Which opioid is commonly used to relieve dyspnea refractory to other measures, with a key consideration to start low and titrate, while monitoring respiration and sedation?

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Relief of refractory dyspnea with opioids relies on reducing the sensation of air hunger and the associated anxiety, rather than simply depressing breathing. Because of this, the approach is to start with a very low dose and carefully titrate upward, while closely monitoring respiratory status and sedation. Both morphine and hydromorphone fit this approach well and are commonly used for this purpose. They have flexible, titratable dosing and routes, allowing clinicians to tailor therapy to the patient’s needs and response, with the aim of alleviating dyspnea while minimizing adverse effects. Fentanyl can be used in select situations, but morphine and hydromorphone are the options most consistently emphasized for routine dyspnea relief with a start-low, monitor-and-titrate strategy.