 mcg of
fentanyl with 2 ml of normal saline admin-
MAY/JUNE 2003 VOLUME 7, NUMBER 3 CLINICAL JOURNAL OF ONCOLOGY NURSING
BARBARA HOLMES GOBEL, RN, MS, AOCN
ASSOCIATE EDITOR
istered every two to three hours as needed.
The nursing staff, rather than respiratory
therapists, administers the medication be-
cause fentanyl is a controlled substance.
Nurses using this intervention should evalu-
ate patients for subjective and objective im-
provements in dyspnea. The only known
contraindication to nebulized fentanyl is an
allergy to fentanyl.
The treatment of dyspnea remains a prob-
lem for many patients. Research clearly is
needed to improve the current interventions.
With regard to the management of dyspnea
with nebulized fentanyl, healthcare provid-
ers need to determine the half-life of nebu-
lized fentanyl, whether it is safe when given
more frequently than every two to three
hours, and whether this treatment can be
used in the homecare setting and adminis-
tered by family and caregivers. Patients ex-
periencing dyspnea require ongoing support
and thorough assessment to ensure maxi-
mum comfort is achieved and maintained.
Author Contact: Patrick J. Coyne, MSN,
APRN, BC, can be reached at user479069@
aol.com.
References
American Association of Colleges of Nursing &
City of Hope Medical Center. (2002). End-of-
Life Nursing Education Consortium. Washing-
ton, DC: Author.
Bianco, S., Vaghi, A., Robuschi, M., & Pasar-
giklian, M. (1998). Prevention of exercise-in-
duced brochoconstriction by inhaled frusemide.
Lancet, 2, 252255.
Bruera, E., deStoutz, N., Valasco-Leiva, A.,
Schoeller, T., & Hanson, J. (1993). Effects of
oxygen on dyspnea in hypoxaemic terminal
Patrick J. Coyne, MSN, APRN, BC, is a clinical
nurse specialist for palliative care and pain
management at the Medical College of Virginia
Hospitals and Virginia Commonwealth Health
Systems in Richmond. (Mention of specific
products and opinions related to those prod-
ucts do not indicate or imply endorsement by
the Clinical Journal of Oncology Nursing or the
Oncology Nursing Society.)
Key Words: dyspnea, fentanyl, nebulizers and
vaporizers
Digital Object Identifier: 10.1188/03.CJON.334-336
 cancer patients. Lancet, 2, 1314.
Coyne, P.J., Lyne, M.E., & Watson, A.C. (2002).
Symptom management in people with AIDS.
American Journal of Nursing, 102(9), 4856.
Coyne, P.J., Viswanathan, R., & Smith, T. (2002).
Nebulized fentanyl citrate improves patients
perception of breathing, respiratory rate, and
oxygen saturation in dyspnea. Journal of Pain
and Symptom Management, 2, 157160.
Davis, C., Penn, K., AHern, R., Daniels, J., &
Slevin, M. (1996). Single-dose randomized
controlled trial of nebulized morphine in pa-
tients with cancer-related breathlessness. Pal-
liative Medicine, 10, 6465.
Newshan, G., & Sherman, D.W. (1999). Palliative
care: Pain and symptom management in per-
sons with HIV/AIDS. Nursing Clinics of North
America, 34(1), 131145.
Ripamonti, C. (1999). Management of dyspnea in
advanced cancer patients. Supportive Care in
Cancer, 7, 233243.
Runo, J., & Ely, E. (2001). Treating dyspnea in a
patient with advanced chronic obstructive pul-
monary disease. Western Journal of Medicine,
3, 197201.
Storey, P. (1994). Symptom control in advanced
cancer. Seminars in Oncology, 21, 748758.
Twycross, R. (1994). Pain relief in advanced can-
cer. New York: Churchill Livingston.
Control of Pain After Breast
Reconstruction Procedure
Deena Damsky Dell,
MSN, RN, BC, AOCN
Q
uestion: After undergoing trans-
verse rectus abdominis myocu-
taneous (TRAM) flap surgery,
many patients say that the procedure made
them feel like they had been run over by a
truck. What are some things that I can do
to help these patients with their postopera-
tive pain?
Preoperative view following breast biopsy
FIGURE 1. PEDICLED TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP PROCEDURE
CLINICAL JOURNAL OF ONCOLOGY NURSING VOLUME 7, NUMBER 3 CLINICAL Q&A
nswer: The TRAM flap procedure
A is an optional breast reconstructive
surgery for patients having a mas-
tectomy. The procedure requires two large
incisions, one hip to hip and one for the mas-
tectomy. Muscle, fat, and skin are dissected
and moved. In the pedicled (attached
muscle) TRAM flap procedure, the entire
rectus abdominis muscle(s) is used (see Fig-
ure 1). The dissected flap remains attached
by a stem to its blood supply. The flap then
is pulled under the diaphragm to the mas-
tectomy site, where it is attached and a new
blood supply develops. In the free (non-
pedicled) TRAM flap procedure (see Figure
2), the lower abdominal skin and fatty tis-
sues are removed along with a small portion
of the lower rectus abdominis muscle(s)
with its perforators (i.e., blood vessels that
connect superficial to deep blood vessels).
