- Dyspnoea is a common and distressing symptom for patients.
- The guidelines below refer to dyspnoea that is refractory. Patients should be assessed for reversible causes of dyspnoea and these should be treated appropriately (e.g. LVF, COPD, asthma, pleural or pericardial effusion, mechanical airway obstruction, etc.).
- Consider therapy directed at the underlying condition, such as chemotherapy or radiation therapy.
- Explore the patient's fears and anxieties around their dyspnoea. Dyspnoea is an extremely anxiety-provoking symptom. Explanation and reassurance is essential.
- Morphine has been proven to reduce dyspnoea - the mechanism is not clear.
- Usually lower doses are required than those for pain, e.g. 2.5 - 10 mg of elixir 4 hourly or PRN. The dose can be gradually titrated as for pain, but comfort rather than resolution of dyspnoea is generally the desired end point.
- Low dose m-EslonTM or low dose morphine infusion may be more convenient if a trial of elixir has proved helpful. However, patients may choose to remain on regular elixir.
- Patients rarely need doses >40 mg per day of oral morphine for dyspnoea alone.
- Nebulised morphine has NO demonstrable advantage over morphine elixir.
- There is currently no strong evidence for opioids other than morphine for the relief of dyspnoea, although oxycodone is sometimes trialled as an alternative for patients who cannot take morphine.
- Most useful in patients who describe an anxiety component to their dyspnoea.
- Take an anxiety history - Is the anxiety situational and related to specific tasks, or more generalised throughout the day?
- Clonazepam oral drops 2.5 mg/ml (1 drop = 0.1 mg): 1-3 drops 4-6 hourly PRN.
- Long acting benzodiazepine - Can be useful as a nocte or bd dose for those patients with high background anxiety levels.
- Lorazepam 0.5 - 1 mg PO 4-6 hourly.
- Midazolam 10 – 20 mg/24 hours via subcut infusion.
- Midazolam can also be used as a nasal spray. See Intranasal Midazolam Protocol. Short acting with rapid onset of action. Useful for situational anxiety – e.g. prior to a shower.
- Patients with severe generalised anxiety may require an SSRI/TCA, or input from the psychiatry service.
- Sedation is sometimes needed towards the end of life. Morphine plus a benzodiazepine via subcut infusion is recommended.
- Recommended for bronchial obstruction, Superior Vena Cava Obstruction (SVCO), and radiation pneumonitis.
- A therapeutic trial can sometimes be worthwhile if cause unclear. Cease if ineffective after 3-4 days.
- Either prednisone 20-40 mg mane, or dexamethasone 8-12 mg mane – aim to reduce gradually to lowest effective dose.
Ipratropium (Univent™) or Salbutamol (Asthalin™) Nebulisers
- Ipratropium or salbutamol may be useful, especially if there is some degree of airflow obstruction – not more than 4 hourly.
The use of oxygen in a non-cyanotic hypoxaemic patient is controversial. However, there is extensive anecdotal evidence to warrant a trial if other measures have failed. Patients in the terminal phase of their illness who wish to die at home can be considered for home oxygen – referrals to the Palliative Care Physician via Respiratory Outreach.
See Palliative Home Oxygen.
- Saline nebulisers can help with tenacious sputum - See Cough section.
- Non-pharmacological treatments are an important part of managing breathlessness.
- Consider a review by a physiotherapist.
- Breathing control techniques, advice on positioning, and a walking frame have all been shown to be helpful in managing refractory dyspnoea.
- Physiotherapy and occupational therapy review can be helpful for advice on activity pacing and review of the home environment.
- A fan can be helpful in providing a flow of air. It should be directed at the face. Alternatively, opening a door or window can have a similar effect.
- Distraction techniques, counselling, relaxation, and music therapy all have a role in the management of dyspnoea and should be considered.
Breathlessness Management Plans
- Breathlessness management plans are often helpful for patients who require a combination of the above interventions.
- They provide a simple, stepwise approach that the patient and carers can follow in the event of a severe episode of breathlessness.
- In general, they should commence with non-pharmacological measures, followed by stepwise instructions regarding medication use at appropriate time intervals.
- They should include contact details for an appropriate person to call if the plan is ineffective.
- Please contact the palliative care team if you require assistance with writing breathlessness management plans.
Topic Code: 4109