8th January 2024

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