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Covid-19 HSE Clinical Guidance and Evidence

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Management of severe breathlessness

Initial Management of Severe Breathlessness in Dying Patients with Covid-19 (in the Last Hours or Days of Life) (CD19-070 001 / 15.04.20)

  • For more detailed guidance, see AND/OR contact Specialist Palliative Care team for advice.
  • Adherence to guideline recommendations will not ensure a successful outcome in every case. It is the responsibility of all professionals to exercise clinical judgement in the management of individual patients. Palliative care specialists occasionally prescribe or recommend other drugs, doses or drug combinations.
  • This guidance document was developed by the National Palliative Care Clinical Programme in accordance with HPSC guidance,

Who is this guide for?

  • All health care providers.
  • The anticipatory prescribing and syringe pump one-pagers will provide symptom control for most patients, however some patients with Covid-19 may experience severe, uncontrolled breathlessness that requires rapid dose titration and urgent palliative care advice.
  • This is a guide to assist in the first 90 minutes of management of severe breathless only.

Principles of management

  • A clear decision to incorporate a palliative care approach has been made by senior decision-maker
  • Start with lowest effective dose and titrate to effect.
  • Reassess frequently.
  • Use in combination with other one pagers.
  • Seek specialist palliative care advice early
  • Start a regular infusion to maintain symptom control once acute distress is relieved (specialist palliative care can advise as needed).
Supplemental Oxygen for patients at end of life
  • Patients who are hypoxic may benefit from supplemental oxygen for comfort, if available. 
  • However, patients who are agitated/distressed by oxygen masks or tubing can have oxygen discontinued and breathlessness managed with an opioid/anxiolytic combination instead.
  • Monitoring oxygen saturations is not required at end of life.
  • High flow oxygen systems, NIV (BiPAP and CPAP) are not appropriate for patients at end of life.
Medication titration in the first 90 minutes

Initial Medication:

  • Opioid naive: Give Morphine Sulphate 2.5mg SC
  • If already on opioids: Give the appropriate PRN dose of the patient’s regular opioid. The appropriate PRN dose is calculated as follows:
    • Divide the total 24-hour oral dose of opioid by 6 to get the oral PRN dose
    • Divide that number by 2 to obtain the SC PRN dose
    • E.g. The SC PRN dose for a patient taking MST 30mg PO BD is Morphine Sulphate 5mg SC hourly prn.

Reassessment at 30 minutes:

  • If effective and patient is now comfortable PRNs may be repeated at hourly intervals as needed. 


  • If ineffective repeat previous PRN opioid dose SC in combination with midazolam 2.5mg SC.

Reassessment at 60 minutes:

  • If effective and the patient is now comfortable  PRNs may be repeated at hourly intervals as needed


  • If ineffective increase the Morphine Sulphate PRN dose to 5mg SC (or in non-opioid naive increase dose by 50%) and give in combination with midazolam 5mg SC.

Reassessment at 90 minutes:

  • If ineffective, repeat the last dose of the PRN opioid and midazolam AND seek IMMEDIATE palliative care advice which is available 24/7.
Diuretics if evidence that fluid overload is contributing to breathlessness
  • Patients who have a history of congestive cardiac failure or who have received large volume fluid resuscitation may benefit from Furosemide 20-40mg SC PRN.
  • Reassurance
  • Well ventilated room/open window if possible
  • Partial upright supported positioning in the bed as tolerated (see images below)


Further management
  • Patients will require commencement of a syringe pump to maintain comfort following initial period of dose titration. Specialist palliative care will advise on appropriate doses.

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