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
 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