Breathlessness

1. Breathlessness Barbara Mackie and Jo Lenton Community Specialist Palliative Care Nurses

2. Breathlessness

3. Breathlessness • Breathlessness is an uncomfortable sensation or awareness of breathing. • Subjective – measuring lung function does not correlate with sensation or severity of breathlessness • A complex experience of mind and body that is likely to progress with disease severity • Significant correlation with impaired quality of life and poor survival. Effects Patients and Carers. • A common complex distressing symptom at the end of life

4. Prevalence of Breathlessness in cancer • The prevalence of breathlessness varies with the primary tumour site; • Breathlessness occurs as a symptom most frequently in lung cancer, where it might affect 75% of people with primary disease of the lung, bronchus and trachea (Muers & Round 1993).

5. Breathlessness in non-malignant disease • For patients with COPD, intractable breathlessness develops late in the course of the disease, gradually increasing in severity over a period of years in the majority of people. • There is a long pre-clinical phase when patients may not have any respiratory symptoms at all, although lung damage exists.

6. Breathlessness in non-malignant disease • There is then a protracted period of gradual decline punctuated by severe exacerbations, which may be life-threatening and require inpatient management. • Breathlessness tends to be associated with exertion. • However at end of life it may be present at rest.

7. What are the Causes of Breathlessness?

9. Psychological Aspect of Breathlessness

10. Assessment of breathlessness • Listen/Observe • What does it mean to the patient / carer? • Onset • Triggers / What eases it? • Levels of significance – during activity, in • different positions, at rest • Pattern of breathing, colour, respiratory rate • Are they anxious? • Oxygen saturations

11. Manage reversible causes optimally according to patients wishes • Consider active treatment of: • Infection • Pleural effusion • Pneumothorax • PE • Airway obstruction SCVO • Anaemia • CCF

12. Non Pharmacological Management • Positioning • Airflow - use of fan /window • Relaxation / Distraction/ Reassurance • Energy conservation / Pacing • Controlled Breathing techniques /physio • Loose clothing • Mouth Care

13. Comfortable Positions if short of breath

14. Breathing Techniques • Start with position of ease • Relax shoulders / upper chest • Diaphragmatic ‘tummy’ breathing • Breath out twice as long as breath in • Pursed lips on breathing out if needed

15. Relaxation • Time and calm environment essential • Relax and Breathe CD • Visual imagery • ‘Calming hand’ • Touch across back • Distraction

16. . Pacing activities • Encourage activity • Allow time for tasks • Starting and stopping with rest intervals • Inspiration: expiration ratio during activity • Use of aids – stair lift etc • Adapting functional tasks, e.g. Ironing sitting down

17. Pharmacological Management • Opioids • Opioids are the most effective pharmacological agents for the relief of dyspnoea • Oral morphine (normal release) 2.5mg (if Opioid naive/elderly and renal impairment) • Gradual titration upwards according to response • High level evidence supports: • Low dose slow release oral morphine for opioid naïve (10-20mg/24hours), • .

18. Pharmacological management • Benzodiazepines • Lorazepam 0.5-1mg sublingual (SL) - rapid relief during panic attacks • Diazepam (oral) for longer term management • Midazolam 2.5mg subcutaneous 5 -10mg in Syringe driver over 24hrs • Above medication are sedative, therefore should be monitored carefully. However in the terminal stages of illness the benefits usually out-weigh the risks.

19. Pharmacological Management • Oxygen therapy only where appropriate (mixed evidence, check sats if hypoxic resting O2 below 90% 2l/min) • Steroids • Bronchodilators nebulised (Salbutomol 2.5 5mg prn) • Antibiotics • Nebulised saline to thin secretions or Carbocisteine if secretions difficult to expectorate and exacerbating breathing difficulties • Blood transfusion

20. End of life secretions • Often referred to as ‘death rattle’ • Caused when a patient’s coughing and swallowing reflex is impaired or absent, causing fluids to collect • Not easily relieved by drug therapy once established • Treatment should therefore be started at first sign of rattle

21. Non-pharmacological management of secretions • Re-positioning of the patient by tilting side to side, or tipping bed ‘head up’ to reduce noise • Management of halitosis with frequent mouth care and aromatherapy • Discrete management of oral secretions mouth care – oral hygiene • Suction not advised, except when secretions are excessive • Reassurance to family that the noise is due to secretions, and not causing suffocation, choking or distress • Reduce oral fluids if at risk of aspiration

22. Pharmacological management of secretions • Hyoscine Butylbromide (Buscopan) • 60- 240mg/24hr s/driver, prn dose SC 20mg hrly • If not effective, discuss with palliative care team who may consider - • Glycopyronium Bromide (Glycopyrolate) • 400-2400mcg/24hr s/driver or prn dose 200mcg • NB: Hyoscine Hydrobromide was historically drug of choice, but not currently recommended due to side effects of sedation and confusion

23. References • DAVIS.C(1998) Breathlessness,cough and other respiratory problems.In: FALLON.N.O’NEILL.B(eds)ABC of Palliative Care BMJ Books. London pp 8-15 • MUERS.M. ROUND.C (1993)Palliation of symptoms in Non –Small Cell Cancer:A Study by the Yorkshire Regional Cancer Organisation Thoracic Group. Thorax.48 (7) 339-349 • Sheffield Palliative Care Formulary 3rd Edition

24. Thank you for listening