5th January 2024

Respiratory

Breathing at the End of Life

When approaching the end of life, patients’ breathing may become laboured. Cheyne-Stokes breathing pattern may be seen; this is a pattern of crescendo-decrescendo respirations followed by a period of apnoea. Agonal breathing may also be observed as slow, shallow, irregular respirations.

Due to an inability to cough or swallow effectively, a build-up of secretions in the respiratory system can lead to noisy, rattling breathing. The secretions do not usually distress the patient but can be significantly distressing to their loved ones. They can be managed with simple education of the patient’s loved ones, positioning the patient differently or an anticholinergic such as glycopyrronium bromide, hyoscine butylbromide or hyoscine hydrobromide. One of these pharmacological options will usually be prescribed as an anticipatory medication at the end of life.

Dyspnoea

Breathlessness is a common issue in palliative medicine, affecting over half of patients at the end of life. It is not always associated with lung or pleural pathology. The management of breathlessness depends on the cause and the individual patient. Multiple causes may be identified. Management may be a mixture of pharmacological, non-pharmacological and interventional procedures.

Anticipatory prescribing for terminal breathlessness is usually in the form of PRN subcutaneous doses of morphine sulphate (2mg – 5mg) or midazolam for breathlessness associated with anxiety and distress (2mg – 5mg).

Causes of Dyspnoea

Source: Created by Dr Tasneem Wadee. Adapted from Back I, Watson M, Armstrong P, et al. Palliative Care Adult Network Guidelines. Dyspnoea/Breathlessness. [Internet]. 2021 [cited 2023 Jul 16]. Available from: https://book.pallcare.info/index.php

Non-Pharmacological Management of Dyspnoea

• Handheld fan
• Breathing exercises
• Positioning
• Pulmonary rehabilitation
• Complementary therapy
• Physiotherapy
• Anxiety reduction strategies

Cough

Cough may be due to effects of cancer in the lungs or airways, as well as end-stage COPD and heart failure. There are also causes that can potentially be reversed, such as asthma, infection and reflux.

Treatment of the causative issue, such as aspirations of pleural effusions, radiotherapy for tumour masses and antibiotics for infection, may all be appropriate interventions. Symptom control can be in the form of a cough suppressant, such as a simple linctus, codeine or morphine. Humidified air, nebulised saline and mucolytics can all help to encourage expectoration.