- Opioids, either oral or parenteral, are effective in relieving the symptom of breathlessness from both cancer and non-malignant causes. [1-3] 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. 
- The opioids that have evidence for their use in dyspnoea are morphine, diamorphine and dihydrocodeine. 
- Although widely used, the role of benzodiazepines and other psychotropic drugs in dyspnoea is not established by evidence.  They can be considered as second line treatment, in a therapeutic trial, after opioids and non-pharmacological methods have been tried, or as an adjunct to opioids. 
- While oxygen has not been shown to be better than air for breathless patients with chronic terminal illness , there may be a sub-population who benefit. Oxygen prescription should therefore be individualised, based on a formal assessment of benefit after a therapeutic trial in the individual patient and treatment of any other contributing factors.
- If a malignant pleural effusion requires drainage, thoracoscopic talc pleurodesis is the first line option. It is clinically appropriate to consider this option when the patient has a life expectancy of months or more. Tunneled pleural catheters may also offer effective palliation, but have been less well studied. 
- Medications for terminal respiratory secretions have not so far been shown to be more effective than placebo, although they are widely used.  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.
Breathing problems are a significant issue for many palliative care patients and occur with increasing frequency in the terminal stage of most palliative conditions.
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 Neurone 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)
- 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
- There is little consensus on how to measure and assess dyspnoea in palliative care patients, for the purposes of both research and patient care. Development of agreed tools and approaches to measuring this symptom are needed. [7,8]
- It is unclear which patients with breathlessness experience relief from therapy with either oxygen or air.  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. [9-11]
- Episodic dyspnoea appears to be a common but poorly understood aspect of dyspnoea. An agreed definition and further research is needed. 
- A range of nonpharmacological strategies for management of breathlessness are being investigated, and have been shown to be effective in advanced cancer. [13-14]
- Studies are under way to establish a strategy for dose titration of morphine for dyspnoea.
- Further research is needed to assess the potential benefits of nebulised frusemide for breathlessness. 
- Further studies are needed to clarify the role of medications in managing respiratory secretions at the end of life.
- Breathlessness Intervention Services are identified as a strategy to manage the multiple factors associated with breathlessness, and provide both pharmacological and non-pharmacological treatment.