Breathing

Key messages

  • 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. [3]
  • 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] 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. [1]
  • While oxygen has not been shown to be better than air for breathless patients with chronic terminal illness [4], 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. [5]
  • Medications for terminal respiratory secretions have not so far been shown to be more effective than placebo, although they are widely used. [6] 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.

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)
  • 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

  • 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. [4] 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. [12]
  • 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. [15]
  • 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. [13]
  1. Ben-Aharon I, Gafter-Gvili A, Paul M, Leibovici L, Stemmer SM. Interventions for alleviating cancer-related dyspnea: a systematic review. J Clin Oncol. 2008 May 10;26(14):2396-404.
  2. Booth S, Moosavi SH, Higginson IJ. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy. Nat Clin Pract Oncol. 2008 Feb;5(2):90-100.
  3. Viola R, Kiteley C, Lloyd NS, Mackay JA, Wilson J, Wong RK, et al. The management of dyspnea in cancer patients: a systematic review. Support Care Cancer. 2008 Apr;16(4):329-37. Epub 2008 Jan 24.
  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.
  5. 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.
  6. Wee B, Hillier R. Interventions for noisy breathing in patients near to death. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD005177.
  7. Johnson MJ, Oxberry SG, Cleland JG, Clark AL. Measurement of breathlessness in clinical trials in patients with chronic heart failure: the need for a standardized approach: a systematic review. Eur J Heart Fail. 2010 Feb;12(2):137-47. 
  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.
  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. J Pain Symptom Manage. 2006 Dec;32(6):541-50. 
  10. Dorman S, Jolley C, Abernethy A, Currow D, Johnson M, Farquhar M, et al. Researching breathlessness in palliative care: consensus statement of the National Cancer Research Institute Palliative Care Breathlessness Subgroup. Palliat Med. 2009 Apr;23(3):213-27. Epub 2009 Feb 27.
  11. Gysels M, Bausewein C, Higginson IJ. Experiences of breathlessness: a systematic review of the qualitative literature. Palliat Support Care. 2007 Sep;5(3):281-302.
  12. Simon ST, Bausewein C, Schildmann E, Higginson IJ, Magnussen H, Scheve C, et al. Episodic breathlessness in patients with advanced disease: a systematic review. J Pain Symptom Manage. 2013 Mar;45(3):561-78. Epub 2012 Aug 24.
  13. Thomas S, Bausewein C, Higginson I, Booth S. Breathlessness in cancer patients - implications, management and challenges. Eur J Oncol Nurs. 2011 Dec;15(5):459-69. Epub 2011 Jan 15.
  14. Zhao I, Yates P. Non-pharmacological interventions for breathlessness management in patients with lung cancer: a systematic review. Palliat Med. 2008;22(6):693-701.
  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.

Last updated 17 January 2017