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Handbook of Palliative Medicine

Breathlessness

Breathlessness is a common symptom in palliative care affecting between 40% and 80% of patients from a variety of underlying diagnoses. The symptom itself is often multifactorial with significant psychological interplay as breathlessness is one of the more frightening symptoms a person may experience.

The cycle of breathlessness
The cycle of breathlessness

The first step in managing breathlessness, as with any symptom, is to assess the causes and triggers. There will need to be baseline investigations such as a chest X ray, blood tests, oxygen saturation levels and probably more targeted investigations such as CT scans, echocardiograms, and blood gases. A careful history will describe triggers both physical and emotional.

Once reversible factors have been addressed a therapeutic trial of interventions can be implemented to assess what works for an individual patient.

Non-drug treatments

  • Communication to explore, explain and reassure
  • Fan therapy (either handheld or standing) is beneficial in regaining control of breathing patterns due to the cool air moving across the face
  • Breathing exercises such as square breathing
  • Visualisation
  • Positioning
  • Complementary therapies such as acupuncture, aromatherapy, or reflexology
  • Pulmonary rehabilitation in either physiotherapist of nurse led service
Square breathing
Square breathing

Drug treatments

  • Opioids can reduce the sensation of breathlessness; given in low doses (oramorph 1.25mg) four times a day. There is no indication that use in this way shortens life or compromises breathing
  • Benzodiazepines (lorazepam 0.5mg) may be used alone or in combination with opioids especially when breathlessness is provoking anxiety and vice versa
  • Oxygen has a variable effect of the symptom of breathlessness, and it is difficult to predict who will benefit so individual therapeutic trials are the only way to assess
    • Care must be taken in patients with propensity for carbon dioxide retention
    • Nasal cannulae are often preferred over masks as less confining, however nasal irritation may cause discomfort
    • For some the burden of continuous oxygen attachment is too great without significant benefit
  • Nebulised saline or other mucolytics are beneficial to those with difficult secretions
  • Steroids for bronchoconstriction, superior vena cava obstruction, lymphangitis carcinomatosis