Breathing

Background

Breathing problems are a significant issue for many palliative care patients. Problems can include:

The main palliative diagnoses causing breathing problems are: primary lung cancer; other cancer involving lung or chest wall, or obstructing airways or mediastinum; lymphangitis carcinomatosis; end-stage cardiac failure; end-stage respiratory failure; and neuromuscular diseases eg, Motor Neuron Disease.

Other potentially treatable factors that contribute to breathing problems should also be sought and treated if appropriate:

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
Patterns of physical activity that are not adapted to limitations in respiratory status.

Key messages

Opioids, either oral or parenteral, are effective in relieving the symptom of breathlessness. [1]
Nebulised opioids have not been shown to have any benefit for breathlessness. [1]
If a malignant pleural effusion requires drainage, thoracoscopic talc pleurodesis has been shown to be the most effective approach. [2] It is clinically appropriate 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. [3] 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.
The role of benzodiazepines and other psychotropic drugs in dyspnoea is not established by evidence. [4]

Active research areas / controversies

It is unclear which patients with breathlessness experience relief from therapy with either oxygen or air. [5] 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. [6]
Randomised controlled trials and a Cochrane systematic review are under way to clarify this question. [7]
Studies are under way to establish a strategy for dose titration of morphine for dyspnoea.
Further research is needed to assess the effects of non-pharmacological approaches to breathlessness. [8]
Further studies are needed to clarify the role of medications in managing respiratory secretions at the end of life.

References

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
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
Ripamonti C. Management of dyspnea in advanced cancer patients. Supportive Care in Cancer. 1999 Jul;7(4):233-43.
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
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
Cranston JM, Currow DC, Bowden JJ, Crockett AJ, Saccoia L. Oxygen therapy for dyspnoea. (Protocol) Cochrane Database of Systematic Reviews 2004, Issue 2. Art. No.: CD004769. DOI: 10.1002/14651858.CD004769.
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.

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