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 http://book.pallcare.info/

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 ○ AIDS  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

LINKS AND RESOURCES

FOR PATIENTS

Irish Cancer Society on breathlessness https://www.cancer.ie/cancer-information-and-support/cancer-information/cancer-treatments-and-side-effects/coping-with-side-effects/breathlessness

A useful page from the British Lung Foundation on breathlessness focussing on non-pharmacological techniques https://www.blf.org.uk/support-for-you/breathlessness/how-to-manage-breathlessness

A brief introduction from Cancer Research https://www.cancerresearchuk.org/about-cancer/coping/physically/breathing-problems/shortness-of-breath

A page from Cancer. Net https://www.cancer.net/coping-with-cancer/physical-emotional-and-social-effects-cancer/managing-physical-side-effects/shortness-breath-or-dyspnea

Royal Castle Lung cancer foundation https://www.roycastle.org/

NHS Inform coping with breathlessness https://www.nhsinform.scot/care-support-and-rights/palliative-care/symptom-control/coping-with-breathlessness

Calming hand exercise https://ellenor.org/Media/Default/PDFs/The-calming-hand.pdf

Canadian Cancer Society on difficulty breathing https://www.cancer.ca/en/cancer-information/diagnosis-and-treatment/managing-side-effects/difficulty-breathing/?region=on

BC cancer Agency printable info on breathlessness http://www.bccancer.bc.ca/managing-symptoms-site/Documents/BCCA%20-%20Managing%20Symptom%20and%20Side%20Effects/Breathlessness_Patient_Handout.pdf

Patient information morphine in breathlessness from Brighton and Sussex University Hospitals https://www.bsuh.nhs.uk/wp-content/uploads/sites/5/2016/09/Morphine-for-use-in-breathlessness.pdf

Velindre Cancer Centre Wales on breathlessness- 8 page information leaflet http://www.velindrecc.wales.nhs.uk/sitesplus/documents/1087/Breathlessness.pdf

Patient resource com on dyspnea https://www.patientresource.com/Dyspnea.aspx

INFORMATION FOR CLINICIANS

Patient UK on dyspnoea in palliative care https://patient.info/doctor/dyspnoea-in-palliative-care

Pall car Info – please bookmark this a very useful contribution helping in the management of palliative care patients https://book.pallcare.info/

Lothian Palliative Care guidelines – https://www.palliativedrugs.com/download/LGGbreath.pdf

TREATMENT OF DYSPNOEA IN ADVANCED CANCER PATIENTS: ESMO CLINICAL PRACTICE GUIDELINES https://www.esmo.org/guidelines/supportive-and-palliative-care/dyspnoea-in-advanced-cancer-patients

Scottish Palliative Care guideline breathlessness https://www.palliativecareguidelines.scot.nhs.uk/guidelines/symptom-control/breathlessness.aspx

Oncology Nursing Society – Dyspnoea Improving symptoms management in cancer care through evidence based practice https://www.cancernurse.eu/documents/EONSPEPDyspneaEnglish.pdf

References 

Treatment of Dyspnoe in Advanced Cancer Patients : ESMO Clinical Practice Guidelines Ann Oncol ( 2015 ) 26 ( suppl 5 ) : v169-v173
Respiratory symptoms : Oxford Handbook of Palliative Care Max S Watson et al
Dyspnoe in Palliative Care Patient UK
Yorkshire Cancer Network and North East Yorkshire and Humber Clinical Alliance : A guide to symptom management in Palliative Care Version 5.1 February 2012
Scottish Palliative Care Guidelines : Breathlessness Palliative care-
Dyspnoea CKS NHS December 2016
Management of Dyspnea in Cancer Patients Susan J McCall , MSN , RN The Abramson Cancer Center of the University of Pennysylvania September 2012
Lanarkshire Palliative Care Guidelines
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
Managing breathlessness : a palliative care approach Chloe Chin, Sara Booth Postgraduate Medical Journal April 2016
Opoids for the palliation of breathlessness in terminal illness Cochrane Database Syst Rev. 2014; (4) : CD 002066
Wessex palliative care handbook accessed via https://www.ruh.nhs.uk/For_Clinicians/departments_ruh/Palliative_Care/documents/palliative_care_handbook.pdf

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