Management of Breathlessness

General (non-drug) measures

Explanation of cause/reassurance
Calm manner; fan or open window in acute attack
Posture – ideally upright and leaning forward if possible
Diaphragmatic breathing through pursed lips; visualisation techniques to encourage longer expiratory phase
Nutritional advice (e.g. small frequent meals, easily chewed)
Relaxation training and/or complementary therapy
Energy conservation/pacing training/equipment
Treat depression and anxiety if present
Benefits advice
Encourage social interaction (e.g. peer group support, Breathe Easy Club, breathlessness management in a hospice day unit)

Specific measures

Conditions such as pneumonia, COPD, asthma, effusions etc. should be dealt with using standard management. Seek further advice if needed.

For patients with SVC obstruction see Chapter: Palliative Care Emergencies.

For patients with stridor consider urgent referral to oncology or respiratory colleagues – high dose dexamethasone 16mg-40mg per day may be of benefit. For some patients however this may be part of a terminal process – see Section: Management of breathlessness in the dying phase.

Nebulised saline (sodium chloride 0.9%) may be of some benefit to patients to aid in the expectoration of secretions. Carbocisteine can also be used to reduce sputum viscosity (capsules or oral liquid – 750mg tds initially, reducing to 750mg bd once satisfactory response obtained).

Psychological measures

Psychological factors (e.g. anxiety, fear of death from choking or suffocation) often exacerbate any breathlessness resulting from physical disease.

Occasionally breathlessness may be largely due to psychological factors.

In such circumstances, good palliation depends on exploring the patient’s beliefs about their breathlessness and their concerns. Reliance on pharmacological treatment alone will lead to unsatisfactory control of breathlessness.

Palliative therapies

Oxygen

Oxygen should be prescribed with a target oxygen saturation specified
Limited value if oxygen saturation is already >90% prior to starting oxygen therapy
1-2 litres per minute would be usual flow rate unless blood gases dictate otherwise
In palliative care routine monitoring with blood gases is not usually required but use oxygen with caution in patients who are known to retain CO2
Risk factors for CO2 retention: –
- Previous episode of CO2 retention
- Known COPD/other lung pathology
- Long history of smoking

Monitor for signs of CO2 retention e.g. drowsiness, tremor, new confusion

Non-opioid drugs

Bronchodilators – via inhaler +/- spacer or nebuliser. Stop if no benefit.

Steroids – especially if previous therapy has been beneficial e.g. for COPD.

Typical doses are:

- 30mg prednisolone (or 4mg oral dexamethasone) per day for exacerbations;
- 2.5mg-10mg oral prednisolone per day for maintenance (not normally recommended because of long term side effects – see Chapter: Corticosteroids and consider osteoporosis prophylaxis).
- May be worth considering as a therapeutic trial in patients with lymphangitis (typically oral dexamethasone 16mg per day).
- High dose dexamethasone (20mg-40mg orally, daily) can also be used to relieve stridor due to malignant upper airway obstruction .

Benzodiazepines

May be useful for those patients with marked anxiety/panic attacks associated with episodes of breathlessness
Less evidence for efficacy vs opioids in relieving breathlessness
e.g. Lorazepam (scored 1mg blue tablet – Genus brand) 0.5mg sublingual 4–6 hourly P.R.N. or Diazepam 2mg–5 mg o.n. regularly for patients with ongoing debilitating anxiety

Opioid drugs

Opioids can relieve the sensation of breathlessness- this is of most benefit to breathlessness at rest rather than on exertion.
More evidence of opioid efficacy vs. benzodiazepines in relieving breathlessness.
Morphine sulphate is the 1st line opioid of choice as it has the most robust evidence base.
Give a therapeutic trial – monitor benefits and side effects. Titrate slowly if required.
Long-acting opioids should be considered as first line as more evidence than PRN opioids.
Alternative opioids maybe considered in some patients who cannot tolerate morphine (seek specialist palliative care advice)
Explain to the patient that morphine maybe useful to relieve the sensation of breathlessness
Dosage: For opioid-naïve patients prescribe a slow-release morphine sulphate (e.g. MST 5mg BD or Zomorph 10mg BD and titrate if beneficial, to a maximum dose of 20mg bd (taking renal function into consideration)
Some patients already established on opioids for pain may find their PRN requirements for breathlessness may be lower than the dose for pain.
Use lower doses if patient frail, elderly or you have other concerns about sensitivity.
Ensure laxatives are co-prescribed.
In severe renal or hepatic disease see these chapters for prescribing advice.

Please also see also: Section: Management of breathlessness in the dying phase.

Disclaimer

This Guide is intended for use by healthcare professionals and the expectation is that they will use clinical judgement, medical, and nursing knowledge in applying the general principles and recommendations contained within. They are not meant to replace the many available texts on the subject of palliative care.

Some of the management strategies describe the use of drugs outside their licensed indications. They are, however, established and accepted good practice. Please refer to the current BNF for further guidance.

While WMPCPS takes every care to compile accurate information , we cannot guarantee its correctness and completeness and it is subject to change. We do not accept responsibility for any loss, damage or expense resulting from the use of this information.