{"version":"1.0.0","segments":[{"startTime":0.375,"endTime":3.13,"body":"♪ (music) ♪"},{"startTime":3.13,"endTime":5.527,"body":"(Cathy) Hi, welcome"},{"startTime":3.13,"endTime":5.527,"body":"to \u003ci\u003eHarrison's Podclass\u003c/i\u003e,"},{"startTime":5.527,"endTime":8.642,"body":"where we discuss important concepts"},{"startTime":5.527,"endTime":8.642,"body":"in internal medicine."},{"startTime":8.642,"endTime":11.028,"body":"- I'm Cathy Handy."},{"startTime":8.642,"endTime":11.028,"body":"- (Charlie) And I'm Charlie Wiener,"},{"startTime":11.028,"endTime":14.059,"body":"and we're coming to you"},{"startTime":11.028,"endTime":14.059,"body":"from the Johns Hopkins School of Medicine."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":15.844,"endTime":19.695,"body":"A 68-Year-Old with Dyspnea."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":19.695,"endTime":21.024,"body":"(Charlie) Here's the question."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":21.024,"endTime":23.354,"body":"You're caring for a 68-year-old man"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":23.354,"endTime":26.266,"body":"with end-stage idiopathic"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":23.354,"endTime":26.266,"body":"pulmonary fibrosis."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":26.266,"endTime":29.347,"body":"His performance status currently is zero."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":29.347,"endTime":32.428,"body":"He is bedbound,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":29.347,"endTime":32.428,"body":"and he's starting home hospice."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":32.428,"endTime":35.625,"body":"(Cathy) Well, I do commend the provider"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":32.428,"endTime":35.625,"body":"on enrolling this patient in hospice,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":35.625,"endTime":37.989,"body":"which can be very helpful"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":35.625,"endTime":37.989,"body":"for managing symptoms,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":37.989,"endTime":39.553,"body":"especially at the end of life."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":39.553,"endTime":42.09,"body":"And fortunately, we've seen"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":39.553,"endTime":42.09,"body":"an increase in enrollment in hospice,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":42.09,"endTime":44.09,"body":"which can be good for many patients."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":44.09,"endTime":45.658,"body":"(Charlie) Okay, let me continue."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":45.658,"endTime":48.639,"body":"He's chronically"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":45.658,"endTime":48.639,"body":"on nasal oxygen at 4L/min,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":48.639,"endTime":51.773,"body":"with saturation of 94% while at rest."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":51.773,"endTime":53.882,"body":"He does not ambulate at all."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":53.882,"endTime":56.346,"body":"The patient reports"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":53.882,"endTime":56.346,"body":"relentless and severe dyspnea"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":56.346,"endTime":59.064,"body":"that has worsened"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":56.346,"endTime":59.064,"body":"over the last one to two months."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":59.064,"endTime":61.738,"body":"It is now his most notable complaint."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":61.738,"endTime":64.586,"body":"Physical examination is notable"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":61.738,"endTime":64.586,"body":"for normal vital signs"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":64.586,"endTime":67.124,"body":"other than a respiratory rate of 25/min."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":67.124,"endTime":70.084,"body":"Cathy, any thoughts on the approach"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":67.124,"endTime":70.084,"body":"to the diagnosis in this patient?"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":70.084,"endTime":73.071,"body":"(Cathy) It's common for patients"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":70.084,"endTime":73.071,"body":"with end-stage lung and heart disease"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":73.071,"endTime":75.23,"body":"to develop debilitating dyspnea,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":75.23,"endTime":77.634,"body":"and it can be an extremely"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":75.23,"endTime":77.634,"body":"distressing symptom,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":77.634,"endTime":80.163,"body":"even worse than pain for some patients."