Barbara Mackie and Jo Lenton
Community Specialist Palliative Care
• Breathlessness is an uncomfortable sensation or
awareness of breathing.
• Subjective – measuring lung function does not correlate
with sensation or severity of breathlessness
• A complex experience of mind and body that is likely to
progress with disease severity
• Significant correlation with impaired quality of life and poor
survival. Effects Patients and Carers.
• A common complex distressing symptom at the end of life
Prevalence of Breathlessness in cancer
• The prevalence of breathlessness varies with the
primary tumour site;
• Breathlessness occurs as a symptom most frequently in
lung cancer, where it might affect 75% of people with
primary disease of the lung, bronchus and trachea
(Muers & Round 1993).
Breathlessness in non-malignant disease
• For patients with COPD, intractable breathlessness
develops late in the course of the disease, gradually
increasing in severity over a period of years in the
majority of people.
• There is a long pre-clinical phase when patients may not
have any respiratory symptoms at all, although lung
damage exists.
Breathlessness in non-malignant disease
• There is then a protracted period of gradual decline
punctuated by severe exacerbations, which may be lifethreatening and require inpatient management.
• Breathlessness tends to be associated with exertion.
• However at end of life it may be present at rest.
• What are the Causes of
Psychological Aspect of
Assessment of breathlessness
What does it mean to the patient / carer?
Triggers / What eases it?
Levels of significance – during activity, in
different positions, at rest
Pattern of breathing, colour, respiratory rate
Are they anxious?
Oxygen saturations
Manage reversible causes optimally
according to patients wishes
Consider active treatment of:
Pleural effusion
Airway obstruction SCVO
Non Pharmacological
Airflow - use of fan /window
Relaxation / Distraction/ Reassurance
Energy conservation / Pacing
Controlled Breathing techniques /physio
Loose clothing
Mouth Care
Comfortable Positions if short of breath
Breathing Techniques
• Start with position of ease
• Relax shoulders / upper chest
• Diaphragmatic ‘tummy’ breathing
• Breath out twice as long as breath in
• Pursed lips on breathing out if needed
Time and calm environment essential
Relax and Breathe CD
Visual imagery
‘Calming hand’
Touch across back
. Pacing activities
Encourage activity
Allow time for tasks
Starting and stopping with rest intervals
Inspiration: expiration ratio during activity
Use of aids – stair lift etc
Adapting functional tasks, e.g. Ironing sitting
Pharmacological Management
• Opioids
• Opioids are the most effective pharmacological agents
for the relief of dyspnoea
• Oral morphine (normal release) 2.5mg (if Opioid
naive/elderly and renal impairment)
• Gradual titration upwards according to response
• High level evidence supports:
• Low dose slow release oral morphine for opioid naïve
• .
Pharmacological management
• Benzodiazepines
• Lorazepam 0.5-1mg sublingual (SL) - rapid relief during
panic attacks
• Diazepam (oral) for longer term management
• Midazolam 2.5mg subcutaneous 5 -10mg in Syringe
driver over 24hrs
• Above medication are sedative, therefore should be monitored
carefully. However in the terminal stages of illness the benefits
usually out-weigh the risks.
Pharmacological Management
• Oxygen therapy only where appropriate (mixed
evidence, check sats if hypoxic resting O2 below 90%
• Steroids
• Bronchodilators nebulised (Salbutomol 2.5 5mg prn)
• Antibiotics
• Nebulised saline to thin secretions or Carbocisteine if
secretions difficult to expectorate and exacerbating
breathing difficulties
• Blood transfusion
End of life secretions
• Often referred to as ‘death rattle’
• Caused when a patient’s coughing and
swallowing reflex is impaired or absent, causing
fluids to collect
• Not easily relieved by drug therapy once
• Treatment should therefore be started at first
sign of rattle
Non-pharmacological management of
• Re-positioning of the patient by tilting side to side, or tipping bed
‘head up’ to reduce noise
• Management of halitosis with frequent mouth care and
• Discrete management of oral secretions mouth care – oral hygiene
• Suction not advised, except when secretions are excessive
• Reassurance to family that the noise is due to secretions, and not
causing suffocation, choking or distress
• Reduce oral fluids if at risk of aspiration
Pharmacological management of
Hyoscine Butylbromide (Buscopan)
60- 240mg/24hr s/driver, prn dose SC 20mg hrly
If not effective, discuss with palliative care team who may consider -
Glycopyronium Bromide (Glycopyrolate)
400-2400mcg/24hr s/driver or prn dose 200mcg
NB: Hyoscine Hydrobromide was historically drug of choice, but not
currently recommended due to side effects of sedation and confusion
• DAVIS.C(1998) Breathlessness,cough and other
respiratory problems.In: FALLON.N.O’NEILL.B(eds)ABC
of Palliative Care BMJ Books. London pp 8-15
• MUERS.M. ROUND.C (1993)Palliation of symptoms in
Non –Small Cell Cancer:A Study by the Yorkshire
Regional Cancer Organisation Thoracic Group.
Thorax.48 (7) 339-349
• Sheffield Palliative Care Formulary 3rd Edition
Thank you for listening
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