Non-Pharmacological
Management of Breathlessness
A Physiotherapy & Occupational Therapy Perspective
Fiona Cahill – Senior Physiotherapist SFH
Linda Gormley– A/Occupational Therapy Manager SFH
Introduction
• Breathlessness can be a terrifying and
exhausting symptom for palliative care
patients, therefore a collaborate approach
enables professional/patients to work towards
a common goal( Syrett & Taylor 2003)
Interdisciplinary working
• Physio and OT play an important role in the nonpharmacological management of breathlessness
• Both disciplines have core skills which when
successfully integrated can enhance best
practice/patient care
• Collaborative working between the two
disciplines lends itself to a holistic approach
• NICE guidelines for the management of Lung
Cancer recommend access to nonpharmacological interventions
Types of breathlessness
• Activity induced breathlessness
• Anxiety induced breathlessness
• Medical conditions
– Chest Infections
– Acute Cardiac conditions
ACTIVITY INDUCED
BREATHLESSNESS
• Breathlessness is a normal response to
exercise / activity
• Exercise tolerance varies depending on age,
illness and previous activity levels
• With illness, people are anxious re exercise
and then to avoid it
Sensation
of SOB
↑effort
required
Muscle
weakness
develops
Avoid
activity
↓
cardiovascula
r fitness
Borg Breathlessness Scale
Rating
Severity
Can you .......
0
No Breathlessness
Sing / whistle
0.5
Very Very Slight (just noticeable)
Sing / whistle
1
Very Slight
Sing/whistle
Slight
Talk comfortably
1.5
2
2.5
Talk but aware of your breathing
3
Moderate
Say short sentences
4
Somewhat severe
Say 2 – 3 word answers
5
Severe
Say one word answer
Very Severe
Occasionally say one word answers
9
Very very severe
Unable to talk
10
Maximum
Gasping
6
7
8
Exercise
• The risk associated with exercise far outweighs
the risk of NOT exercising
Benefit of exercise
General Benefits




Improve / maintain physical functioning
Reduce risk of falls
Improve mental health
Reduce pain associated with degenerative disease
Illness specific
• COPD
• Heart Failure
• Cardiovascular Disease
Incorporating exercise
• Where possible get guidance from a
physiotherapist
• Encourage patients to walk where possible
rather than using wheelchairs
• Use the BORG scale to guide intensity
– level 3 – 4 is normal for ‘exercise’
• HSE Easy Exercises – A Chair based
Programme for older adults
Pursed Lip Breathing Technique
• Keeps the airways open longer and reduces
effort to breathe
• Slows the breathing rate
• Improves breathing patterns by moving old air
out of the lungs and allowing for new air to
enter the lungs
• Relieves shortness of breath
• Causes general relaxation
Pursed Lip Breathing Technique
• Focus on ‘the exhale’
• Slow exhale for a count of 4 through ‘pursed
lips’
• Breathe in for a count of 2
• Many patients who experiences
breathlessness have adopted this technique
without instruction
• Not suitable for all patients
Positions of ease
Positions of ease
Positioning
Occupational therapists aim to help patients to
• Understand and recognise periods of breathlessness
and anxiety
• Integrate the principles of breathlessness management
(4 Ps) into their lifestyle!
• Understand the pattern of their own activities, so that
they can improve their management
• Set goals for achievement of activities of importance
• Integrate anxiety breaking techniques into their lives
• Review changes in condition and function
Impact of Breathlessness
•
•
•
•
•
•
•
Tension / panic
reduced energy for activities
insomnia
avoidance of situations
role loss
low mood
family and carer stress
Interventions
• Education about strategies to improve
performance for ADLs
• Activity analyses
• Goal setting
• Aids and adaptations
• Anxiety management
Education: The 4 Ps!!
• Remember
– Plan
– Prioritise
– Pace
– Posture
Also, delegate, modify, adapt!
Goal setting
• Help patients to achieve a sense of
control, and mastery
• Goal set round three areas:
- productivity - work related roles
- self maintenance - all we need to do to
look after ourselves in our own
environment
- leisure - activities that give us a sense of
pleasure and enjoyment
Activity analyses
• Break down tasks into stages
• Learn about how task components combine to
achieve an activity
• Identify skills required to perform each part of
the activity
• Understand environmental and social
supports that may be required for completion
of the activity
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