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":80.163,"endTime":83.232,"body":"The symptoms often don't correlate"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":80.163,"endTime":83.232,"body":"with objective parameters either,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":83.232,"endTime":85.288,"body":"like oxygen or carbon dioxide."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":85.288,"endTime":88.261,"body":"(Charlie) Yeah, and in fact, in this case,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":85.288,"endTime":88.261,"body":"he's having all these symptoms"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":88.261,"endTime":92.606,"body":"with saturations [unintelligible]"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":88.261,"endTime":92.606,"body":"are reportedly consistently above 94%."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":92.606,"endTime":94.824,"body":"(Cathy) Right, so that's"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":92.606,"endTime":94.824,"body":"a perfect example of that."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":94.824,"endTime":97.104,"body":"And the other thing to remember,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":94.824,"endTime":97.104,"body":"too, is that there can be"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":97.104,"endTime":100.11,"body":"potentially reversible"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":97.104,"endTime":100.11,"body":"or treatable causes of dyspnea."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":100.11,"endTime":103.868,"body":"Some examples would be infection,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":100.11,"endTime":103.868,"body":"pleural effusions, pulmonary emboli,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":103.868,"endTime":107.342,"body":"pulmonary edema, asthma,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":103.868,"endTime":107.342,"body":"or, if there was some malignancy,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":107.342,"endTime":109.684,"body":"you can get tumor encroachment"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":107.342,"endTime":109.684,"body":"on the airway."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":109.684,"endTime":112.796,"body":"And depending on the diagnosis"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":109.684,"endTime":112.796,"body":"and the overall prognosis,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":112.796,"endTime":115.876,"body":"specific therapy to address"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":112.796,"endTime":115.876,"body":"whatever the underlying issue is"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":115.876,"endTime":118.048,"body":"may be indicated in some cases."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":118.048,"endTime":120.811,"body":"But the risk-versus-benefit ratio"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":118.048,"endTime":120.811,"body":"of the diagnostic"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":120.811,"endTime":122.708,"body":"and therapeutic interventions"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":120.811,"endTime":122.708,"body":"for patients,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":122.708,"endTime":125.214,"body":"especially at the end of life,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":122.708,"endTime":125.214,"body":"must be considered carefully"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":125.214,"endTime":127.879,"body":"before you undertake"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":125.214,"endTime":127.879,"body":"any of these diagnostic steps."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":127.879,"endTime":131.045,"body":"(Charlie) Okay. So, in this case,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":127.879,"endTime":131.045,"body":"there's no evidence of ongoing infection"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":131.045,"endTime":133.286,"body":"or other acute pulmonary process."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":133.286,"endTime":136.034,"body":"His weight has not increased"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":133.286,"endTime":136.034,"body":"in the last two to four weeks;"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":136.034,"endTime":138.697,"body":"in fact, he's lost eight pounds"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":136.034,"endTime":138.697,"body":"in the past month."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":138.697,"endTime":140.733,"body":"(Cathy) All right, so it sounds"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":138.697,"endTime":140.733,"body":"like he doesn't have"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":140.733,"endTime":142.437,"body":"an acute infection or volume overload,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":142.437,"endTime":146.598,"body":"which could be treated and would provide"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":142.437,"endTime":146.598,"body":"some symptomatic benefit as well."