General (non-drug) measures
- Explanation of cause/reassurance
- Calm manner; fan or open window in acute attack
- Posture – ideally upright and leaning forward if possible
- Diaphragmatic breathing through pursed lips; visualisation 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
- Benefits advice
- 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: Palliative Care Emergencies.
For patients with stridor consider urgent referral to oncology or respiratory colleagues – high dose dexamethasone 16mg-40mg per day may be of benefit. For some patients however this may be part of a terminal process – see Section: Management of breathlessness in the dying phase.
Nebulised saline (sodium chloride 0.9%) may be of some benefit to patients to aid in the expectoration of secretions. Carbocisteine can also be used to reduce sputum viscosity (capsules or oral liquid – 750mg tds initially, reducing to 750mg bd once satisfactory response obtained).
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.
- Oxygen should be prescribed with a target oxygen saturation specified
- 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
Monitor for signs of CO2 retention e.g. drowsiness, tremor, new confusion
Bronchodilators – via inhaler +/- spacer or nebuliser. Stop if no benefit.
Steroids – especially if previous therapy has been beneficial e.g. for COPD.
Typical doses are:
- 30mg prednisolone (or 4mg dexamethasone) per day for exacerbations;
- 2.5mg-10mg prednisolone per day for maintenance (not normally recommended because of long term side effects – see Chapter: Corticosteroids and consider osteoporosis prophylaxis).
- May be worth considering as a therapeutic trial in patients with lymphangitis (typically dexamethasone 16mg per day).
- High dose dexamethasone (20mg-40mg daily) can also be used to relieve stridor due to malignant upper airway obstruction .
- May be useful for those patients with marked anxiety/panic attacks associated with episodes of breathlessness
- Less evidence for efficacy vs opioids in relieving breathlessness
- e.g. Lorazepam (scored 1mg blue tablet – Genus brand) 0.5mg sublingual 4–6 hourly P.R.N. or Diazepam 2mg–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
- Long acting opioids may be considered for some patients with continuous breathlessness who gain relief from regular immediate release preparations
- Alternative opioids may be considered in some patients who cannot tolerate morphine (seek specialist palliative care advice)
Prescribing for Opioid-naïve patients:
- Explain to the patient that morphine may be useful to relieve the sensation of breathlessness
- For patients with breathlessness due to cancer prescribe immediate release oral morphine (e.g. Oramorph®) 2.5mg–5mg po P.R.N., then regularly 4-6 hourly if beneficial
Prescribing for 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 sufficient for breathlessness, e.g. 25-50% of the current P.R.N. breakthrough analgesic dose; others may require 100%
Lower doses of morphine
(e.g. Oral Morphine IR liquid 1mg-2mg po P.R.N.) may be more appropriate in the following patients:
- Severe lung disease
- Heart failure
- Renal or hepatic impairment
A low-dose and slow titration is recommended for patients with COPD and significant breathlessness despite usual treatments. Start with morphine (e.g.Oral Morphine IR liquid 1mg po bd, increasing to 1mg po qds over one week. Thereafter increase dose gradually each week until satisfactory relief obtained.
Please also see also: Section: Management of breathlessness in the dying phase.