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
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