• Evidence supports the use of either oral or parenteral opioids for relieving the symptom of dyspnoea. There is no evidence to support the use of nebulised opioids, however. [4]
• A recent meta-analysis has shown that oxygen does not improve symptoms of dyspnoea in cancer patients who are mildly or non-hypoxaemic, although there may be a sub-population who do experience benefit. [5]  A systematic review found no strong evidence for the benefit of oxygen in patients with dyspnoea and advanced disease from any cause, although the numbers studied were very small. [6] 
• If drainage of a malignant pleural effusion is required and is clinically appropriate, evidence supports the effectiveness of thoracoscopic talc pleurodesis. [7] 
• Research from small trials supports non-pharmacological interventions including breathing re-training, activity planning and adaptation strategies, counselling and relaxation. [1] A recent Cochrane review has not identified strong evidence to support these interventions, however, most studies were not done in a palliative care population and were small. [8] Nurse or physiotherapist-led interventions including breathlessness clinics may improve management of dyspnoea in palliative care patients with lung cancer [9]. For Chronic Obstructive Pulmonary Disease (COPD) patients who are able to participate in pulmonary rehabilitation, there is evidence of a clinically significant benefit in terms of dyspnoea, fatigue and wellbeing. [10]
• Benzodiazepines are frequently prescribed for management of distress associated with dyspnoea, but have not been well studied. They were not of benefit in four out of five randomized controlled trials when used in COPD, [11] but numbers were small.  

• Opioids are the first line pharmacological management for dyspnoea patients with advanced disease or cancer. [4] Morphine was the most commonly used opioid in these studies.
• Oxygen prescription should be individualised, based on a formal assessment of benefit in the individual patient [12].
• Allied health and nursing interventions provide an additional strategy to help patients manage their symptoms. 
• Refractory dyspnoea at the end-of-life, which causes severe distress and does not respond to medical management is a challenging problem. Sometimes sedation is required. Guidelines for sedation for refractory symptoms at the end of life have been proposed. [13]  

Guidelines

• Adult domiciliary oxygen therapy: Position statement of the Thoracic Society of Australia and New Zealand 

Link to prescribing information
NB Prescribing information may not yet have been updated to include the most recent evidence.

• Online Palliative Medicine Handbook 
  Click on “Notes on Prescribing”
  This prescribing information is from the UK and some medications may not be available in Australia
• Therapeutic Guidelines for Palliative Care
  An Australian source of prescribing information not available directly online through CareSearch, but can be accessed online in most hospitals, or purchased

Overview article

• The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy (Booth, Moosavi et al. 2008)

1. Ripamonti C, Fusco F. Respiratory problems in advanced cancer.  Supportive care in cancer. 2002 Apr;10(3):204-16 
2. Mercadante S, Casuccio A, Fulfaro F. The course of symptom frequency and intensity in advanced cancer patients followed at home. Journal of Pain and Symptom Management. 2000 Aug;20(2):104-12  
3. Maltoni M, Caraceni A, Brunelli C, Broeckaert B, Christakis N, Eyschmueller S, et al. Prognostic factors in advanced cancer patients: evidence-based clinical recommendations – a study by the Steering Committee of the European Association for Palliative Care.  Journal of Clinical Oncology. 2005 Sep 1;23(25):6240-8 
4. Jennings AL, Davies AN, Higgins JP, Broadley K.  Opioids for the palliation of breathlessness in terminal illness. Cochrane Database of Systematic Reviews. 2001;(4):CD002066  
5. Uronis HE, Currow DC, McCrory DC, Samsa GP, Abernethy AP. Oxygen for relief of dyspnoea in mildly – or non-hypoxaemic patients with cancer: a systematic review and meta-analysis. British Journal of Cancer. 2008 Jan 29;98(2):294-9 
6. Gallagher R, Roberts D. A systematic review of oxygen and airflow effect on relief of dyspnoea at rest in patients with advanced disease of any cause. Journal of Pain and Palliative Care Pharmacotherapy. 2004;18(4):3-15.  
7. Shaw P, Agarwal R.  Pleurodesis for malignant pleural effusions. Cochrane Database of Systematic Reviews. 2004;(1):CD002916  
8. Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of Systematic Reviews 2008, Issue 2. Art. No.: CD005623. DOI: 10.1002/14651858.CD005623.pub2.
9. Scottish Intercollegiate Guidelines Network (SIGN).  Management of patients with lung cancer. A national clinical guideline.  2005 Feb;SIGN publication no. 80. 
10. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database of Systematic Reviews 2006 Oct 18;(4):CD003793.  
11. Ripamonti C. Management of dyspnea in advanced cancer patients. Supportive Care in Cancer. 1999 Jul;7(4):233-43. 
12. Booth S, Wade R, Johnson M, Kite S, Swannick M, Anderson H; Expert Working Group of the Scientific Committee of the Association of Palliative Medicine. The use of oxygen in the palliation of breathlessness. A report of the expert working group of the Scientific Committee of the Association of Palliative Medicine. Respiratory Medicine. 2004 Jan;98(1):66-77.  
13. de Graeff AD, Dean M. Palliative sedation therapy in the last weeks of life: a literature review and recommendations for standards. Journal of Palliative Medicine.  2007 Feb;10(1):67-85 

This page was created in 29 April 2008 and is due for review in 2010