3BreathlessnessBreathlessness is an uncomfortable sensation or awareness of breathing.Subjective – measuring lung function does not correlate with sensation or severity of breathlessnessA complex experience of mind and body that is likely to progress with disease severitySignificant correlation with impaired quality of life and poor survival. Effects Patients and Carers.A common complex distressing symptom at the end of life
4Prevalence 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).
5Breathlessness 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.
6Breathlessness 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.
10Assessment of breathlessness Listen/ObserveWhat does it mean to the patient / carer?OnsetTriggers / What eases it?Levels of significance – during activity, indifferent positions, at restPattern of breathing, colour, respiratory rateAre they anxious?Oxygen saturations
11Manage reversible causes optimally according to patients wishes Consider active treatment of:InfectionPleural effusionPneumothoraxPEAirway obstruction SCVOAnaemiaCCF
12Non Pharmacological Management PositioningAirflow - use of fan /windowRelaxation / Distraction/ ReassuranceEnergy conservation / PacingControlled Breathing techniques /physioLoose clothingMouth Care
14Breathing Techniques Start with position of ease Relax shoulders / upper chestDiaphragmatic ‘tummy’ breathingBreath out twice as long as breath inPursed lips on breathing out if needed
15Relaxation Time and calm environment essential Relax and Breathe CD Visual imagery‘Calming hand’Touch across backDistraction
16. Pacing activities Encourage activity Allow time for tasks Starting and stopping with rest intervalsInspiration: expiration ratio during activityUse of aids – stair lift etcAdapting functional tasks, e.g. Ironing sitting down
17Pharmacological Management OpioidsOpioids are the most effective pharmacological agents for the relief of dyspnoeaOral morphine (normal release) 2.5mg (if Opioid naive/elderly and renal impairment)Gradual titration upwards according to responseHigh level evidence supports:Low dose slow release oral morphine for opioid naïve (10-20mg/24hours),.
18Pharmacological management BenzodiazepinesLorazepam 0.5-1mg sublingual (SL) - rapid relief during panic attacksDiazepam (oral) for longer term managementMidazolam 2.5mg subcutaneous 5 -10mg in Syringe driver over 24hrsAbove medication are sedative, therefore should be monitored carefully. However in the terminal stages of illness the benefits usually out-weigh the risks.
19Pharmacological Management Oxygen therapy only where appropriate (mixed evidence, check sats if hypoxic resting O2 below 90% 2l/min)SteroidsBronchodilators nebulised (Salbutomol 2.5 5mg prn)AntibioticsNebulised saline to thin secretions or Carbocisteine if secretions difficult to expectorate and exacerbating breathing difficultiesBlood transfusion
20End 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 collectNot easily relieved by drug therapy once establishedTreatment should therefore be started at first sign of rattle
21Non-pharmacological management of secretions Re-positioning of the patient by tilting side to side, or tipping bed ‘head up’ to reduce noiseManagement of halitosis with frequent mouth care and aromatherapyDiscrete management of oral secretions mouth care – oral hygieneSuction not advised, except when secretions are excessiveReassurance to family that the noise is due to secretions, and not causing suffocation, choking or distressReduce oral fluids if at risk of aspiration
22Pharmacological management of secretions Hyoscine Butylbromide (Buscopan)mg/24hr s/driver, prn dose SC 20mg hrlyIf not effective, discuss with palliative care team who may consider -Glycopyronium Bromide (Glycopyrolate)mcg/24hr s/driver or prn dose 200mcgNB: Hyoscine Hydrobromide was historically drug of choice, but not currently recommended due to side effects of sedation and confusion
23ReferencesDAVIS.C(1998) Breathlessness,cough and other respiratory problems.In: FALLON.N.O’NEILL.B(eds)ABC of Palliative Care BMJ Books. London pp 8-15MUERS.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