See also the related separate article Breathlessness.

Dyspnoea is the distressing awareness of the process of breathing - either the frequency or the effort involved. It is very frightening and occurs in about a third of all patients receiving palliative care¹ but in up to three-quarters of patients with advanced cancer² and in over a half of patients with end-stage AIDS, chronic obstructive pulmonary disease (COPD), heart disease and renal disease.³ It is important to realise it is not limited to those with cancer or respiratory disease.

Palliative care has been defined as 'an approach that improves the quality of life of individuals and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual'.⁴ See Palliative Care article.

Congestive heart failure, COPD and advanced neurological or muscular disease are all highly likely to cause dyspnoea as a main symptom, and are amenable to a palliative approach.

Aetiology

The drive to breathe and the stimulus for dyspnoea is quite complex and multifactorial:

• The main driving force of blood gases is pCO₂ rather than pO₂ (the exception being in COPD) although significant hypoxia can augment the hypercapnic drive.
• Mechanical stimuli such as pulmonary stretch and proprioceptive input from the chest wall and diaphragm are also important.
• Proprioception in the lungs and chest wall provide additional stimulus.
• Pyrexia stimulates the thalamus and can cause tachypnoea.
• Emotions (anxiety, fear, anger, etc.) and arousal state also modulate breathing.

It is important to distinguish potentially reversible causes from those which are fixed and irreversible.

Assessment

Dyspnoea is subjective and, especially in these circumstances, may correlate poorly with objective assessment of lung function including blood gas analysis and airways obstruction. There is no universally accepted measure of breathlessness in palliative care patients and several scales are in use, most looking at the functional impact of the breathlessness.⁵ Self-rating scales are often helpful in assessment and monitoring of response to treatment.⁶

History⁶

Should include information about:

• Previous or pre-existing conditions (comorbidities may exacerbate symptoms)
• Recent treatments, e.g. radiotherapy
• Recent medication changes

Questions regarding the breathlessness should include:

• Rapidity of onset (insidious and relentless vs sudden) and time course (acute or chronic, intermittent)
• Associated symptoms
• Relationship to exercise
• Impact on simple daily activities, e.g. washing, toileting, dressing
• Role of carers
• Episodes of panic
• Impact on quality of life and any mood disturbance
• Any known relieving factors

Examination⁶

Including:

• Assess effort and efficacy of breathing (e.g. depth of breathing, use of of accessory muscles of respiration, expectoration of secretions)
• Observe the patient at rest and, where appropriate, walking or undertaking a small task
• Assessment of degree of anxiety (e.g. Hospital Anxiety and Depression Scale) - chest breathing (as opposed to abdominal breathing, with use of the diaphragm) may indicate anxiety
• Cardiac status (heart rate, rhythm, cardiac murmurs, signs of cardiac failure)
• Clinical signs of infection, effusion, anaemia or cyanosis
• Examination of the respiratory system based on known disease, looking for signs of stridor and progressive disease

Investigations

Avoid unnecessary investigation: consider the stage of disease, risk-to-benefit ratio and the wishes of the patient and their family. In primary care, investigations which may be done for non-acute breathlessness include:⁶

• CXR
• Spirometry
• ECG to exclude arrhythmia
• FBC to exclude anaemia
• Pulse oximetry

Blood gas analysis is not usually available outside hospital but a pulse oximeter may be a useful tool in the community.⁷

