Morphine and grogginess

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JohnHMich

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We finally got ou act together after the last ALS clinic visit and hospice startup. Things are going pretty well. She is still getting fluids and Kate Farms thru the gtube. The BM problems have subsided. Most recently, we did a morphine test because she has a family history of not tolerating it. No problem with the morphine dose and an improvement in her breathing effort perception. She doesn’t like the sleepiness however. We cut the dose in ½ and changed the time from 1pm to 8pm. She still feels sleepy around noon. I wonder if this is really the morphine? Do we think she would be drowsy 16 hours after the dose?
 

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what are the tolerance issues in her family?
if her breathing is poor, then CO2 is building up and this will cause grogginess.
 

JohnHMich

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Anaphylactic shock was the concern. She describes her breathing effort off the vent and without morphine at 7 out of 10. On morphine at a 3.
 

JohnHMich

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The other question was sort of covered by @lgelb in a separate thread on titration. My wife tends to not use the Bipap during the day. At this point should we be treating the air hunger with morphine or by encouraging more bipap use? She gets about 2 hours off the bipap before she has been asking for morphine.
 

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it sounds like she needs to be on the bipap as much as possible. you may have to work together a bit to find the balance that works, but of course that will be a moving target too

I would not hold back on titrating if she is in distress of any kind
 

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She got a pretty profound improvement from the morphine. It wasn't until then that she mentioned that her breathing was so compromised. It was all a big surprise to me that most of June she had been feeling air hunger. I think she wants to talk and is trying to get a morphine dose that lets her do that off the mask. Hard to tell.
 

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It may be worth trying to titrate the amount of morphine up a bit and increase the bipap - go back on even for half an hour at a time during the morning.
 

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The object of adjusting the BiPAP settings would be to minimize the morphine while providing the right amount of support for breathing. Instead of morphine for air hunger, most people, until the very end, only need a settings adjustment. Through managing the number of breaths and how they are triggered/structured, as well as the volume of each breath, we can provide just the right amount of air to make the PALS comfortable so they are not feeling the air hunger that the morphine is supposed to address. It's when there's air hunger but nowhere else to go on settings that morphine is advised.

Well-intentioned clinicians who know more about morphine than BiPAP will argue that using morphine earlier keeps breathing shallow and therefore more comfortable by reducing the work of breathing, when the BiPAP is well equipped to do that more directly and reproducibly [there are more settings for BiPAP than morphine, and real-time adjustment] when set properly and does not cause sedation/fatigue.

It is true that CO2 buildup can manifest as fatigue, confusion, headaches, lack of appetite, and irritability, and that buildup is often down to settings not being reduced when muscles/lungs/other organs can no longer handle the same volume of air, or need the same volume at a different interval/rhythm. And what causes CO2 buildup? Not being able to exhale the air that has that CO2 in it. But most PALS are getting too much air in late disease, not too little, and morphine makes it harder to exhale it.

Again, at the end, this balance no longer holds and so we typically play it out with morphine because CNS effects and CO2 levels are not the issue any more.

I'll PM you about her settings.
 
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