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":146.598,"endTime":148.8,"body":"(Charlie) What other symptoms"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":146.598,"endTime":148.8,"body":"do you generally ask about"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":148.8,"endTime":149.833,"body":"in patients like this?"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":149.833,"endTime":152.482,"body":"(Cathy) So, other common symptoms"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":149.833,"endTime":152.482,"body":"that I would want to know about--"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":152.482,"endTime":156.133,"body":"any pain, fatigue, or weakness,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":152.482,"endTime":156.133,"body":"insomnia, anorexia."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":156.133,"endTime":159.502,"body":"These can all be very disturbing,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":156.133,"endTime":159.502,"body":"and approaches to managing can vary"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":159.502,"endTime":161.906,"body":"but also vary sometimes"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":159.502,"endTime":161.906,"body":"by the underlying disease"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":161.906,"endTime":163.939,"body":"that's contributing to the symptoms."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":163.939,"endTime":166.256,"body":"(Charlie) Why do patients"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":163.939,"endTime":166.256,"body":"with interstitial lung disease"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":166.256,"endTime":169.087,"body":"typically have"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":166.256,"endTime":169.087,"body":"so much discomfort and dyspnea?"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":169.087,"endTime":171.134,"body":"(Cathy) So, the mechanisms"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":169.087,"endTime":171.134,"body":"are multifactorial."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":171.134,"endTime":175.18,"body":"But, as I said, many of these patients"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":171.134,"endTime":175.18,"body":"don't have a reduced oxygen saturation"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":175.18,"endTime":178.595,"body":"or elevated pCO2 to explain the symptoms."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":178.595,"endTime":180.638,"body":"One mechanism that's likely"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":178.595,"endTime":180.638,"body":"in these patients"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":180.638,"endTime":182.817,"body":"is activation of the respiratory center,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":182.817,"endTime":186.574,"body":"due to the small lung volumes"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":182.817,"endTime":186.574,"body":"and reduced lung compliance."},{"speaker":"(Cathy) Welcome to Episode 34","startTime":186.574,"endTime":189.14,"body":"And the sensation of air hunger"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":186.574,"endTime":189.14,"body":"due to small lung volumes"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":189.14,"endTime":191.068,"body":"can be remarkably uncomfortable,"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":191.068,"endTime":193.621,"body":"and the patient feels"},{"speaker":"(Cathy) Welcome to Episode 34","startTime":191.068,"endTime":193.621,"body":"as though they're suffocating."},{"speaker":"(Charlie) Okay, so the question asks","startTime":195.909,"endTime":198.919,"body":"\"Which of the following interventions"},{"speaker":"(Charlie) Okay, so the question asks","startTime":195.909,"endTime":198.919,"body":"would be a reasonable first step"},{"speaker":"(Charlie) Okay, so the question asks","startTime":198.919,"endTime":201.409,"body":"to improve the comfort for this patient?\""},{"speaker":"(Charlie) Okay, so the question asks","startTime":201.409,"endTime":203.466,"body":"Option A is albuterol;"},{"speaker":"(Charlie) Okay, so the question asks","startTime":203.466,"endTime":205.594,"body":"option B is codeine;"},{"speaker":"(Charlie) Okay, so the question asks","startTime":205.594,"endTime":209.844,"body":"option C is increase"},{"speaker":"(Charlie) Okay, so the question asks","startTime":205.594,"endTime":209.844,"body":"the nasal oxygen to 8L/min;"},{"speaker":"(Charlie) Okay, so the question asks","startTime":209.844,"endTime":211.938,"body":"option D is lorazepam;"},{"speaker":"(Charlie) Okay, so the question asks","startTime":211.938,"endTime":215.042,"body":"and option E is nebulized morphine."},{"speaker":"(Charlie) Okay, so the question asks","startTime":215.042,"endTime":216.943,"body":"(Cathy) It's unlikely"},{"speaker":"(Charlie) Okay, so the question asks","startTime":215.042,"endTime":216.943,"body":"that an increase in oxygen"},{"speaker":"(Charlie) Okay, so the question asks","startTime":216.943,"endTime":219.013,"body":"will benefit this patient's dyspnea,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":219.013,"endTime":224.772,"body":"given that he's already on 4-6 L/min"},{"speaker":"(Charlie) Okay, so the question asks","startTime":219.013,"endTime":224.772,"body":"and his oxygen saturation is already 94%."