Definition of chronic breathlessness syndrome is breathlessness that persists despite optimal treatment of the underlying pathophysiology and that results in disability.
Breathlessness is a very common distressing symptom in malignant and non-malignant disease. Up to 70% patients with cancer experience breathlessness in the 6 weeks prior to death, and this may be greater in lung cancer patients because of co-existent COPD. It is a frightening symptom for the patient and for those caring for them. There are specific resources for carers here.
Consider reversibility if appropriate – antibiotics for infection, steroids for lymphangitis and SVC obstruction, furosemide for heart failure, drainage for pleural effusions.
Non –drug interventions
Interventions of benefit in helping breathlessness
- Keep room cool and open windows
- Pursed-lip breathing -patients inhale through their nose for several seconds with their mouth closed, then exhale slowly through pursed lips for 4 to 6 seconds.
- Drop the shoulders to reduce the 'hunched' posture that comes with anxiety.
- Sitting upright and lean forward with arms bracing a chair or knees
- Visualisation and complementary therapy
- Nutritional advice (e.g. small frequent meals, easily chewed)
- A hand-held fan
- Anxiety management
- Social interaction eg Breatheasy groups
Medicines that help Breathlessness
- Relieve the sensation of breathlessness and there is much evidence of efficacy and safetyin doses of less than 20mg per day
- Start low and go slow e.g. prescribe immediate release oral Morphine (e.g. Oramorph®) 2.5mg–5mg po P.R.N., then regularly 4-6 hourly if beneficial
- Long-acting opioids can be very effective and are safe eg Morphine Modified Release Tablets 5mg bd
- Useful for those patients with anxiety/panic associated with episodes of breathlessness
- Less evidence for efficacy than opioids in relieving breathlessness
- e.g. Lorazepam (1mg blue tablet – Genus brand) 0.5mg sublingual 4–6 hourly P.R.N. or Diazepam 2mg-4mg mg o.n. regularly
Some evidence that this can specifically help the sensation of breathlessness, possibly by reducing panic. Start with 15mg
For breathless patients already on opioids for pain
Lower opioid dose needed than their current breakthrough analgesic dose is often sufficient for breathlessness, e.g. 25-50% of the current PRN analgesic dose
Limited value if oxygen saturation is already >90% even if breathless. Though some patients find the work of breathing is eased by oxygen - so keep an open mind if if SATs are good.
Breathlessness in the last days
- Morphine 10 mg over 24 hours via a syringe pump, increasing stepwise to Morphine 30 mg over 24 hours as needed (start with 5mg if very frail)
- Midazolam 10 mg over 24 hours via the syringe driver, increasing stepwise to Midazolam 60 mg over 24 hours as required (start with 5mg if very frail)
- Morphine 2.5 mg to 5 mg and Midazolam 2.5 mg -5mg subcutaneously as needed for repiratory distress - this is important as no-one wants to experience or watch someone gasping for breath
- Do contact the local specialist palliative care team for more specific advice
- Lower starting doses in frail elderly and those in renal failure
- Remember non-drug methods to relieve breathlessness
- Identify and treat reversible causes of breathlessness in the dying person, for example pulmonary oedema or pleural effusion, if appropriate
- Consider an opioid and benzodiazepine combination for patients at the end of life
- Sedation and opioid use should not be withheld because of a fear of causing respiratory depression. The intention is to relieve respiratory distress, not to hasten death