Breathlessness: Information for clinicians

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.

Chronic breathlessness syndrome is breathlessness that persists despite optimal treatment of the underlying pathophysiology.

Consider reversibility if appropriate – antibiotics for infection, steroids for lymphangitis and SVC obstruction, furosemide for heart failure, drainage for pleural effusions.

Non–pharmacological interventions

Interventions of benefit in helping breathlessness
  • Keep room cool and open windows
  • A hand-held fan blowing towards the face
  • Pursed-lip breathing - inhale through nose with mouth closed, then exhale slowly through pursed lips for 4 to 6 seconds.
  • 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
  • Anxiety management
  • Social interaction eg Breatheasy groups

Medicines that help Breathlessness

Opioids
  • Relieve the sensation of breathlessness - there is much evidence of efficacy and safety in 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 P.R.N., then regularly 4-6 hourly if beneficial
  • Even lower doses may help if elderly or frail eg 1mg to 2mg oral Morphine
  • Long-acting opioids can be very effective and are safe eg Morphine Modified Release Tablets 5mg bd
Benzodiazepines
  • 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 or Teva brand) 0.5mg sublingual 4–6 hourly P.R.N. 
Mirtazapine

Some evidence that this can help the sensation of breathlessness, possibly by reducing panic. Start with 15mg at night.

For breathless patients already on opioids for pain

Lower opioid dose needed than breakthrough analgesic dose is often sufficient for breathlessness, e.g. 25-50% of the current PRN analgesic dose.

Oxygen

Limited value if oxygen saturation is already >92%. Some patients however find the work of breathing is eased by Oxygen even if if SATs are good.

Breathlessness in the last days
  • Continue non-pharmacological treatments
  • Morphine 2.5 mg to 5 mg and Midazolam 2.5 mg -5mg subcutaneously P.R.N. for repiratory distress - this is important as no-one wants to experience or watch someone gasping for breath
  • If several injections are needed, then a syringe pump may be beneficial
  • 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)

Key Points

  • 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

Recommended Resources

West Midlands Palliative Care - Breathlessness in the last days

Published 1st July 2024

Scottish Palliative Care Guidelines - Breathlessness

Published 1st April 2020

Palliat Med: Use of mirtazapine in patients with chronic breathlessness: A case series

Published 1st October 2018

Share

Related Services

Breatheasy groups
Close

The support group is a way to learn more about living with a lung condition and share your experiences and stories with others.

Care Chemists
Close

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 5 Buckingham Parade The Broadway Stanmore HA7 4EB

Opening hours: Monday to Friday 9.00am to 6.00pm. Saturday 9.00am to 5.30pm

Carters Chemist
Close

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 24 Bridge Street, Pinner, Middlesex, HA5 3JF

Opening hours: Monday to Friday 9.00am to 6.00pm. Saturday 9.00am to 5.00pm

Harrow Community Palliative Care
Close

Harrow Community Palliative Care

T. 020 8102 6163

Harrow Community Specialist Palliative Care Team (LNWHT) provides advice and visiting to palliative care patients in Harrow.

They can be contacted Monday to Friday 8.30am to 4.30pm.

They are based at Honeypot Lane Health Centre, 839 Honeypot Lane, HA7 1AT.

Out of Hours the Pall24 Helpline can be used 3000 200 224

Referral form for clinician use only.

Community Specialist Palliative Care Referral Form V4.1 (DOCX)
Kings Pharmacy
Close

Kings Pharmacy

T. 020 8952 1260

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 903 Honeypot Lane, Stanmore, Middlesex HA7 1AR

Opening hours: Monday to Friday 9.00am to 6.30pm

Lloyds Pharmacy
Close

Lloyds Pharmacy

T. 0208 9072720

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 5 Warwick Parade, Belmont Circle, Harrow HA3 8SA

Opening hours: Monday to Friday 9.00am to 8.00pm. Saturday 9.00am to 4.00pm

Macmillan Cancer Support
Close

Macmillan provide cancer information, support and help everyone with cancer live life as fully as they can.

Visit the website to get help with paying bills, advice on benefits or treatment, or to just chat.

Marie Curie
Close

Marie Curie provide support for patients and carers through terminal illness.

Find information and support through the telephone helpline and online chat via their website.

Other services include Marie Curie nurses, Hospice care, helper and companion services.

Murrays Chemist
Close

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 172 Kenton Road, Kenton, Harrow, Middlesex HA3 8BL

Opening hours: Monday to Friday 9.00am to 7.00pm. Saturday 9.00am to 2.00pm

Shaftesbury Pharmacy
Close

Shaftesbury Pharmacy

T. 0208 864 9436

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 6 Shaftesbury Parade, Shaftesbury Avenue, South Harrow, HA2 0AJ

Opening hours: Monday to Friday 9.00am to 7.00pm. Saturday 10.00am to 1.00pm

Tanna Chemist
Close

Tanna Chemist

T. 0208 4284195

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 320 Uxbridge Road, Hatch End, Pinner, Middlesex, HA5 4HR

Opening hours: Monday to Friday 9.00am to 6.00pm. Saturday 9.00am to 5.00pm

The Harrow Pharmacy
Close

A community pharmacy which stocks common palliative medicines to support people being cared for at home

Address: 73 Station Road, Harrow, HA1 2TY

Opening hours: Monday to Friday 7.45am to 10.45pm. Saturday 8.00am to 9.00pm. Sunday 9.00am to 9.00pm

Related Articles

19th June 2024

Caring for a breathless patient at home

Feedback