The flap then is transplanted to the mastec-
tomy site with microvascular techniques. A
newer version of the free flap is the deep
inferior epigastric perforator flap (see Fig-
ure 3). Skin and fat (with their perforators)
are taken from the lower abdomen. No
muscle is removed. The nerves that provide
sensation to the transplanted abdominal skin
and fat are transected in both procedures
(Nahabedian, 2001; Sandau, 2002; Van-
couver Hospital, 2002; Zenn, 2001).
After TRAM flap procedures, women of-
ten complain of tightness, pulling, and numb-
ness in their abdominal and rib cage areas, as
well as back pain. Patients with preexisting
back pain may experience an exacerbation of
this pain from the procedure. Initially, pa-
tients must follow certain activity and posi-
tion restrictions to prevent tension on the ab-
dominal incision that could cause wound
dehiscence. Patients must stand bent forward
for the first 10 days and avoid twisting their
spines. This is to avoid muscle tension and
stress. The weakening of the lower abdomi-
Reconstructed breast following a pedicled (at-
tached muscle) transverse rectus abdominis
myocutaneous flap procedure in which a rectus
abdominal muscle is pulled under the diaphragm
to the mastectomy site
nal muscles as a result of the removal of part
or all of the rectus abdominis muscle(s) fur-
ther increases the strain on the lower back
(Edsander-Nord, Jurell, & Wickman, 1998;
Kind, Rademaker, & Mustoe, 1997; Petit et
al., 1997; Zenn, 2001).
Opioid analgesics are required immedi-
ately after the TRAM flap surgery. Patient-
controlled analgesia (PCA) is a frequently
used pain management delivery method;
patients are able to control the amount of
medication that they receive to maximize
pain relief and minimize side effects. Mor-
phine sulfate or hydromorphone (Dilaudid,
Knoll Laboratories, Mount Olive, NJ) are
the drugs of choice for PCA. Correll,
Viscusi, Grunwald, and Moore (2001) found
that epidural analgesia following TRAM
flap surgery improved pain control better
than IV analgesia. However, many institu-
tions have found that IV analgesia provides
satisfactory pain relief (Correll et al.; Kross,
Sharma, & Koutz, 2001; Larson, Yousif,
Sinha, Latoni, & Korkos, 1999; Sandau,
2002). Ketorolac (Toradol, Roche Labora-
tories, Nutley, NJ), a nonsteroidal anti-in-
flammatory drug (NSAID), frequently is
used as an adjunct to potentiate the actions
of opioid analgesics. Sharma and colleagues
(2001) reported a decrease in morphine re-
quirements in patients who received IV
ketorolac following TRAM flap reconstruc-
Deena Damsky Dell, MSN, RN, BC, AOCN , is
a clinical nurse specialist and clinical educa-
tor at Fox Chase Cancer Center in Philadel-
phia, PA. (Mention of specific products and
opinions related to those products do not in-
dicate or imply endorsement by the Clinical
Journal of Oncology Nursing or the Oncology
Nursing Society.)
Key Words: reconstructive surgical proce-
dures; pain, postoperative
Later postoperative view following right nipple
reconstruction and tattoo of areola
335

Abdomen marked prior to free transverse rectus
abdominis myocutaneous flap procedure in
which the flap containing a rectus abdominal
muscle is detached and transplanted to the mas-
tectomy site
Postoperative view showing transplanted flap
FIGURE 2. FREE TRANSVERSE RECTUS ABDOMINIS MYOCUTANEOUS FLAP PROCEDURE
A B
(A) Preoperative view
(B) Intraoperative view of the deep inferior epi-
gastric perforator flap
(C) Postoperative view showing deep inferior epi-
gastric perforator (DIEP) flap in which no
muscle is removed and the free flap consist-
ing of skin and fat is transplanted to the mas-
tectomy site
(D) Later postoperative view showing left nipple
reconstruction, tattoo of areola, and right
breast reduction
(E) Complete healing following DIEP flap procedure
FIGURE 3. DEEP INFERIOR EPIGASTRIC PERFORATOR FLAP PROCEDURE
336
Preoperative view
Later postoperative view following nipple recon-
struction, tattoo of areola, and right breast reduc-
tion surgery
D E
MAY/JUNE 2003 VOLUME 7, NUMBER 3 CLINICAL JOURNAL OF ONCOLOGY NURSING
tion, and the incidence of hematomas did not
increase.
Before patients are discharged, they are
switched to an oral opioid analgesic. One ex-
ample of an appropriate oral agent for pain
is oxycodone with acetaminophen (Perco-
cet, Endo Pharmaceuticals Inc., Chadds
Ford, PA). Oral NSAIDs such as rofecoxib
(Vioxx, Merck & Co., Inc., West Point,
PA) may be used to potentiate oral analge-
sics, and, eventually, patients may be able
to switch to NSAIDs for around-the-clock
use and take opioids as needed.
