Palliation of breathlessness
Breathlessness is a common symptom in both malignant and nonmalignant disease1. Up to 70% patients with cancer experience breathlessness in the 6 weeks prior to death2, and this may be greater in lung cancer patients because of co-existent chronic obstructive pulmonary disease (COPD)3. Up to 40% of heart failure patients are breathless in the 6 months before death, rising to 65% in the three days leading up to death4. Breathlessness is almost universal in patients with more than mild COPD. With very advanced disease specific pharmacological treatment aimed at particular lung pathology (e.g. bronchodilators for bronchospasm) may have limited success and more general symptom control measures are often necessary5.
The use of low dose opioids, titrated carefully, can help to relieve the sensation of breathlessness in patients with lung pathology, heart failure and cancer.
Oxygen therapy should not be used routinely – it may give symptom benefit if the patient is known to be hypoxic. The use of a fan or other draught of air may be just as effective as oxygen.
Non drug intervention may be of benefit in helping patients manage their symptoms; however in advanced illness patients may often require opioid and/ or benzodiazepine medication. These can be given by different routes of administration e.g. orally, sublingually (lorazepam), by continuous subcutaneous infusion via syringe driver or bolus PRN dosing (subcutaneously or in exceptional circumstances intravenously).
ASSESSMENT OF THE BREATHLESS PATIENT
•Determine the correct diagnosis
•Consider any other contributing factors e.g. dysrhythmia, anaemia
•Is there anything that can be corrected or treated? Seek advice if unsure
•Consider the use of oximetry, if available, to guide if oxygen therapy is likely to be of benefit (i.e. if oxygen saturation less than 90%) •Consider psychological factors especially anxiety and the fear of choking/ suffocation
•Decide on the optimal management
•Only consider investigations which are likely to lead to a change in clinical management
MANAGEMENT OF BREATHLESSNESS
General (non-drug) measures
•Explanation of cause/reassurance
•Calm manner; fan or open window in acute attack
•Diaphragmatic breathing through pursed lips; visualization 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
•Encourage social interaction (e.g. peer group support, Breathe Easy Club, breathlessness management in a hospice day unit)
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 6 Palliative Care Emergencies.
For patients with stridor consider urgent referral to oncology or respiratory colleagues – high dose dexamethasone, 16 mg per day may be of benefit. For some patients however this may be part of a terminal process – see Management of breathlessness in the dying phase, see Breathlessness in the Dying Phase. Nebulised saline may be of some benefit to patients to aid in the expectoration of secretions.
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 drug treatment alone will only result in partial control of breathlessness.
•Should be prescribed
•Target oxygen saturation may be useful to document
•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
Please monitor for signs of CO2 retention e.g. drowsiness, tremor, new confusion
•Bronchodilators – via inhaler / spacer or nebulizer. Stop if no benefit
•Steroids – especially if previous therapy has been beneficial e.g. for asthma / COPD. Typical doses are 30–40 mg prednisolone per day or 4 mg dexamethasone per day. May be worth considering as a therapeutic trial in patients with lymphangitis (typically dexamethasone 16 mg per day )
•May be useful for those patients with marked anxiety associated with episodes of breathlessness
•Less evidence for efficacy vs opioids in relieving breathlessness e.g. Lorazepam (scored blue tablet ) 0.5mg sublingual 4–6 hourly PRN or Diazepam 2–5 mg o.n. regularly for patients with ongoing debilitating anxiety
•Can relieve the sensation of breathlessness. This is of most benefit for breathlessness at rest rather than on exertion.
•More evidence of efficacy vs benzodiazepines in relieving breathlessness
•Give as a therapeutic trial – monitor benefits and side effects. Titrate up slowly if required by 30% increments
- Explain to the patient that morphine may be useful to relieve the sensation of breathlessness
- Prescribe immediate release oral morphine (e.g Oramorph®) 2.5–5mg every 4–6 hours and/or PRN 2 hourly
•Patients on opioids for pain currently:-
- Explain to the patient that morphine may also be useful to relieve the sensation of breathlessness
- Some patients may find a lower opioid dose than their current breakthrough analgesic dose helpful for breathlessness, e.g. 25% of the current PRN breakthrough analgesic dose
•Long acting opioids may be considered for some patients with continuous breathlessness (seek specialist palliative care advice)
•Alternative opioids may be considered in some patients who cannot tolerate morphine (seek specialist palliative care advice)
•Lower doses of morphine (e.g Oramorph®) 1.25–2.5mg every 4–6 hours and/or PRN 2 hourly may be more appropriate in the following patients:-
- severe lung disease
- heart failure
- renal impairment
Please see also breathlessness in the dying phase.
1. Booth S and Dudgeon D. Editors. Dyspnoea in advanced disease. A guide to clinical management. Oxford University Press, New York. 2006.
2. Reuben DB and Mors V. Dyspnoea in terminally ill patients. Chest, 1986,
3. Dudgeon DJ et al. Dyspnea in cancer patients: prevalence and associated factors. Journal of Pain and Symptom Management, 2001, 21 :95-102.
4. Levenson JW et al. The last six months of life for patients with congestive heart failure. Journal of the American Geriatric Society, 2000, 45:S101.
5. Scottish Palliative Care guidelines NHS Lothian August 2010: http://www.palliativecareguidelines.scot.nhs.uk; accessed October 2011.
6. Joint Formulary Committee (British Medical Association and Royal Pharmaceutical Company). British National Formulary (BNF 62). bnf.org 2011.
7. Jennings A. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database of Systematic Reviews 2001, Issue 3 http://www.cochrane.org/reviews/en/ab002066. html.
8. NICE. Chronic obstructive pulmonary disease. Management of chronic obstructive pulmonary disease in adults in primary and secondary care. Chapter 1.2 Managing stable COPD. June 2010. http://publications.nice.org.uk/chronic-obstruture- pulmonary-disease-cg101. accessed 20.01.2012.