1. UNDERSTANDING BREATHLESSNESS IN 10’ish MINUTES!
Dr David Plume
Macmillan Palliative Care GP Facilitator, Central Norfolk

2. Dyspnoea Unpleasant awareness of difficulty in breathing
Pathological when ADLs affected and associated with disabling anxiety
Resulting in : physiological behavioural responses

3. Dysponea
Breathlessness experienced by 70% cancer patients in last few weeks of life
Severe breathlessness affects 25% cancer patients in last week of life

4. Causes of breathlessness-Cancer
Pleural effusion
Large airway obstruction
Replacement of lung by cancer
Lymphangitis carcinomatosa
Tumour cell microemboli
Pericardial Effusion
Phrenic nerve palsy
SVC obstruction
Massive ascites
Abdominal distension
Cachexia-anorexia syndrome respiratory muscle weakness.
Chest infection

5. Causes of Breathlessness-Treatment
Pneumonectomy
Radiation induced fibrosis
Chemotherapy induced
Pneumonitis
Fibrositis
Cardiomyopathy
Progestogens
Stimulates ventilation
Increased sensitivity to carbon dioxide.

6. Causes of Breathlessness- Debility
Anaemia
Atelectasis PE
Pneumonia
Empyema
Muscle weakness

7. Causes of Breathlessness-Concurrent
COPD
Asthma HF
Acidosis
Fever
Pneumothorax
Panic disorder, anxiety, depression

8. Reversible causes of breathlessness!
Resp. Infection
COPD/Asthma
Hypoxia
Obstructed Bronchus/SVC
Lymphangitis Carcinomatosa
Pleural Effusion
Ascites
Pericardial Effusion
Anaemia
Cardiac Failure PE

9. Breathlessness Cycle

10. Independent predictor of survival
weeks
days
months
Symptomatic drug treatment
Non-drug treatment
Correct the correctable
Breathless on exertion
Breathless at rest
Terminal breathlessness

12. Non-Drug Therapies Explore perception of patient and carers
Maximise the feeling of control over the breathing
Maximise functional ability
Reduce feelings of personal and social isolation.

13. Patient and Carer Perception
Meaning to patient and carer
Explore anxiety esp. fear of sudden death
Inform that not life threatening
State what is likely to/not to happen
Realistic goal setting
Help patient and carer adjust to loss of roles/abilities.

14. Maximize control Breathing control advice Relaxation techniques
Diaphragmatic breathing
Pursed lips breathing
Relaxation techniques
Plan of action for acute episodes
Written instructions step by step
Increased confidence coping
Electric fan
Complementary therapies

15. Maximize function
Encourage exertion to breathlessness to improve tolerance/desensitise to breathlessness
Evaluation by physios/OT’s/SW to target support to need.

16. Reduce feelings of isolation
Meet others in similar situation
Day centre
Respite admissions

17. Drug Treatment

18. What do I give?
Bronchodilators work well in COPD and Asthma even if nil known sensitivity.
O2 increases alveolar oxygen tension and decreases the work of breathing to maintain an arterial tension.
Usual rules regarding COPD/Hypercapnic Resp. failure apply.
Opioids reduce the vent.response to inc. CO2, dec O2 and exercise hence dec resp effort and breathlessness.
If morphine naïve-Start with stat dose of Oramorph 2.5-5mg or Diamorphine 2.5-5mg sc and titrate Repeated 4hrly as needed.
If on morphine already for pain a dose 100% or > of q4h dose may be needed, if less severe 25% q4h may be given
Benzodiazipines stat dose of Lorazepam 0.5mg SL, Diazepam 2-5mg or Midazolam 2.5-5mg sc
Repeated 4hrly as needed

19. Ongoing treatment
A syringe driver should be commenced if a 2nd stat dose is needed within 24hrs
Diamorphine 10-20mg CSCI / 24hrs
Midazolam 5-20mg CSCI / 24hrs
Remember to prescribe stats
Review & adjust dose daily if needed

20. Terminal Breathlessness
Great fear of patients and relatives
Treat appropriately- Opioid and sedative/anxiolytic- Diamorphine and midazolam-PRN and CSCI
If agitation or confusion -haloperidol or Nozinan
Some patients may brighten.
Sedation not the aim but likely due to drugs and disease.

21. Respiratory Secretions (death rattle)
Rattling noise due to secretions in hypopharynx moving with breathing
Usually occurs within days-hours of death
Occurs in ~40% cancer patients (highest risk if existing lung pathology or brain metastases)
Patient rarely distressed
Family commonly are distressed
Treat early
Position patient semi-prone
Suction rarely helpful

22. Respiratory Secretions
Absent
Prescribe stat doses Hyoscine Hydrobromide 0.4mg 4hrly prn
If 2 or more doses required in 24hrs, consider adding to CSCI
Present
Stat Hyoscine Hydrobromide 0.4mg sc
Repeat 4hrly prn
Start Hyoscine Hydrobromide 1.2mg CSCI / 24hrs
Prescribe stats
Review & adjust dose daily

23. Alternative anti-secretory agents
These unlike Hyoscine Hydrobromide don’t cross the BBB and hence are less likely to cause sedation and confusion.
Hyoscine Butylbromide
stat dose 20mg 1hrly
CSCI mg/ 24hrs
Glycopyrronium
stat dose 0.4mg 6hrly
CSCI mg/ 24hrs

25. All clear?
Any Questions?