Management

General

• Try to address breathlessness as soon as distress becomes apparent rather than waiting until it is well-established. Endeavour to establish a cause or causes of the dyspnoea.
• Anxiety inevitably accompanies the symptom and can be alleviated by explaining the current situation and management options. Explore ongoing fears (fears of suffocation, choking, dying in sleep are common). Someone should stay with an acutely distressed patient to give reassurance and possibly distraction. If left alone, a call bell should be available.
• Useful strategies include:
  • Positioning - the most comfortable position is usually sitting upright with support.
  • Keeping the room cool.
  • Moving air from a fan (hand-held or stationary) or open window helps provides psychological relief.
  • Teaching and use of breathing exercises and relaxation methods.
  • Encourage modification of lifestyle in reducing nonessential activities, whilst trying to maintain mobility and independence as far as possible.
  • Encourage exertion to the point of breathlessness to build tolerance and maintain fitness - this will vary considerably between individuals. Pulmonary rehabilitation appears to be well-tolerated and to provide symptomatic relief in many patients with severe COPD. It is increasingly being used in a palliative setting.⁸
  • Dietary modifications with small frequent drinks and meals being best tolerated. Patients with cancer or end-stage respiratory disease are frequently cachexic and advice from a dietician may be helpful.
  • Mouth breathing dries the mouth and oxygen will be very dry unless it has been humidified so attention to oral hygiene is important.
  • Complementary therapies such as aromatherapy, hypnosis and acupuncture may be helpful to some patients but the evidence base is weak.⁹
• A breathing management programme can help people to learn how to control their breathing. These are usually accessible via a 'breathlessness clinic' (where they exist) or from specialist respiratory nurses or physiotherapists. After a full assessment, various techniques are demonstrated and advice given. There is evidence that working with both patients and carers significantly improves control and satisfaction.¹⁰ Typical areas covered are:
  • Breathing retraining exercises
  • Advice about managing attacks of breathlessness with possible panic attacks using cognitive behavioural therapy (CBT) techniques
  • Coping with activities of daily living, e.g. use of walking aids
  • Relaxation techniques
  • Emotional support for both the patient and those around
• A recent Cochrane Review concluded that chest wall vibration and neuro-electrical muscle stimulation were both effective non-pharmacological interventions for relieving breathlessness in advanced stages of disease.¹¹

Medical interventions

Physical interventions may help to relieve or even reverse the cause of the dyspnoea. The degree of intervention desired by the patient will vary and management decisions should be made with them and their families. Discussing possible eventualities can help patients make important, informed decisions about their future care such as the need for emergency hospital admissions, use of artificial ventilation and aggressive treatment of infections.

Primary care

Treatment of reversible or partially reversible causes of dyspnoea. For example:

• Optimising treatment of asthma, COPD, heart failure.
• Infections will aggravate dyspnoea and whilst pneumonia may be 'the old man's best friend', treatment of the infection will improve matters where the patient is not strictly terminal.

Secondary care

Refer to secondary care, where appropriate, for:

• Blood transfusion - anaemia can exacerbate dyspnoea on exertion, and blood transfusion can be justified on this basis. One study looking at practice in 6 British hospices found that patients received blood transfusions in about 6% of all hospice admissions.¹²
• Treatment of the underlying disease, for example:
  • Pleural effusion tapping - for recurrent effusion, pleurodesis is often effective, but it is a painful procedure. Some centres are pioneering the use of implantable access devices for recurrent tapping.¹³
  • Tapping ascites can relieve pressure on the diaphragm and improve ventilation.
  • Superior vena caval (SVC) obstruction can arise from compression of the SVC by mediastinal tumour. In three-quarters of cases it is from primary lung tumours but intraluminal thrombosis may also occur. There is dyspnoea and gross venous congestion and oedema of the head, neck and upper limbs. High-dose steroids with radiotherapy or chemotherapy may help. Dilatation, stenting and anticoagulants may also be tried.
  • Tumour may impinge on the tracheal or bronchus causing collapse of a segment or a complete, lung. Treatments include steroids, external radiotherapy, chemotherapy (for small cell cancer of the lung) and endobronchial treatments such as laser, radiotherapy, stenting, cryotherapy and balloon dilatation.¹⁴
• Emergencies such as pulmonary embolism and pneumothorax may justify admission to hospital for active treatment.

Drugs^6,14

In some situations, physical interventions may not be possible. This is especially true of neuromuscular disease. Nonetheless, medication (including oxygen) may be useful in reducing symptoms.

