1. Breathlessness Barbara Mackie and Jo Lenton
Community Specialist Palliative Care Nurses

2. Breathlessness

3. Breathlessness
Breathlessness is an uncomfortable sensation or awareness of breathing.
Subjective – measuring lung function does not correlate with sensation or severity of breathlessness
A complex experience of mind and body that is likely to progress with disease severity
Significant correlation with impaired quality of life and poor survival. Effects Patients and Carers.
A common complex distressing symptom at the end of life

4. Prevalence of Breathlessness in cancer
The prevalence of breathlessness varies with the primary tumour site;
Breathlessness occurs as a symptom most frequently in lung cancer, where it might affect 75% of people with primary disease of the lung, bronchus and trachea (Muers & Round 1993).

5. Breathlessness in non-malignant disease
For patients with COPD, intractable breathlessness develops late in the course of the disease, gradually increasing in severity over a period of years in the majority of people.
There is a long pre-clinical phase when patients may not have any respiratory symptoms at all, although lung damage exists.

6. Breathlessness in non-malignant disease
There is then a protracted period of gradual decline punctuated by severe exacerbations, which may be life-threatening and require inpatient management.
Breathlessness tends to be associated with exertion.
However at end of life it may be present at rest.

7. What are the Causes of Breathlessness?

9. Psychological Aspect of Breathlessness

10. Assessment of breathlessness
Listen/Observe
What does it mean to the patient / carer?
Onset
Triggers / What eases it?
Levels of significance – during activity, in
different positions, at rest
Pattern of breathing, colour, respiratory rate
Are they anxious?
Oxygen saturations

11. Manage reversible causes optimally according to patients wishes
Consider active treatment of:
Infection
Pleural effusion
Pneumothorax PE
Airway obstruction SCVO
Anaemia
CCF

12. Non Pharmacological Management
Positioning
Airflow - use of fan /window
Relaxation / Distraction/ Reassurance
Energy conservation / Pacing
Controlled Breathing techniques /physio
Loose clothing
Mouth Care

13. Comfortable Positions if short of breath

14. Breathing Techniques Start with position of ease
Relax shoulders / upper chest
Diaphragmatic ‘tummy’ breathing
Breath out twice as long as breath in
Pursed lips on breathing out if needed

15. Relaxation Time and calm environment essential Relax and Breathe CD
Visual imagery
‘Calming hand’
Touch across back
Distraction

16. . Pacing activities Encourage activity Allow time for tasks
Starting and stopping with rest intervals
Inspiration: expiration ratio during activity
Use of aids – stair lift etc
Adapting functional tasks, e.g. Ironing sitting down

17. Pharmacological Management
Opioids
Opioids are the most effective pharmacological agents for the relief of dyspnoea
Oral morphine (normal release) 2.5mg (if Opioid naive/elderly and renal impairment)
Gradual titration upwards according to response
High level evidence supports:
Low dose slow release oral morphine for opioid naïve (10-20mg/24hours), .

18. Pharmacological management
Benzodiazepines
Lorazepam 0.5-1mg sublingual (SL) - rapid relief during panic attacks
Diazepam (oral) for longer term management
Midazolam 2.5mg subcutaneous 5 -10mg in Syringe driver over 24hrs
Above medication are sedative, therefore should be monitored carefully. However in the terminal stages of illness the benefits usually out-weigh the risks.

19. Pharmacological Management
Oxygen therapy only where appropriate (mixed evidence, check sats if hypoxic resting O2 below 90% 2l/min)
Steroids
Bronchodilators nebulised (Salbutomol 2.5 5mg prn)
Antibiotics
Nebulised saline to thin secretions or Carbocisteine if secretions difficult to expectorate and exacerbating breathing difficulties
Blood transfusion

20. End of life secretions Often referred to as ‘death rattle’
Caused when a patient’s coughing and swallowing reflex is impaired or absent, causing fluids to collect
Not easily relieved by drug therapy once established
Treatment should therefore be started at first sign of rattle

21. Non-pharmacological management of secretions
Re-positioning of the patient by tilting side to side, or tipping bed ‘head up’ to reduce noise
Management of halitosis with frequent mouth care and aromatherapy
Discrete management of oral secretions mouth care – oral hygiene
Suction not advised, except when secretions are excessive
Reassurance to family that the noise is due to secretions, and not causing suffocation, choking or distress
Reduce oral fluids if at risk of aspiration

22. Pharmacological management of secretions
Hyoscine Butylbromide (Buscopan)
mg/24hr s/driver, prn dose SC 20mg hrly
If not effective, discuss with palliative care team who may consider -
Glycopyronium Bromide (Glycopyrolate)
mcg/24hr s/driver or prn dose 200mcg
NB: Hyoscine Hydrobromide was historically drug of choice, but not currently recommended due to side effects of sedation and confusion

23. References
DAVIS.C(1998) Breathlessness,cough and other respiratory problems.In: FALLON.N.O’NEILL.B(eds)ABC of Palliative Care BMJ Books. London pp 8-15
MUERS.M. ROUND.C (1993)Palliation of symptoms in Non –Small Cell Cancer:A Study by the Yorkshire Regional Cancer Organisation Thoracic Group. Thorax.48 (7)
Sheffield Palliative Care Formulary 3rd Edition

24. Thank you for listening