breathlessness in palliative care

Last edited 03/2020

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 chronic obstructive pulmonary disease (COPD)

Up to 40% of heart failure patients are breathless in the 6 months before death, rising to 65% in the three days leading up to death.

Breathlessness is almost universal in patients with more than mild COPD. With very advanced disease specific pharmacological treatment aimed at particular lung pathology (e.g. bronchodilators for bronchospasm) may have limited success and more general symptom control measures are often necessary

The use of low dose opioids, titrated carefully, can help to relieve the sensation of breathlessness in patients with lung pathology, heart failure and cancer.

Oxygen therapy should not be used routinely - it may give symptom benefit if the patient is known to be hypoxic. The use of a fan or other draught of air may be just as effective as oxygen.

Non drug intervention may be of benefit in helping patients manage their symptoms; however in advanced illness patients may often require opioid and/ or benzodiazepine medication. These can be given by different routes of administration e.g. orally, sublingually (lorazepam), by continuous subcutaneous infusion via syringe driver or bolus PRN dosing (subcutaneously or in exceptional circumstances intravenously).

ASSESSMENT OF THE BREATHLESS PATIENT

• determine the correct diagnosis
• consider any other contributing factors e.g. dysrhythmia, anaemia
• is there anything that can be corrected or treated? Seek advice if unsure
• consider the use of oximetry, if available, to guide if oxygen therapy is likely to be of benefit (i.e. if oxygen saturation less than 90%)
• consider psychological factors especially anxiety and the fear of choking/ suffocation
• decide on the optimal management
• only consider investigations which are likely to lead to a change in clinical management

MANAGEMENT OF BREATHLESSNESS

General (non-drug) measures

• explanation of cause/reassurance
• calm manner; fan or open window in acute attack
• posture - ideally upright and leaning forward if possible
• diaphragmatic breathing through pursed lips; visualization techniques to encourage longer expiratory phase
• nutritional advice (e.g. small frequent meals, easily chewed)
• relaxation training and/or complementary therapy
• energy conservation/pacing training/equipment
• treat depression and anxiety if present
• benefits advice
• encourage social interaction (e.g. peer group support, Breathe Easy Club, breathlessness management in a hospice day unit)

Palliative therapies

Oxygen

• do not routinely start oxygen to manage breathlessness. Only offer oxygen therapy to people known or clinically suspected to have symptomatic hypoxaemia (1)
• target oxygen saturation may be useful to document
• limited value if oxygen saturation is already >90% prior to starting oxygen therapy
• 1-2 litres per minute would be usual flow rate unless blood gases dictate otherwise
• in palliative care routine monitoring with blood gases is not usually required but use oxygen with caution in patients who are known to retain CO2
• risk factors for CO 2 retention:-
  • previous episode of CO 2 retention
  • known COPD/other lung pathology
  • long history of smoking

Non-opioid drugs

• bronchodilators - via inhaler / spacer or nebulizer Stop if no benefit
• steroids - especially if previous therapy has been beneficial e.g. for asthma / COPD. Typical doses are 30-40 mg prednisolone per day or 4 mg dexamethasone per day
• may be worth considering as a therapeutic trial in patients with lymphangitis (typically dexamethasone 16 mg per day

NICE suggest (1):

• consider managing breathlessness with:
  • an opioid or
  • a benzodiazepine
  • or a combination of an opioid and benzodiazepine

Benzodiazepines

• may be useful for those patients with marked anxiety associated with episodes of breathlessness
• less evidence for efficacy vs opioids in relieving breathlessness e.g. Lorazepam (scored blue tablet ) 0.5mg sublingual 4-6 hourly PRN or Diazepam 2-5 mg o.n. regularly for patients with ongoing debilitating anxiety

Opioid drugs

• can relieve the sensation of breathlessness. This is of most benefit for breathlessness at rest rather than on exertion
• more evidence of efficacy vs benzodiazepines in relieving breathlessness
• give as a therapeutic trial - monitor benefits and side effects. Titrate up slowly if required by 30% increments
• opioid-naïve patients:-
  • explain to the patient that morphine may be useful to relieve the sensation of breathlessness
  • prescribe immediate release oral morphine (e.g Oramorph ® ) 2.5-5mg every 4-6 hours and/or PRN 2 hourly
• patients on opioids for pain currently:-
  • explain to the patient that morphine may also be useful to relieve the sensation of breathlessness
  • some patients may find a lower opioid dose than their current breakthrough analgesic dose helpful for breathlessness, e.g. 25% of the current PRN breakthrough analgesic dose
• long acting opioids may be considered for some patients with continuous breathlessness (seek specialist palliative care advice)
• alternative opioids may be considered in some patients who cannot tolerate morphine (seek specialist palliative care advice)
• lower doses of morphine (e.g Oramorph ®) 1.25 -2.5mg every 4 -6 hours and/or PRN 2 hourly may be more appropriate in the following patients:-
  • elderly
  • frail
  • severe lung disease
  • heart failure
  • renal impairment

Reference:

• NICE (December 2015). Care of dying adults in the last days of life
• West Midlands Palliative Care Physicians (2012). Palliative care - guidelines for the use of drugs in symptom control.