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Dyspnoe in Palliative care

Breathlessness can be quite distressing for the patients and carers.This chart on A4Medicine starts with looking at the causes and a focussed assessment. Interventions for reversible causes is mentioned to remind the reader of the scope of treatment available. Pharmacological interventions are mentioned side by side to help make a choice. Link is for the Palliative Care Adult Network Guideline which can be accessed via

Dyspnoe is common in palliative care
 Major cause of suffering and distress , for eg -in people with
○ End stage COPD
○ Severe heart disease
○ End stage renal disease
○ Cancer – particularly primary lung cancer
○ Respiratory diseases as lung fibrosis
 Can be described along three dimensions
○ Air hunger – need to breathe while being unable to increase ventilation
○ Effort of breathing – physical tiredness associated with breathing
○ Chest tightness – the feeling of constriction and inability to breathe in and out

” A subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity “
 Encompasses physical , psychological , social and spiritual domains
 Pathophysiology is poorly understood and little is known about the trajectory of breathlessness near death
 One of the most distressing symptoms in cancer patients

Sudden-Asthma Pulmonary oedema Pneumonia Pneumothorax Pericardial effusion Pulmonary embolism Over a few days -COPD exacerbation Pneumonia Bronchial obstruction by tumour Superior vena caval obstruction More gradual-Congestive cardiac failure Anaemia Pleural effusion Pulmonary fibrosis Ascites Pulmonary / secondary carcinoma lung Carcinomatous lymphangitis Anxiety / Psychological

history-Severity , timing , onset , precipitating and relieving factors Cough , sputum , haemoptysis , wheeze , stridor , pleuritic pain , fatigue Impact on daily living Explore symptoms of anxiety Medications eg any drug change Chemo , radiotherapy treatments ( recent ) Examination-
Focused examination based on suspicion
 General examination Resp and CVS exam Vital signs – signs of infection etc
saturation Assessment of anxiety
 CXR ECG Bloods

general measures-Dyspnoe is frightening to patient , family and staff Reassurance , explanation of factors contributing towards dyspnoe is important- whatever the cause Explain management options , discuss fears openly and acknowledge the impact of breathlessness Simple measures can help as 
○ cooling the face ( portable fan )
○ opening windows
○ adequate positioning
○ oral care ( if persistent mouth breathing ) Teaching and use of breathing exercises and relaxation methods
( physiotherapists or clinical nurse specialists can help ) Advice against smoking Lifestyle modifications ( reduce non-essential activities ) Pulmonary rehabilitation ( if available ) based on prognosis

Opioids started
 slowly – low dose and 
gradual titration
 does not cause
 resp depression
 in patient with cancer , 
COPD or heart failure opioids Evidence to support use Most helpful at relieving breathlessness at rest , particularly in last days of life Immediate release opioid is the usual first line
○ 2.5 to 5 mg / 4hrly orally
○ gradually titrate upwards
○ if helpful consider changing to a long acting morphine ( check local guidance )  If already on strong opioids consider advice from palliative care team If unable to tolerate oral morphine consider diamorphine bolus prn or s/c infusion Warn about common SEs as
○ drowsiness
○ constipation , nause and vomiting
○ Strong opioids –> dry mouth , sweating , pruritis , hallucinations , myoclonus , bronchoconstriction

Benzodiazepines-Can be used alone or in addition to opioids
( particularly in anxious patients ) Reduces the unpleasantness of dyspnoea and provides anxiolysis Diazepam , lorazepam and midazolam are commonly used Initial dose based on
○ age
○ general condition
○ previous BZD use
○ intensity of distress Lorazepam- is short acting ( 1/2 life 12-15 hrs ) useful in acute scenarios and sublingually can work within 10 mins Diazepam is medium to long acting and useful in chronic anxiety ( 1/2 life 20-100 hrs ) Midazolam for intractable breathlessness
○ usually as s/c infusion
○ compatible with most other drugs used in syringe drivers

Steroids-Trial of Dexamethasone 8-16 mg 
( oral or s/c ) for lymphangitis or tumour associated airway obstruction Thought to reduce tumour induced oedema Consider gastric protection Usually given in morning 
( unless starting emergency pack ) Stop if no effect after a week or reduce gradually to lowest effective dose



Irish Cancer Society on breathlessness

A useful page from the British Lung Foundation on breathlessness focussing on non-pharmacological techniques

A brief introduction from Cancer Research

A page from Cancer. Net

Royal Castle Lung cancer foundation

NHS Inform coping with breathlessness

Calming hand exercise

Canadian Cancer Society on difficulty breathing

BC cancer Agency printable info on breathlessness

Patient information morphine in breathlessness from Brighton and Sussex University Hospitals

Velindre Cancer Centre Wales on breathlessness- 8 page information leaflet

Patient resource com on dyspnea


Patient UK on dyspnoea in palliative care

Pall car Info – please bookmark this a very useful contribution helping in the management of palliative care patients

Lothian Palliative Care guidelines


Scottish Palliative Care guideline breathlessness

Oncology Nursing Society – Dyspnoea Improving symptoms management in cancer care through evidence based practice



  1. Treatment of Dyspnoe in Advanced Cancer Patients : ESMO Clinical Practice Guidelines Ann Oncol ( 2015 ) 26 ( suppl 5 ) : v169-v173
  2. Respiratory symptoms : Oxford Handbook of Palliative Care Max S Watson et al
  3. Dyspnoe in Palliative Care Patient UK
  4. Yorkshire Cancer Network and North East Yorkshire and Humber Clinical Alliance : A guide to symptom management in Palliative Care Version 5.1 February 2012
  5. Scottish Palliative Care Guidelines : Breathlessness Palliative care-
  6. Dyspnoea CKS NHS December 2016
  7. Management of Dyspnea in Cancer Patients Susan J McCall , MSN , RN The Abramson Cancer Center of the University of Pennysylvania September 2012
  8. Lanarkshire Palliative Care Guidelines
  9. Benzodiazepine for the relief of breathlessness in advanced malignant and non-malignant diseases in adults Steffeb T Simon et al Cochrane Pain , Palliative and Supportive Care Group Aug 2016
  10. Managing breathlessness : a palliative care approach Chloe Chin, Sara Booth Postgraduate Medical Journal April 2016
  11. Opoids for the palliation of breathlessness in terminal illness Cochrane Database Syst Rev. 2014; (4) : CD 002066
  12. Wessex palliative care handbook accessed via



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