Opiates

Reticence about the use of morphine for palliation of dyspnoea is common, especially in nonmalignant disease (COPD in particular), for fear of causing respiratory depression. Oral and parenteral opiates can provide good symptom relief,¹⁵ and the risk of significant respiratory depression is much less than anticipated.¹⁶

• Oral morphine is widely used to manage dyspnoea, although the mechanism of action is not fully understood. Morphine can be used safely in cancer patients without producing any changes in pCO₂.¹⁷ The anxiolytic and antitussive effects of diamorphine make it ideal for lung cancer.
• Expert opinion is that oral morphine can be used safely for the management of dyspnoea, even with COPD, if the patient is started on a low dose, and it is titrated according to response and side-effects. Patients not already receiving morphine should start at doses of 5 mg 4-hourly/prn. For those already on morphine, whether for pain or dyspnoea, the overall dose may need to be increased by 30 to 50%.
• When the oral route is no longer available, administration by continuous subcutaneous infusion is acceptable. It can even be combined with a benzodiazepine.
• In extreme dyspnoea and distress, intravenous or subcutaneous diamorphine is often used for more rapid relief than by the oral route.
• Evidence for the use of nebulised opioids for dyspnoea comes largely from uncontrolled or small trials and is of poor quality.^18,19

Anxiolytics

There is as much reason to be cautious about respiratory depression with benzodiazepines as with opiates but they are commonly used to treat dyspnoea in palliative care, although the evidence for benefit is much weaker.

• A recent Cochrane Review suggested that their use should be second-line or third-line (where opioids and non-pharmacological interventions have failed) and should be used on an individual therapeutic trial basis.²⁰
• Diazepam, lorazepam and midazolam are most frequently used. Selection is dependent on the stage of terminal disease, the severity of anxiety, and the desired onset of action.
• In terminal care or in those with severe anxiety, combining an opioid and benzodiazepine may be beneficial, but increases the need for monitoring.²¹

Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) may be helpful, especially for panic attacks.

Oxygen therapy

The role of oxygen therapy for palliation of dyspnoea is unclear.^22,23

• There is conflicting evidence, particularly with lung cancer patients who are not significantly hypoxaemic. The few published studies do not clearly demonstrate that oxygen relieves dyspnoea in these patients. The consensus amongst respiratory physicians is that supplemental oxygen should not be used when the resting oxygen saturation is normal.
• Some patients with significant hypoxaemia will derive benefit. A pulse oximeter is more useful than clinical cyanosis in the situation where repeated blood gas analyses are not available or not desirable.
• A person's need for oxygen therapy should be clinically assessed including potential risks from the oxygen use (for example, a smoker in the household). A trial of short-burst oxygen therapy may be initiated in primary care, preferably after discussion with a specialist, and should be tailored to a person's needs. Short-burst oxygen therapy should be initiated at 2 L/minute for an initial duration of treatment of between 15 and 30 minutes (although others suggest continuing until benefit is felt).
• Either a mask or nasal cannulae may suit patient preference and comfort. Patients need to be encouraged not to become dependent upon their oxygen supply, as this may severely limit their lifestyle.
• Humidified oxygen may be more acceptable to some patients, particularly those with an already dry mouth.