Patients who undergo the TRAM flap
procedure generally will be unable to work
(including work around the home) for six to
eight weeks, and substantial pain and de-
creased energy levels may last for quite a
while (six weeks to three months). Full re-
covery may take six months to a year (Petit
et al., 1997; Zenn, 2001).
Educating patients undergoing TRAM
flap surgery is very important. They need
to know that they may require pain medi-
cation at least on an as-needed basis for
many weeks after surgery. They also need
to learn what activities cause pain. If a
woman is relaxed in bed or a lounge chair,
she may not feel much discomfort; how-
ever, standing or sitting in a straight chair
may be intolerable. Standing erect after a
TRAM flap procedure is similar to bearing
weight on a sprained ankle. Women need
C
b
Clinical Q&A (Continued from page 336)
to anticipate and medicate themselves be-
fore activities that cause pain. Taking pain
medication before sitting down at the fam-
ily dinner table or going out to lunch or a
movie may enable women to participate
more fully in life as opposed to sitting at
home, doing nothing and becoming de-
pressed. Following guidelines for suggested
activities and exercises after a TRAM flap
procedure, as well as seeing a physical thera-
pist as soon as allowed, also speeds healing,
strengthens weak muscles, and provides ad-
ditional pain relief (Kozempel, Dell, &
Weaver, 2003). Use of an abdominal binder
(or, later on, control-top pantyhose or tight
jeans) also may be helpful. Heat, if used at
all, must be applied with extreme caution be-
cause the transection of nerves with this pro-
cedure results in numbness and patients are
at an increased risk for burns from the heat-
ing pad.
Author Contact: Deena Damsky Dell,
MSN, RN, BC, AOCN , can be reached at
D_Dell @fccc.edu.
Send your questions and comments about this issues Clinical Q&A to the attention of Associate Editor
Would you like to comment on the questions and responses published in this issue?
338
References
Correll, D., Viscusi, E.R., Grunwald, Z., & Moore,
J.H. (2001). Epidural analgesia compared with
intravenous morphine patient-controlled anal-
gesia: Postoperative outcome measures after
mastectomy with immediate TRAM flap breast
reconstruction. Regional Anesthesia and Pain
Medicine, 26, 444449.
Edsander-Nord, A., Jurell, G., & Wickman, M.
(1998). Donor-site morbidity after pedicled or
free TRAM flap surgery: A prospective and
objective study. Plastic and Reconstructive
Surgery, 102, 15081516.
Kind, G., Rademaker, A.W., & Mustoe, T.A.
(1997). Abdominal-wall recovery following
TRAM flap: A functional outcome study. Plas-
tic and Reconstructive Surgery, 99, 417428.
Kozempel, J., Dell, D.D., & Weaver, C. (2003).
Abdominal-wall recovery following TRAM
flap surgery. Rehabilitation Oncology, 21(1),
1016.
Kross, S.S., Sharma, S., & Koutz, D. (2001). Post-
operative morphine requirements of free
TRAM and DIEP flaps. Plastic and Recon-
structive Surgery, 107, 338341.
Larson, D.L., Yousif, N.J., Sinha, R.K., Latoni, J.,
& Korkos, T.G. (1999). A comparison of
MAY/JUNE 2003 VOLUME 7, NUMBER 3 CLINICAL JOURNAL OF ONCOLOGY NURSING
pedicled and free TRAM flaps for breast recon-
struction in a single institution. Plastic and
Reconstructive Surgery, 104, 674680.
Nahabedian, M. (2001). Nerve regeneration and re-
turn of sensation following breast reconstruction
with abdominal flaps. Artemis. Retrieved May
23, 2002, from http://www.hopkinsmedicine.org/
breastcenter/artemis/200101feature.html
Petit, J.Y., Rietjens, M., Ferreira, M.A., Mon-
trucoli, D., Lifrange, E., & Martinelli, P.
(1997). Abdominal sequelae after pedicled
TRAM flap breast reconstruction. Plastic Re-
constructive Surgery, 99, 723729.
Sandau, K.E. (2002). Free TRAM flap breast re-
construction. American Journal of Nursing,
102(4), 3644.
Sharma, S., Chang, D.W., Koutz, C., Evans, G.R.,
Robb, G.L., Langstein, H.N., et al. (2001). Inci-
dence of hematomas associated with ketorolac
after TRAM flap breast reconstruction. Plastic
and Reconstructive Surgery, 107, 352355.
Vancouver Hospital. (2002). What are the most
common methods of breast reconstruction?
Retrieved May 23, 2002, from www.vanhosp
.bc.ca/html/women_breast_methods.html
Zenn, M.R. (2001). Breast reconstruction: TRAM,
unpedicled. EMedicine, Retrieved January 24,
2003, from www.emedicine.com/plastic/
topic141.htm