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16.9 Breathlessness in palliative care
Dyspnoea is a common symptom that can be very frightening and patients may fear that they will suffocate.
The pathophysiology of dyspnoea is poorly understood and the cause usually multi-factorial. Investigations such as chest x-rays, scans and blood gases are often of limited value in patients with advanced cancer.
However, reversible causes should be considered and managed appropriately e.g. pulmonary embolism, congestive cardiac failure, cardiac arrhythmias, pleural effusion, infection, severe anaemia, SVCO.
Non-pharmacological approaches are often helpful. These may include using a fan or draft from an open window, physiotherapy, positioning, breathing techniques, massage, visualisation, CBT and distraction.
The relative contribution of non-pharmacological and pharmacological treatments vary according to the stage of the patient's illness i.e. non pharmacological methods are likely to be most useful in patients who are only breathless on exertion, whereas for patients in the last few hours or days of life, pharmacological treatments predominate.
Bronchodilators
- may be helpful even in the absence of obvious wheeze
- salbutamol 2.5 - 5mg 6 hourly via nebuliser or spacer
- Ipratropium bromide 250 – 500 micrograms 6 hourly via nebuliser or spacer
Opioids
- opioids reduce excessive respiratory drive and may make breathing more efficient, reducing the sensation of breathlessness
- opioids are useful treatments for breathlessness in patients with cancer and terminal respiratory failure e.g. secondary to COPD
- there is no evidence that opioids cause respiratory depression if used in appropriate, proportionate doses in keeping with recognised best practice e.g. oral morphine 2.5 - 5mg when required or 4 hourly
- doses of oral morphine above 10 - 20mg 4 hourly are unlikely to produce further benefit
- morphine modified release seems to be less effective for breathlessness for some patients than immediate release morphine preparations given 4 hourly
Benzodiazepines
- whilst there is no evidence for the use of benzodiazepines in relieving breathlessness, they may be helpful in patients who feel anxious or panicky when breathless
- diazepam 2 - 5mg 12 hourly and when required
- lorazepam 0.5 – 1mg 8 hourly when required, sublingual or oral for acute exacerbations
- lorazepam has a more rapid onset of action than diazepam and can be given sublingually, making it useful for acute panic
MHRA Drug Safety Update (March 2020): Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression.
Undesirable effects include drowsiness, falls, and memory and cognitive impairment. Use with appropriate monitoring and caution, particularly in elderly and frail patients.
Tolerance and dependence are unlikely to be problematic when used for 4 weeks or less.
Oxygen
It is difficult to predict which patients will benefit from the use of oxygen other than by therapeutic trial. Some patients may derive considerable benefit although no change in blood gases can be detected (may be a result of facial or nasal cooling or placebo). The same benefit may be derived by using a fan. Patients can become dependent on oxygen leading to increased social isolation.
- if available, assess for hypoxia (may occur post exertion) using a pulse oximeter
- offer a trial of oxygen if SaO2 90% or lower on air
- offer a trial of oxygen for a fixed period e.g. 15 – 30 minutes and assess response
Intermittent or continuous domiciliary oxygen can be prescribed. An oxygen concentrator is generally more cost-effective for patients requiring oxygen for more than 8 hours a day.
For further information see formulary page on Oxygen Therapy
Patients may be fearful, often unspoken, that they will die with acute, distressing breathlessness or suffocation. It can be helpful to discuss the management of breathlessness in the last few hours or days of life with patients, if appropriate.
A calm, positive and logical approach can do much to alleviate the distress of severe breathlessness in a dying patient. Occasionally breathlessness can be very difficult to control in the terminal phase, and sedation may then be necessary to alleviate distress.
See Care of the dying person section
