8th January 2024

Respiratory

Dyspnoea

Dyspnoea, or breathlessness, is the subjective experience of breathing discomfort. This encompasses effort of breathing, chest tightness and air hunger. Dyspnoea is complex and occurs due to the interplay of physical, psychological and social factors. It affects patients with both malignant and non-malignant disease and is a common reason for hospital attendance, with figures suggesting up to 25% of accident and emergency (A&E) visits in the UK are due to dyspnoea.

Causes of Dyspnoea

Dyspnoea is often multi-factorial, and thorough assessment should exclude reversible causes, such as infection, anaemia or pulmonary embolus. Consider the speed of onset of breathlessness and its behaviour (Present at rest? Present on minimal exertion? Present on certain activities, or less predictable?)

• Respiratory – COPD, pneumonia, pleural effusion, pulmonary embolus
• Cardiac – Heart failure, arrhythmias
• Musculoskeletal – Respiratory muscle weakness, e.g., motor neuron disease, chest wall deformities
• Systemic – Anaemia, ascites, obesity
• Malignancy-Related – Lung malignancy, airway obstruction by tumour, mesothelioma, side-effects of treatment, including radiation-induced fibrosis or chemotherapy-induced pneumonitis, superior vena cava obstruction (SVCO)
• Psychological – Anxiety, panic disorder

Management of Dyspnoea

Dyspnoea is a distressing and frightening symptom for patients and their families. Explanation of the factors contributing to dyspnoea and what can be done to treat it or ease the symptoms can help with anxiety, and patients should be encouraged to discuss their fears.

Non-Pharmacological:

• Energy Conservation Techniques
  • Sitting upright and leaning forward improves ventilatory capacity
  • Exercise and pulmonary rehabilitation can prevent deconditioning
  • Physiotherapy can help with breathing exercises and techniques to reduce breathlessness
  • Occupational therapy input for home adaptations
• Cognitive Behavioural Strategies
  • Manages anxiety and negative thoughts due to breathlessness
• Breathing Strategies
  • Controlled breathing techniques, e.g., pursed lip breathing
  • Breathing retraining – Improves respiratory muscle strength and sense of control
  • Handheld fan blows air across the face and nose and reduces the sensation of breathlessness

Pharmacological:

• Opioids
  • Reduce breathlessness at rest and end-of-life stage by slowing the ventilatory response to hypoxia and hypercapnia
  • Morphine can be given as regular, low-dose modified release for constant dyspnoea, 10-20mg per day, or as immediate release 2.5-5mg as needed. Subcutaneous morphine should be used if the patient cannot swallow
  • Monitor for side effects, especially nausea and constipation
• Steroids
  • Useful for lymphangitis or airway obstruction due to tumour
  • Dexamethasone 8-16mg given orally in the morning
• Benzodiazepines
  • Relieves anxiety associated with breathlessness
  • Not as effective as opioids for breathlessness
  • Lorazepam is short-acting, and 500mcg 4-6 hourly sublingual PRN can be useful acutely, or longer-acting diazepam 2 or 5mg or clonazepam 0.5-1mg if continuous anxiety
• Oxygen
  • Patients with dyspnoea who are hypoxaemic (SP02 ≤ 92%) may benefit from supplemental oxygen
  • There is a poor relationship between breathlessness, hypoxaemia and response to oxygen therapy

Secretions

Secretions can accumulate in a palliative patient’s oropharynx and cause a rattling or gurgling noise (‘death rattle’). This can occur if clearance of secretions is inadequate, such as impaired cough or swallow when approaching the end of life, or due to sedating medications. There may be increased viscosity of secretions due to dehydration or illness, or being nursed in a supine position means secretions accumulate in the hypopharynx.

Secretions may also be excessive if there is a chest infection or fluid overload resulting in pulmonary oedema, both of which can be difficult to diagnose in the final stage of life.

Management

The noises may be distressing for patients or their families but aren’t usually uncomfortable. Explanation may be adequate to reassure the person and their family.

Non-Pharmacological:

• Positioning
• Gentle oral suctioning

Pharmacological:

• Glycopyronnium bromide
• Hyoscine hydrobromide
• Hyoscine butylbromide – Crosses blood-brain barrier
• Side effects can include sedation, confusion, agitation, dry mouth and confusion, which should be closely monitored
• In a patient approaching end of life, antibiotics may be considered if a patient has large amounts of purulent sputum that is causing distress

References

• • Boland JW, Boland EG Noisy upper respiratory tract secretions: pharmacological management BMJ Supportive & Palliative Care 2020;10:304-305
  • Chin C, Booth S. Managing breathlessness: a palliative care approach. Postgraduate Medical Journal. 2016;92(1089):393-400.
  • Parshall M, Schwartzstein R, Adams L, Banzett R, Manning H, Bourbeau J et al. An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea. American Journal of Respiratory and Critical Care Medicine. 2012;185(4):435-452.
  • Watson M, Campbell R, Vallath N, Ward S, Wells J. Oxford Handbook of Palliative Care. 3rd ed. Oxford University Press; 2019.
  • Palliative Care Guidelines Plus [Internet]. Book.pallcare.info. 2021 [cited 3 April 2022]. Available from: https://book.pallcare.info/index.php
  • Palliative care – dyspnoea | Health topics A to Z | CKS | NICE [Internet]. Cks.nice.org.uk. 2022 [cited 3 April 2022]. Available from: https://cks.nice.org.uk/topics/palliative-care-dyspnoea/
  • Palliative care – secretions | Health topics A to Z | CKS | NICE [Internet]. Cks.nice.org.uk. 2022 [cited 18 Aug 2022]. Available from: https://cks.nice.org.uk/topics/palliative-care-secretions/