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


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•
Washing ADL chart
Delegate someone to organise your robe, toiletries, hot water
and clothes, where acceptable
Organise/breakdown washing activities
Have all toiletries together
Plan how you layout activities - undressing, washing, drying,
dressing
Give yourself a break. You may not need a shower or bath
every day!
Sit at the wash hand basin to wash
A long-handled sponge may save a little energy
Avoid long, hot showers or baths
A small grab-rail in the bath or shower may help.
An absorbent towelling bathrobe will help you
to dry yourself without too much effort
Weather permitting, have the window slightly ajar when
having your shower
Aids and Adaptations
ANXIETY INDUCED
BREATHLESSNESS
Anxiety
Important and Necessary Anxiety
•
•
•
•
•
Motivates us
Helps us to pay attention
Helps us to get out of dangerous situations
Helps us to perform and excel!
Prepares us for rapid action
The anxiety cycle
Anxiety and shortness of breath
Tonya Pomerantz
Anxiety Management
• Normalises anxiety
• Helps patients recognise what triggers anxiety
• Assists in integrating anxiety management
techniques into lifestyle
• Helps in the management of breathlessness
associated with anxiety
• Helps regain control over activities
• Challenges negative thinking
Interventions
• Education
– Normal Anxiety and anxiety cycle
• Symptoms
– Physical
– Cognitive
– Behavioural
Formal Relaxation Exercises
•
•
•
•
Visualisation
Body scans
Mindfulness
Yoga
Quick Techniques
The "feather technique“
coutesy of Royal marlsdon Hospital Occupational Therapy Department
Tape recorder imagery
The "Stop technique”
•
•
•
•
Say Stop
Let your breathe go
Relax your shoulders
Breathe in, and then
exhale
• Relax your face and jaw
• Think of a relaxing
image
Sleep Hygiene
• Maintain a regular sleep and wake-up time
• Use your bedroom only for sleep – create a good sleep
environment
• Distract your mind. Try reading or listening to music or using
your relaxation techniques
• Write it down what is on your mind may help or a to-do list
• Avoid caffeine within four to six hours of bedtime.
• Avoid the use of nicotine close to bedtime or during the night.
• Do not drink alcoholic beverages within four to six hours of
bedtime.
• A light snack before bedtime can help promote sound sleep,
but avoid large meals.
• Exercise during the morning can induce better overall sleep
but avoid strenuous exercise within six hours of bedtime,
• Minimize light, noise, and extremes in temperature in the
bedroom
Calming Hand
• Developed by the physiotherapy team in
Dorothy House Hospice
• Useful in managing anxiety
• 1st step is recognising triggers of anxiety /
breathlessness
• Combinations of breathing technique &
Mitchell method of relaxation
Calming Hand
Relax
Exhale Slowly
Inhale
Sigh Out
Recognition
“There are moments when all anxiety and stated
toil are becalmed in the infinite leisure and
repose of nature."
Henry David Thoreau
OXYGEN & BREATHLESSNESS
• Normal Oxygen levels range 95 – 98%
• Chronic Illness levels > 90%
• Body is capable of delivering 3 – 4 times
the amount of oxygen required
• No evidence for the use of oxygen in
breathless patients
• Remember
– people can have low oxygen levels without
being breathless
– Being breathless doesn’t mean oxygen
levels are low
SIMPLE TIPS FOR MANAGING
BREATHLESSNESS
The Dos
•
•
•
•
•
•
Give the patient space
Open windows and doors or switch on a fan
Loosen any tight clothes
Slowly & softly talk to the patient
Keep instructions simple
Encourage any techniques that they have used
in the past
The Don’ts
•
•
•
•
Don’t Panic
Don’t crowd the patient
Do not try and teach new techniques
Don’t engage in small talk when they are
breathless
Language Used ....
• ‘Take a deep breath’
• ‘Just keep breathing’
• References available on request
Contact Details
Linda Gormley
lgormley@sfh.ie
Fiona Cahill
fcahill@sfh.ie
Ph: 01 8327535
Ph: 01 8327535