},{"speaker":"(Charlie) Okay, so the question asks","startTime":224.772,"endTime":226.885,"body":"Since his functional status is zero,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":226.885,"endTime":229.621,"body":"I don't think he's having"},{"speaker":"(Charlie) Okay, so the question asks","startTime":226.885,"endTime":229.621,"body":"enough exertion to desaturate,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":229.621,"endTime":232.73,"body":"and he's telling us that his dyspnea"},{"speaker":"(Charlie) Okay, so the question asks","startTime":229.621,"endTime":232.73,"body":"is mostly bothersome at rest,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":232.73,"endTime":236.176,"body":"so I would remove that one"},{"speaker":"(Charlie) Okay, so the question asks","startTime":232.73,"endTime":236.176,"body":"from the possible choices."},{"speaker":"(Charlie) Okay, so the question asks","startTime":236.176,"endTime":238.214,"body":"(Charlie) So, the other options"},{"speaker":"(Charlie) Okay, so the question asks","startTime":236.176,"endTime":238.214,"body":"are all medications."},{"speaker":"(Charlie) Okay, so the question asks","startTime":238.214,"endTime":239.93,"body":"Which of those do you like best?"},{"speaker":"(Charlie) Okay, so the question asks","startTime":239.93,"endTime":241.863,"body":"(Cathy) Well, codeine"},{"speaker":"(Charlie) Okay, so the question asks","startTime":239.93,"endTime":241.863,"body":"is the best first choice,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":241.863,"endTime":245.282,"body":"so for this question, I would say"},{"speaker":"(Charlie) Okay, so the question asks","startTime":241.863,"endTime":245.282,"body":"the answer is B, codeine."},{"speaker":"(Charlie) Okay, so the question asks","startTime":245.282,"endTime":248.936,"body":"Opioids reduce the sensitivity"},{"speaker":"(Charlie) Okay, so the question asks","startTime":245.282,"endTime":248.936,"body":"of the central respiratory drive center"},{"speaker":"(Charlie) Okay, so the question asks","startTime":248.936,"endTime":251.936,"body":"and often reduce"},{"speaker":"(Charlie) Okay, so the question asks","startTime":248.936,"endTime":251.936,"body":"the sensation of dyspnea."},{"speaker":"(Charlie) Okay, so the question asks","startTime":251.936,"endTime":254.244,"body":"In patients who are already on opioids,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":254.244,"endTime":258.108,"body":"morphine or another strong opioid"},{"speaker":"(Charlie) Okay, so the question asks","startTime":254.244,"endTime":258.108,"body":"may be used in place of codeine."},{"speaker":"(Charlie) Okay, so the question asks","startTime":258.108,"endTime":261.688,"body":"This patient isn't on any opioid,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":258.108,"endTime":261.688,"body":"so it's reasonable to start with codeine."},{"speaker":"(Charlie) Okay, so the question asks","startTime":261.688,"endTime":264.598,"body":"Hydrocodone would be"},{"speaker":"(Charlie) Okay, so the question asks","startTime":261.688,"endTime":264.598,"body":"another option in this patient."},{"speaker":"(Charlie) Okay, so the question asks","startTime":264.598,"endTime":267.586,"body":"(Charlie) What dose do you start with,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":264.598,"endTime":267.586,"body":"typically, in these patients?"},{"speaker":"(Charlie) Okay, so the question asks","startTime":267.586,"endTime":270.825,"body":"(Cathy) Typically about 30 mg"},{"speaker":"(Charlie) Okay, so the question asks","startTime":267.586,"endTime":270.825,"body":"every four hours as needed"},{"speaker":"(Charlie) Okay, so the question asks","startTime":270.825,"endTime":273.411,"body":"for patients who, again,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":270.825,"endTime":273.411,"body":"haven't had opioids."},{"speaker":"(Charlie) Okay, so the question asks","startTime":273.411,"endTime":275.591,"body":"But it really can depend"},{"speaker":"(Charlie) Okay, so the question asks","startTime":273.411,"endTime":275.591,"body":"on the degree of severity"},{"speaker":"(Charlie) Okay, so the question asks","startTime":275.591,"endTime":278.246,"body":"and how much opioids"},{"speaker":"(Charlie) Okay, so the question asks","startTime":275.591,"endTime":278.246,"body":"they've been taking historically."},{"speaker":"(Charlie) Okay, so the question asks","startTime":278.246,"endTime":280.302,"body":"The goal is to suppress"},{"speaker":"(Charlie) Okay, so the question asks","startTime":278.246,"endTime":280.302,"body":"the respiratory center"},{"speaker":"(Charlie) Okay, so the question asks","startTime":280.302,"endTime":282.414,"body":"enough to control the dyspnea."},{"speaker":"(Charlie) Okay, so the question asks","startTime":282.414,"endTime":285.779,"body":"You could also start"},{"speaker":"(Charlie) Okay, so the question asks","startTime":282.414,"endTime":285.779,"body":"with morphine 5 mg every four hours."