Document references

1. Potter J, Hami F, Bryan T, et al; Symptoms in 400 patients referred to palliative care services: prevalence and patterns. Palliat Med. 2003 Jun;17(4):310-4. [abstract]
2. Ripamonti C; Management of dyspnea in advanced cancer patients. Support Care Cancer. 1999 Jul;7(4):233-43. [abstract]
3. Solano JP, Gomes B, Higginson IJ; A comparison of symptom prevalence in far advanced cancer, AIDS, heart disease, chronic obstructive pulmonary disease and renal disease. J Pain Symptom Manage. 2006 Jan;31(1):58-69. [abstract]
4. WHO Definition of palliative care
5. Dorman S, Byrne A, Edwards A; Which measurement scales should we use to measure breathlessness in palliative Palliat Med. 2007 Apr;21(3):177-91. Epub 2007 Mar 15. [abstract]
6. Palliative care - dyspnoea, Clinical Knowledge Summaries (2007)
7. Vora VA, Ahmedzai SH; Pulse oximetry in supportive and palliative care. Support Care Cancer. 2004 Nov;12(11):758-61. [abstract]
8. Sachs S, Weinberg RL; Pulmonary rehabilitation for dyspnea in the palliative-care setting. Curr Opin Support Palliat Care. 2009 Jun;3(2):112-9. [abstract]
9. Vickers AJ, Feinstein MB, Deng GE, et al; Acupuncture for dyspnea in advanced cancer: a randomized, placebo-controlled pilot trial . BMC Palliat Care. 2005 Aug 18;4:5. [abstract]
10. Bredin M, Corner J, Krishnasamy M, et al; Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. BMJ. 1999 Apr 3;318(7188):901-4. [abstract]
11. Bausewein C, Booth S, Gysels M, et al; Non-pharmacological interventions for breathlessness in advanced stages of Cochrane Database Syst Rev. 2008 Apr 16;(2):CD005623. [abstract]
12. Brown E, Bennett M; Survey of blood transfusion practice for palliative care patients in Yorkshire: implications for clinical care. J Palliat Med. 2007 Aug;10(4):919-22. [abstract]
13. Daniel C, Kriegel I, Di Maria S, et al; Use of a pleural implantable access system for the management of malignant pleural effusion: the Institut Curie experience. Ann Thorac Surg. 2007 Oct;84(4):1367-70. [abstract]
14. Kvale PA, Simoff M, Prakash UB; Lung cancer. Palliative care. Chest. 2003 Jan;123(1 Suppl):284S-311S. [abstract]
15. Robbins RA; Review: oral or parenteral opioids alleviate dyspnea in palliative care. ACP J Club. 2003 May-Jun;138(3):72.
16. Clemens KE, Klaschik E; Symptomatic therapy of dyspnea with strong opioids and its effect on ventilation in palliative care patients. J Pain Symptom Manage. 2007 Apr;33(4):473-81. [abstract]
17. Walsh TD, Rivera NI, Kaiko R; Oral morphine and respiratory function amongst hospice inpatients with advanced cancer. Support Care Cancer. 2003 Dec;11(12):780-4. Epub 2003 Oct 24. [abstract]
18. Kallet RH; The role of inhaled opioids and furosemide for the treatment of dyspnea. Respir Care. 2007 Jul;52(7):900-10. [abstract]
19. Brown SJ, Eichner SF, Jones JR; Nebulized morphine for relief of dyspnea due to chronic lung disease. Ann Pharmacother. 2005 Jun;39(6):1088-92. Epub 2005 Apr 19. [abstract]
20. Simon ST, Higginson IJ, Booth S, et al; Benzodiazepines for the relief of breathlessness in advanced malignant and Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007354. [abstract]
21. Navigante AH, Cerchietti LC, Castro MA, et al; Midazolam as adjunct therapy to morphine in the alleviation of severe dyspnea perception in patients with advanced cancer. J Pain Symptom Manage. 2006 Jan;31(1):38-47. [abstract]
22. Booth S, Wade R, Johnson M, et al; The use of oxygen in the palliation of breathlessness. A report of the expert working group of the Scientific Committee of the Association of Palliative Medicine. Respir Med. 2004 Jan;98(1):66-77. [abstract]
23. Uronis HE, Abernethy AP; Oxygen for relief of dyspnea: what is the evidence? Curr Opin Support Palliat Care. 2008 Jun;2(2):89-94. [abstract]

Internet and further reading

• Seamark DA, Seamark CJ, Halpin DM; Palliative care in chronic obstructive pulmonary disease: a review for clinicians. J R Soc Med. 2007 May;100(5):225-33. [abstract]
• Macmillan Cancer Suppport (Cancerbackup); Breathlessness.
• Mahler DA, Selecky PA, Harrod CG, et al; American College of Chest Physicians consensus statement on the management of Chest. 2010 Mar;137(3):674-91. [abstract]

Acknowledgements