Dyspnoea (shortness of breath) is described as 'an uncomfortable awareness of breathing'.  It is a subjective symptom which may not correlate with measurable physical abnormalities such as hypoxia. Treating the dominant cause of breathlessness, including the contributing co-morbidities, is likely to be most effective, but is not always possible.
Shortness of breath becomes more frequent in patients as their disease progresses,  is associated with a poorer prognosis,  and is usually multifactorial in patients with advanced disease. The effective assessment and management of dyspnoea is increasingly regarded as an important quality measure in palliative care. 
What is known
Numerous assessment tools for dyspnoea exist, but there is no consensus about which is the appropriate tool for palliative care. 
Evidence supports the use of either oral or parenteral opioids for relieving the symptom of dyspnoea, and most of this evidence relates to morphine. There is no evidence to support the use of nebulised opioids, however. A recent systematic review identified low level evidence for the efficacy of fentanyl for dyspnoea. 
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.  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. 
The use of nebulised frusemide for dyspnoea has been investigated. A recent systematic review suggests it is a promising approach, although the included studies were small and diverse. 
If drainage of a malignant pleural effusion is required and is clinically appropriate, evidence supports the effectiveness of thoracoscopic talc pleurodesis. There is also low level evidence to support the safety and effectiveness of tunneled pleural catheters in this setting. 
Research from small trials supports non-pharmacological interventions including general support, breathing re-training, activity planning and adaptation strategies, counselling and relaxation. [1,10] These are complex interventions and it is not clear which components in the package may be most effective. Nurse or physiotherapist-led interventions including breathlessness clinics may improve management of dyspnoea in palliative care patients with lung cancer.  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  and home-based physiotherapy interventions may also offer benefit. 
Benzodiazepines are frequently prescribed for management of distress associated with dyspnea, but have not been shown to be of benefit. They cause more drowsiness than opioids, and should be used if non-pharmacological methods and opioids have failed to control the symptom. [14,15]
There is limited evidence to support the use of non-invasive ventilation to relieve the experience of dyspnoea in Chronic Obstructive Pulmonary Disease COPD. 
What it means in practice
- Routine assessment of patients for dyspnoea is essential in palliative care, and assessment needs to include a measure both of intensity of the symptom, and of any associated distress or impairment. 
- Opioids are the first line pharmacological management for dyspnoea patients with advanced disease or cancer.
- Oxygen prescription should be individualised, based on a formal assessment of benefit after a therapeutic trial in the individual patient. 
- Non-pharmacological allied health and nursing interventions offer an additional strategy to help patients manage their symptoms. Interventions should be tailored to the individual patient. Those who are very disabled by dyspnoea or close to the end of life may be best cared for with a pharmacological approach.
- 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. 
Finding out more
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End of life care
Review Collection: Dyspnoea
Last updated 26 October 2015
- Ripamonti C, Fusco F. Respiratory problems in advanced cancer. Support care cancer. 2002 Apr;10(3):204-16. Epub 2001 Aug 14.
- Mercadante S, Casuccio A, Fulfaro F. The course of symptom frequency and intensity in advanced cancer patients followed at home. J Pain Symptom Manage. 2000 Aug;20(2):104-12.
- 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. J Clin Oncol. 2005 Sep 1;23(25):6240-8.
- Mularski RA, Campbell ML, Asch SM, Reeve BB, Basch E, Maxwell TL, et al. A review of quality of care evaluation for the palliation of dyspnea. Am J Respir Crit Care Med. 2010 Mar 15;181(6):534-8. Epub 2010 Jan 7.
- Simon ST, Koskeroglu P, Gaertner J, Voltz R. Fentanyl for the relief of refractory breathlessness: a systematic review. J Pain Symptom Manage. 2013 Dec;46(6):874-86. Epub 2013 Jun 4.
- 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. Br J Cancer. 2008 Jan 29;98(2):294-9. Epub 2008 Jan 8.
- 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. J Pain Palliat Care Pharmacother. 2004;18(4):3-15.
- Newton PJ, Davidson PM, Macdonald P, Ollerton R, Krum H. Nebulized furosemide for the management of dyspnoea: does the evidence support its use? J Pain Symptom Manage. 2008 Oct;36(4):424-41. Epub 2008 May 12.
- Van Meter ME, McKee KY, Kohlwes RJ. Efficacy and safety of tunneled pleural catheters in adults with malignant pleural effusions: a systematic review. J Gen Intern Med. 2011 Jan;26(1):70-6. Epub 2010 Aug 10.
- Zhao I, Yates P. Non-pharmacological interventions for breathlessness management in patients with lung cancer: a systematic review. Palliat Med. 2008 Sep;22(6):693-701.
- Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with lung cancer. A national clinical guideline. 2005 Feb;SIGN publication no. 80.
- McCarthy B, Casey D, Devane D, Murphy K, Murphy E, Lacasse Y. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2015 Feb 23;2:CD003793.
- Thomas MJ, Simpson J, Riley R, Grant E. The impact of home-based physiotherapy interventions on breathlessness during activities of daily living in severe COPD: a systematic review. Physiotherapy. 2010 Jun;96(2):108-19. Epub 2010 Jan 18.
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- Simon ST, Higginson IJ, Booth S, Harding R, Bausewein C. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD007354.
- Smith TA, Davidson PM, Lam LT, Jenkins CR, Ingham JM. The use of non-invasive ventilation for the relief of dyspnoea in exacerbations of chronic obstructive pulmonary disease; a systematic review. Respirology. 2012 feb;17(2):300-7.
- Booth S, Wade R, Johnson M, Kite S, Swannick M, Anderson H, et al. 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. Respir Med. 2004 Jan;98(1):66-77.
- Cherny NI, Radbruch L; Board of the European Association for Palliative Care. European Association for Palliative Care (EAPC) recommended framework for the use of sedation in palliative care. Palliat Med. 2009 Oct;23(7):581-93.