Key messages
- Opioids, either oral or parenteral, are effective in relieving the symptom of breathlessness from both cancer and non-malignant causes. [1-4] They have not yet been licensed for this indication on the Pharmaceutical Benefit Schedule, but are widely used in palliative care practice.
- Nebulised opioids have not been shown to have any significant benefit for breathlessness. [3-4]
- The opioids that have evidence for their use in dyspnoea are morphine, diamorphine and dihydrocodeine. [3]
- Although widely used, the role of benzodiazepines and other psychotropic drugs in dyspnoea is not established by evidence. [3, 5] They can be considered as second line treatment, in a therapeutic trial, after opioids and non-pharmacological methods have been tried
- Oxygen has not been shown to be better than air for breathless patients with chronic terminal illness. [6-7]
- If a malignant pleural effusion requires drainage, thoracoscopic talc pleurodesis has been shown to be the most effective approach. [8] It is clinically appropriate to consider this option when the patient has a life expectancy of months or more.
- Medications for terminal respiratory secretions have not so far been shown to be more effective than placebo, although they are widely used. [9] If used, they should be selected on the basis of their side effect profile, recognising that they may cause distress to the semi-conscious patient.
Background
Breathing problems are a significant issue for many palliative care patients and occur with increasing frequency in the terminal stage of most palliative conditions. [4] Problems can include:
The main palliative diagnoses causing breathing problems are: primary lung cancer; other cancer involving lung or chest wall, or obstructing the airways or mediastinum; lymphangitis carcinomatosis; end-stage cardiac failure; end-stage respiratory failure; and neuromuscular diseases eg, Motor Neuron Disease.
Potentially treatable factors that contribute to breathing problems should be sought and treated if appropriate. These include:
- Pulmonary embolus
- Co-morbid lung diseases (eg, Chronic Obstructive Pulmonary Disease - COPD)
- Anaemia
- Weakness and muscle wasting due to cachexia anorexia syndrome
- Pleural effusion
- Pericardial effusion or tamponade
- Ascites or raised intra-abdominal pressure
- Lung toxicity of chemotherapy or radiotherapy
- De-conditioning / reduced physical fitness
- Anxiety / panic / depression
- Need for aids, equipment, increased home support, or modification of daily activities to minimise breathlessness.
Active research areas / controversies
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It is unclear which patients with breathlessness experience relief from therapy with either oxygen or air. [6] Hypoxia is often not correlated with dyspnoea in palliative care patients, and correction of hypoxia with oxygen may or may not improve symptoms. The symptom of dyspnoea is complex and subjective, and difficult to study in the palliative care setting. [4, 10-12]
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Studies are under way to establish a strategy for dose titration of morphine for dyspnoea, and to compare the efficacy of oxycodone and morphine to relieve dyspnoea.
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Further research is needed to assess the potential benefits of nebulised frusemide for breathlessness. [13]
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Further research is needed to assess the effects of non-pharmacological approaches to breathlessness [14-15] as well as other new classes of medication, such as antidepressants.
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Further studies are needed to clarify the role of medications in managing respiratory secretions at the end of life.
References
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- 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
- Simon, S., et al., Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database of Systematic Reviews, 2010( Issue 1, Art. No.: CD007354. DOI: 10.1002/14651858.CD007354.pub2.).
- 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
- Cranston, J., A. Crockett, and D. Currow, Oxygen therapy for dyspnoea in adults. Cochrane Database of Systematic Reviews, 2008. 3(CD004769)
- Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database of Systematic Reviews. 2004;(1):CD002916
- Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database of Systematic Reviews. 2008 Jan 23;(1):CD005177
- Philip J, Gold M, Milner A, Di Iulio J, Miller B, Spruyt O. A randomized, double-blind crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer. Journal of Pain and Symptom Management. 2006 Dec;32(6):541-50
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This page was created on 29 April 2008 and was reviewed in April 2010
Last updated 4 May 2010
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