Palliative Management of
Dyspnea
Katherine Clark
Clinical Associate Professor
Calvary Mater Newcastle
Hunter New England Health
Contents
• Dyspnea defined
• Epidemiology of dyspnea in palliative
care?
• The experience of dyspnea
• Anxiety and dyspnea
• Causes of dyspnea
• Palliation of dyspnea
Dyspnea defined
• Dyspnea is an uncomfortable sensation
or awareness of breathing.
• A complex experience of mind and body
that is likely to progress with disease
severity.
• Significant correlation with impaired QoL
and poor survival.
Prevalence of dyspnea in cancer
• Dyspnea is a common and distressing
symptom experienced by patients with
advanced cancer, occurring in 19–51%
of patients.
• Higher incidences are reported towards
the end of life with dyspnea defined as a
poor prognostic indicator.
Prevalence of dyspnea?
• The prevalence of dyspnea varies with
the primary tumor site;
• It occurs in 46% of patients with
advanced lung cancer, but in only 7% of
those with advanced gastric cancer.
• Of those with the symptom, 60–80% rate
it as clinically important.
Dyspnea 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.
Dyspnea 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
predictably with exertion, until the end of
life when it may be present at rest.
The personal experience of dyspnea
• Many studies have confirmed that
breathlessness is a particularly
distressing symptom for patients and
their families.
• A qualitative study that investigated the
experience of patients with cancer or
COPD and carers, found high levels of
anxiety, particularly at night.
Personal experience’s of dyspnea
• This anxiety was reported in both
relatives and patients.
• Patients reported thinking "Will I get
much shorter of breath? Can I manage
it? Is something terrible going to
happen? Will I suffocate to death?"
• Carers report a sense of helplessness
and fear.
Anxiety and dyspnea
• There is uncertainty about the contribution of
anxiety in breathlessness;
• The incidence of anxiety in patients with the
diagnosis of any cancer greatly exceeds that in
the normal population.
• Neuroimaging and psychophysical studies are
now helping to assess the contribution of
distress and anxiety to the genesis of
breathlessness;
Pathophysiology of dyspnea
• The neurophysiology of dyspnea is complex
and poorly understood, but it is clear that there
is some similarity with the genesis of
intractable pain.
• Both pain and dyspnea are somatopsychic
experiences arising from multiple receptors
integrated at various levels in the central
nervous system and therefore susceptible to
modulation by both physiological and
psychological influences.
Pathophysiology of dyspnea
Some causes of dyspnea in
palliative care
• Direct
– Tumour mass, pleural and pericardial effusion,
phrenic nerve paralysis, vena caval obstruction,
carcinomatosis, airway obstruction.
• Indirect
– Anaemia, radiotherapy, infection, cachexia,
pulmonary embolus.
• Co-morbidity
– Airways, cardiac and renal diseases, depression,
anxiety.
Causes of dyspnea
• Dyspnea in advanced cancer is usually multifactorial:
• Although reversible causes should be sought, a
significant proportion of the underlying causes are
irreversible.
• The burden/benefit of the intervention for the patient
needs to be evaluated by them.
• If extra visits to hospital are required, will the relief
provided exceed the exhaustion incurred?
Palliating Dyspnea
Non-pharmacological approaches
• Good evidence to support behavioural and
nursing interventions to manage dyspnoea.
• Emotional and cognitive aspects which
respond well to:
–
–
–
–
–
Relaxation,
Breathing exercises,
Psychological support,
Positioning,
Moving air over the face.
Pharmacological approaches
•
•
•
•
•
•
Opioids,
Oxygen,
Antidepressants,
Anxiolytics,
(Corticosteroids),
(Bronchodilators).
Opioids
• Opioids are the most effective pharmacological
agents for the relief of dyspnoea.
• High level evidence supports:
– Low dose of oral morphine for opioid naïve
(10-20mg/24hours),
– Increase dose by 25% patients taking
morphine for other reasons.
– No role yet confirmed for nebulised
morphine.
Oxygen
• Regardless of whether people are hypoxic or
non-hypoxic, O2 has little role to play in the
management of the symptom of dyspnea;
• In hypoxic people, O2 confers a survival
benefit.
• In non-hypoxic people, recent RCT supports
the null hypothesis that very few people will
gain any benefit from supplemental O2.
Antidepressants and
Anxiolytics
• There is some evidence which supports
the use of antidepressants in the
palliation of dyspnea;
• But less evidence for the use of
benzodiazepines;
• However, best clinical guidelines
continue to recommend agents such as
lorazepam or clonazepam be readily
available.
An evidence based algorithm to
palliate dyspnea?
Increasing shortness of breath in a
person with life-limiting illness and
estimated prognosis of less then 3
months
Reversible causes of dyspnoea
sought?
Sa02 <90%
on room air
Request for O2
Ongoing dyspnoea?
Referral to palliative care
Trial of O2
Sa02 >90%
on room air
Multidisciplinary referrals:
Physio
Breathing control exercises
Relaxation exercises
Walking frame
Chest physio
OT
Physical aids
Activity pacing
Social work
Social support/finances
Meditation/relaxation
Pastoral Care
Medical Officer
Low dose morphine
Screen for depression and
anxiety
Nursing
Advice re positioning
Moving air
Questions?