Breathing

Key points

• Dyspnoea (difficulty with breathing) is a subjective symptom which is common in palliative care patients. It is often not directly related to lung or pleural pathology and is frequently multifactorial.
• It occurs more frequently as disease progresses, when it may be associated with progressive weakess and/or changes in biomechanics of the chest wall.
• Dyspnoea also has psychological dimensions, and can be extremely frightening for patient and caregivers.
• Oxygen may not relieve the symptom. If oxygen is offered, it should be based on a therapeutic trial, and assessed in terms of symptomatic benefit versus burden, rather than oximetry.

Assessment

• Investigate and optimise any conditions such as chronic obstructive pulmonary disease (COPD), anaemia, congestive heart failure (CCF) and infection as clinically appropriate.
• Hypoxia, lung function studies and imaging may not correlate with the severity of the symptom. Physical signs such as tachypnoea may also be absent.
• Identify patients at risk of obstructing a large airway, and assess for stridor. Airway obstruction, superior vena cava (SVC) obstruction, and pericardial effusion are palliative care emergencies, although the extent to which intervention is possible or appropriate will vary according to the clinical situation. Seek urgent advice from either palliative care team or oncologist.
• Lymphangitis can present with rapidly progressing and severe dyspnoea which is difficult to control.

Approach to management

• Consider both malignant and non-malignant causes. Treat potentially reversible factors as appropriate in the context.
• Consider both pharmacological and non-pharmacological strategies. Low dose opioids have been shown to relieve the symptom and are first-line pharmacological management unless contraindicated.
• Identify if anxiety is associated with dyspnoea. Treatment options include breathing techniques, relaxation / meditation, use of a fan. If refractory or severe, treat with anxiolytics.
• Refer to physiotherapists for education about breathing techniques and relaxation, and to occupational therapists to advise on activity modification, and for aids and equipment.
• When dyspnoea is refractory or severe, refer for palliative care advice.