Key Facts

Breathlessness in palliative care is often irreversible and multifactorial. The focus is on reducing the distressing sensation rather than treating the underlying cause.

Epidemiology

• Affects 50-70% of advanced cancer patients; >90% with advanced COPD/HF
• Most common symptom in last weeks of life (apart from fatigue)
• Strongly associated with anxiety, panic, and reduced quality of life

Aetiology

• Cancer-related: lung cancer, pleural effusion, lymphangitis carcinomatosa, SVC obstruction, pericardial effusion, ascites (diaphragm splinting), tumour in airway
• Treatment-related: pneumonitis (RT, immunotherapy), pulmonary fibrosis (bleomycin), cardiomyopathy (doxorubicin)
• Comorbid: COPD, heart failure, anaemia, pulmonary embolism, infection
• General: anxiety, deconditioning, cachexia

Pathophysiology

• Breathlessness perception involves afferent signals from chemoreceptors (CO2, O2), mechanoreceptors (lung stretch, chest wall), and cortical processing (anxiety amplifies perception)
• Opioids reduce central perception of breathlessness via μ-receptors in brainstem and cortex
• Fan/cool air stimulates V2 branch of trigeminal nerve → reduces breathlessness perception ("open window" effect)

Assessment

• Subjective severity (0-10 NRS or modified Borg scale)
• Temporal pattern (constant, exertional, paroxysmal, nocturnal)
• Associated symptoms (cough, wheeze, chest pain, anxiety, panic)
• Functional impact (what can/cannot do because of breathlessness)
• Psychological impact (fear, anxiety, depression)
• Current interventions and their effectiveness

Red Flags

• Acute deterioration: PE, pneumothorax, cardiac tamponade, SVC obstruction
• Stridor (airway obstruction — emergency)
• Massive haemoptysis
• Severe anxiety/panic attacks
• Terminal breathlessness in last days of life

Bedside

• SpO2, respiratory rate, heart rate
• Breathlessness assessment (NRS, mMRC scale)
• Chest examination
• Anxiety screening

Bloods

• FBC (anaemia)
• BNP (heart failure)
• D-dimer (if PE suspected and would change management)

Imaging

• CXR: pleural effusion, pneumonia, lung mass, collapse
• CTPA: PE (if would change management)
• CT thorax: tumour assessment

Special Tests

• ABG: type 1 or 2 respiratory failure (if would change management)
• Echocardiography: pericardial effusion, cardiac function
• Lung function tests: COPD assessment (if new diagnosis)

Non-pharmacological (FIRST-LINE)

• Handheld fan directed at face (trigeminal nerve stimulation; as effective as oxygen for non-hypoxic breathlessness)
• Breathing techniques: pursed-lip breathing, diaphragmatic breathing
• Positioning: upright, leaning forward (tripod position)
• Pacing and energy conservation: plan activities, rest between tasks
• Anxiety management: relaxation techniques, CBT, mindfulness
• Pulmonary rehabilitation: where appropriate (COPD, deconditioning)
• Cool, well-ventilated room: open window

Pharmacological

• Low-dose opioids:
  • Opioid-naive: morphine 1-2.5mg PO 4-hourly PRN or 5-10mg MR OD
  • Already on opioids: increase by 25% if breathlessness is a significant symptom
  • SC morphine 1-2.5mg PRN if unable to swallow
• Benzodiazepines:
  • Lorazepam 0.5-1mg SL PRN (anxiety-related breathlessness)
  • Midazolam 2.5-5mg SC PRN (terminal breathlessness)
• Corticosteroids:
  • Dexamethasone 4-8mg daily: lymphangitis carcinomatosa, SVC obstruction, tumour-related airway narrowing
• Oxygen: only if hypoxic (SpO2 <92%); short-burst oxygen for exertional desaturation
• Nebulised saline (0.9%): may help with sputum clearance
• Bronchodilators: if reversible airway obstruction (salbutamol, ipratropium)

Surgical/Interventional

• Pleural aspiration/drainage: for symptomatic pleural effusion
• Indwelling pleural catheter (IPC): for recurrent effusions
• Pleurodesis: talc (for recurrent malignant pleural effusion)
• SVC stent: for SVC obstruction
• Airway stenting: for endobronchial obstruction
• Pericardiocentesis: for cardiac tamponade

Referral Criteria

• Refractory breathlessness: specialist palliative care
• Pleural effusion: respiratory/interventional service
• SVC obstruction: oncology emergency
• Complex anxiety: psychology/psychiatry

• Non-pharmacological interventions (fan, breathing techniques): effective in 30-50% of patients
• Low-dose opioids: reduce breathlessness perception safely; do NOT cause respiratory depression at appropriate palliative doses
• Oxygen: no benefit over fan in non-hypoxic breathlessness
• Breathlessness in last days of life: usually manageable with SC morphine + midazolam
• Breathlessness is a strong predictor of mortality in advanced cancer and COPD

Breathlessness Management Algorithm

Key Evidence