Dyspnoea

• Respiratory – Pleural effusion, lymphangitis, lung tumour, pneumonia, pulmonary embolus, COPD exacerbation
• Cardiovascular – Pericardial effusion, congestive cardiac failure, superior vena cava obstruction
• Abdominal – Liver failure causing fluid overload, ascites causing abdominal splinting
• Systemic causes – Anaemia

• Treat reversible causes, if possible
• Treat underlying disease, if possible
• Non-drug measures that optimize coping
• Drug options

Non-pharmacological measures

• Plan and pace activities – Break tasks into smaller bits, walking aids to decrease breathing effort
• Breathing techniques – Pursed lip breathing, anxiety management techniques
• Position – Find the most efficient position for the patient
• Environment – Open windows and fans to increase the sensation of airflow

Pharmacological measures

• Oxygen for hypoxic patients
  
  • For non-hypoxic patients, oxygen may be no better than a fan or draft across the face.
• Opioids
  
  • Usual starting dose of Morphine for opioid naïve patients is 2.5-5mg q4h, dose can be titrated according to response. Please see Using Morphine for more information.
• Steroids
  
  • May reduce peri-tumoural oedema
    (e.g. Dexamethasone dose is 8-16mg/day in lymphangitis and 16mg/day in superior vena cava obstruction)
• Anxiolytics
  
  • Useful as an add-on for patients who are anxious and are not responding to opioids alone (e.g. Lorazepam 0.5mg p.r.n./b.d.). If the patient has a longer prognosis and has panic attacks, consider SSRIs (e.g. Escitalopram 10mg daily)
• Anticholinergics
  • To reduce secretions (in frail patients who are unable to expectorate), but may make them thicker (e.g. Buscopan 20mg p.r.n./t.d.s. subcutaneously)
  • To loosen secretions for patients who are able to expectorate, try nebulised 0.9% saline 5ml p.r.n.

If symptoms are not controlled with measures outlined here, please consult your local palliative care service.

• Ekström MP, Abernethy AP, Currow DC. The management of chronic breathlessness in patients with advanced and terminal illness. BMJ. 2015 Jan;349:g7617.
• Mularski RA, Reinke LF, Carrieri-Kohlman V, Fischer MD, Campbell ML, Rocker G, et al. An official American Thoracic Society workshop report: assessment and palliative management of dyspnea crisis. Ann Am Thorac Soc. 2013 Oct;10(5):S98-S106.
• Abernethy AP, Wheeler JL, Currow DC. Common approaches to dyspnoea management in advanced life-limiting illness. Curr opin Support Palliat Care. 2010 Jun;4(2):53-55.