},{"speaker":"(Charlie) Okay, so the question asks","startTime":285.779,"endTime":288.003,"body":"(Charlie) What are your thoughts"},{"speaker":"(Charlie) Okay, so the question asks","startTime":285.779,"endTime":288.003,"body":"on the other answers--"},{"speaker":"(Charlie) Okay, so the question asks","startTime":288.003,"endTime":290.772,"body":"lorazepam, albuterol,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":288.003,"endTime":290.772,"body":"and nebulized morphine?"},{"speaker":"(Charlie) Okay, so the question asks","startTime":290.772,"endTime":292.818,"body":"(Cathy) So, in the absence"},{"speaker":"(Charlie) Okay, so the question asks","startTime":290.772,"endTime":292.818,"body":"of bronchospasm,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":292.818,"endTime":295.964,"body":"albuterol could worsen the dyspnea"},{"speaker":"(Charlie) Okay, so the question asks","startTime":292.818,"endTime":295.964,"body":"as a respiratory stimulant,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":295.964,"endTime":297.981,"body":"so that should be avoided."},{"speaker":"(Charlie) Okay, so the question asks","startTime":297.981,"endTime":301.318,"body":"Benzodiazepines--"},{"speaker":"(Charlie) Okay, so the question asks","startTime":297.981,"endTime":301.318,"body":"in this question we mention lorazepam--"},{"speaker":"(Charlie) Okay, so the question asks","startTime":301.318,"endTime":303.664,"body":"could be helpful"},{"speaker":"(Charlie) Okay, so the question asks","startTime":301.318,"endTime":303.664,"body":"if there is concurrent anxiety,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":303.664,"endTime":306.701,"body":"but it shouldn't be used"},{"speaker":"(Charlie) Okay, so the question asks","startTime":303.664,"endTime":306.701,"body":"as the sole therapy for dyspnea."},{"speaker":"(Charlie) Okay, so the question asks","startTime":306.701,"endTime":309.282,"body":"They may be added"},{"speaker":"(Charlie) Okay, so the question asks","startTime":306.701,"endTime":309.282,"body":"to a narcotic, if needed."},{"speaker":"(Charlie) Okay, so the question asks","startTime":309.282,"endTime":310.726,"body":"There are no data supporting the use"},{"speaker":"(Charlie) Okay, so the question asks","startTime":310.726,"endTime":313.251,"body":"of nebulized morphine"},{"speaker":"(Charlie) Okay, so the question asks","startTime":310.726,"endTime":313.251,"body":"for dyspnea at the end of life,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":313.251,"endTime":314.985,"body":"so I also wouldn't use that."},{"speaker":"(Charlie) Okay, so the question asks","startTime":314.985,"endTime":316.943,"body":"(Charlie) Okay, so"},{"speaker":"(Charlie) Okay, so the question asks","startTime":314.985,"endTime":316.943,"body":"the teaching point in this case"},{"speaker":"(Charlie) Okay, so the question asks","startTime":316.943,"endTime":321.454,"body":"is that dyspnea can be severe"},{"speaker":"(Charlie) Okay, so the question asks","startTime":316.943,"endTime":321.454,"body":"and is very common in the end of life."},{"speaker":"(Charlie) Okay, so the question asks","startTime":321.454,"endTime":325.16,"body":"It's often not associated"},{"speaker":"(Charlie) Okay, so the question asks","startTime":321.454,"endTime":325.16,"body":"with elevations in pCO2"},{"speaker":"(Charlie) Okay, so the question asks","startTime":325.16,"endTime":327.309,"body":"or reductions in SaO2."},{"speaker":"(Charlie) Okay, so the question asks","startTime":327.309,"endTime":330.41,"body":"In the absence of a reversible cause,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":327.309,"endTime":330.41,"body":"such as volume overload,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":330.41,"endTime":333.921,"body":"it is reasonable to treat the patients"},{"speaker":"(Charlie) Okay, so the question asks","startTime":330.41,"endTime":333.921,"body":"for symptom control only."},{"speaker":"(Charlie) Okay, so the question asks","startTime":333.921,"endTime":337.659,"body":"Opioids are an appropriate place to start"},{"speaker":"(Charlie) Okay, so the question asks","startTime":333.921,"endTime":337.659,"body":"to decrease the symptoms"},{"speaker":"(Charlie) Okay, so the question asks","startTime":337.659,"endTime":340.755,"body":"of increased respiratory drive"},{"speaker":"(Charlie) Okay, so the question asks","startTime":337.659,"endTime":340.755,"body":"and air hunger."},{"speaker":"(Charlie) Okay, so the question asks","startTime":340.755,"endTime":343.195,"body":"(Cathy) And if you want to learn more,"},{"speaker":"(Charlie) Okay, so the question asks","startTime":340.755,"endTime":343.195,"body":"you can read about this"},{"speaker":"(Charlie) Okay, so the question asks","startTime":343.195,"endTime":346.413,"body":"in \u003ci\u003eHarrison's\u003c/i\u003e chapter"},{"speaker":"(Charlie) Okay, so the question asks","startTime":343.195,"endTime":346.413,"body":"on Palliative and End-of-Life Care."},{"speaker":"(Charlie) Okay, so the question asks","startTime":346.413,"endTime":348.538,"body":"♪ (music) ♪"}]}