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We describe eight patients who had terminal lung cancer causing severe dyspnea unrelieved by oxygen, nonnarcotic drugs, or intermittent bolus narcotics. We treated these patients with continuous intravenous infusion of morphine, beginning with bolus IV injections of 1 or 2 mg of morphine every 5 to 10 minutes until the patient reported relief. A continuous morphine infusion was then started, with the hourly dose equal to 50% of the cumulative bolus dose. Vital signs, degree of sedation, and blood gases were serially followed. Six patients achieved good dyspnea relief, one had moderate relief, and one had a poor response. Variable changes were noted in the PaO2, whereas PaCO2 steadily increased in five of seven patients, and pH decreased in six. There was little change in systolic blood pressure or pulse, and only one individual had less than 10 respirations per minute. The major side effect of treatment was sedation, treated by temporarily discontinuing morphine until the patients' mental status improved and then restarting the infusion at a 50% lower hourly morphine dose. Mean time of study was 30 hours (range 16 to 87 hours). Seven of the eight study patients died during treatment. Whether morphine therapy shortened survival is uncertain. We conclude that continuous morphine infusion is effective therapy for severe dyspnea. The treatment is ethically justified. Relief of suffering is the primary goal of therapy, and less risky treatments are unavailable.

We determined the incidence of tuberculosis in lung cancer patients with known tuberculin status. All patients received chemotherapy with or without radiation therapy, corticosteroid therapy, or both, and none received isoniazid prophylaxis. Positive tuberculin reactivity was found in 89 of the 257 patients; among these 89, tuberculosis developed in one patient before and in one patient after chemotherapy. Among the other 168 patients, one case of tuberculosis developed after chemotherapy. For all lung cancer patients, the incidence of tuberculosis was higher than age-specific and race-specific rates in a control population. The risk of tuberculosis was judged to be significantly higher in patients with positive than with negative tuberculin reactivity; among tuberculin reactors, however, the risk of tuberculosis was estimated to be less than the potential risk of isoniazid hepatotoxicity reported in the literature for patients in a similar age group. The median survival for tuberculin-positive lung cancer patients was 9.6 months. Because of the limited survival in these patients, and because of the high risk of isoniazid hepatotoxicity for patients in this age group, we do not recommend isoniazid prophylaxis for tuberculin-positive patients receiving chemotherapy for lung cancer.

In a series of 60 consecutive patients in whom Hickman catheters were placed for treatment of malignancy, four properly positioned catheter tips migrated secondarily from the superior vena cava to the ipsilateral jugular vein 2, 4, 21, and 25 days after placement. Three of the four patients had begun to have catheter dysfunction when the displacement was diagnosed. No satisfactory explanation for this rarely reported complication was evident in three of the cases. Maneuvers such as coughing, Valsalva's maneuver, and forceful heparin flushing produced no motion in three normally directed catheter tips in other patients observed under fluoroscopy. The phenomenon may be more common than previously reported. Evaluation of any new Hickman catheter dysfunction should include a chest x-ray film to ascertain the position of the catheter.