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Dyspnoea

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Dyspnoea
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Dyspnoea (shortness of breath) is described as 'an uncomfortable awareness of breathing'. [1] 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, [2] is associated with a poorer prognosis, [3] and is usually multifactorial in patients with advanced disease.

What is known

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. [5-6] 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. [7]

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. [8] 

If drainage of a malignant pleural effusion is required and is clinically appropriate, evidence supports the effectiveness of thoracoscopic talc pleurodesis. [9] 

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. 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. [11] Nurse or physiotherapist-led interventions including breathlessness clinics may improve management of dyspnoea in palliative care patients with lung cancer. [12] 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. [13]

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, [14] but numbers were small.

What it means in practice

  • 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 after a therapeutic trial in the individual patient. [15]
  • 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. [16]

Finding out more

Guidelines

Link to prescribing information

Free full text overview article

  1. Ripamonti C, Fusco F. Respiratory problems in advanced cancer. Support care cancer. 2002 Apr;10(3):204-16. Epub 2001 Aug 14.
  2. 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.
  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. J Clin Oncol. 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 Syst Rev. 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. Br J Cancer. 2008 Jan 29;98(2):294-9. Epub 2008 Jan 8.
  6. Cranston J, Crockett A, Currow DC. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev. 2008;(3):CD004769.
  7. 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.
  8. 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.
  9. Shaw P, Agarwal R. Pleurodesis for malignant pleural effusions. Cochrane Database Syst Rev. 2004;(1):CD002916.
  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.
  11. Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev. 2008 Apr 16;(2):CD005623.
  12. Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with lung cancer. A national clinical guideline. 2005 Feb;SIGN publication no. 80.
  13. Lacasse Y, Goldstein R, Lasserson TJ, Martin S. Pulmonary rehabilitation for chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003793.
  14. Ripamonti C. Management of dyspnea in advanced cancer patients. Support Care Cancer. 1999 Jul;7(4):233-43.
  15. 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. Respir Med. 2004 Jan;98(1):66-77.
  16. 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.

Last updated 09 July 2010