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Palliative Care

Breathlessness in Palliative Care

Management of the subjective sensation of difficulty breathing in patients with life-limiting illness, often associated with anxiety.

Also known as: Dyspnea Management, Shortness of Breath

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Referral and warning signs

When to refer

Persistent symptoms despite initial measures. Suspected correctable cause requiring specific intervention (e.g., large pleural effusion needing drainage, airway obstruction). Need for specialist palliative care input.

Red flags

  • Sudden onset or worsening of severe breathlessness.
  • Hypoxia unresponsive to oxygen.
  • Signs of airway obstruction (stridor).
  • Associated chest pain.
  • Altered mental status.

Signs and symptoms

  • Patient report of shortness of breath or difficulty breathing.
  • Increased respiratory rate.
  • Use of accessory muscles.
  • Anxiety, fear, panic.
  • Inability to speak in full sentences.

Risk factors

  • Underlying lung disease (COPD, cancer, infection, effusion).
  • Heart failure.
  • Anaemia.
  • Cachexia / Muscle weakness.
  • Anxiety.

Diagnosis

Clinical assessment

Assess patient's subjective experience. Observe respiratory rate, effort, pattern. Assess for anxiety. Auscultate chest. Check oxygen saturation (pulse oximetry). Explore patient's fears and anxieties.

Investigations

  • Pulse oximetry.
  • Chest X-ray (if investigating underlying cause like effusion, infection, obstruction).

Diagnostic criteria

Clinical assessment of breathlessness and associated distress.

Management

Non-pharmacological management

  • Reassurance; explore fears and anxieties.
  • Breathing exercises (pursed lip breathing, diaphragmatic breathing).
  • Relaxation techniques.
  • Positioning for comfort (e.g., sitting upright, leaning forward).
  • Ensure good ventilation (open windows, fan).
  • Loosen tight clothing.
  • Energy conservation techniques.
  • Pulmonary rehabilitation (if appropriate).

Pharmacological treatment

  • Oral Morphine (low dose): 2.5-5 mg PO Q4H (effective even if not hypoxic).
  • Oxygen therapy: Only if patient is hypoxic (SpO2 <90%).
  • Diazepam (for anxiety/panic): 2.5-5 mg PO OD or PRN.

Monitoring

Monitor patient's subjective relief of breathlessness. Monitor respiratory rate and effort. Monitor anxiety levels. Monitor for opioid side effects (sedation, constipation).

Complications

  • Severe respiratory distress.
  • Panic attacks.
  • Exhaustion.
  • Poor quality of life.

Prevention

  • Optimize management of underlying conditions.
  • Teach coping strategies and breathing techniques early.
  • Manage anxiety.

Patient education

  • Explanation of potential causes.
  • Reassurance that breathlessness can be managed.
  • How to use breathing techniques and positioning.
  • Purpose and use of medications (especially morphine for breathlessness).
  • Energy conservation strategies.
  • When to seek help.

Uganda-specific notes

Low-dose oral morphine is a key intervention and should be accessible. Addressing fears around morphine use is important. Fans can be very helpful and are low-cost.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 13, Section 13.2.1

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