Dyspnoea

Evidence Summary  

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. The effective assessment and management of dyspnoea is increasingly regarded as an important quality measure in palliative care. [3]

 

PubMed Searches

Dyspnoea
Free full text only All citations

About these searches


Review Collection

Dyspnoea may serve as an early trigger for referral to palliative care services. [4] Patients experiencing breathlessness find the issues that most impact their lives are the loss of control, social participation and the impact breathlessness has on their relationships. [5] Numerous assessment tools for dyspnoea exist, but there is no consensus about which is the optimal tool for palliative care. [3] It has been proposed that use of the numerical rating scale and visual analog scale may be appropriate. [3]

Evidence supports the use of either oral or parenteral opioids for relieving the symptom of dyspnoea, and most of this evidence relates to morphine. [6,7] Opioids are the preferred treatment in refractory dyspnoea in patients with advanced cancer. [8] There is limited evidence to support the use of nebulised opioids, however patients report a subjective improvement when they are used. [6] A recent systematic review identified some evidence for the efficacy of fentanyl for dyspnoea. [9,10] Combining opioids with bronchodilators has been shown to be effective. [11] There is low quality evidence for the use of opioids to manage dyspnoea in chronic heart failure. [12] There is limited evidence in paediatric palliative care, although opioids are used in clinical practice. [13,14]

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. [15] 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. [16] There does appear to be a knowledge gap regarding the appropriate use of oxygen in breathlessness for health care professionals. [17] 

The use of nebulised frusemide for dyspnoea has been investigated. A systematic review suggests it is a promising approach, although the included studies were small and diverse. [18] There are some positive results to support its use in COPD but limited evidence for use in cancer patients and paediatrics. [14]

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 tunnelled pleural catheters in this setting. [19]

There is a growing body of evidence to support the use of non-pharmacological management of dyspnoea. In general these therapeutic interventions focus on physical activity (including exercise and activity pacing), breathing techniques, and technology based interventions (hand-held fans and neuromuscular electrical stimulation) and psychological interventions. [20] Many of these interventions remain poorly investigated and the therapeutic benefit derived from them may be as general health benefits rather than specific outcomes for the management of dyspnoea. [20] Multi-disciplinary team interventions including breathlessness clinics may improve management of dyspnoea in palliative care patients with lung cancer. [21] 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 [22] and home-based physiotherapy interventions may also offer benefit. [23,24]

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 only be used if non-pharmacological methods and opioids have failed to control the symptom. [25,26]

There is limited evidence to support the use of non-invasive ventilation to relieve the experience of dyspnoea in COPD. [27]

Refractory dyspnoea at the end-of-life, which causes severe distress and does not respond to symptom management is a challenging problem. In the rare instances where dyspnoea remains refractory at end of life, light sedation may be considered. Guidelines for sedation for refractory symptoms at the end of life have been proposed. [28]

Practice Implications

  • 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. [3]
  • Opioids are the first line pharmacological management for dyspnoea in patients with advanced disease or cancer.
  • Oxygen prescription should be individualised, based on the presence of hypoxia and a formal assessment of benefit after a therapeutic trial in the individual patient. [17,29]
  • There is growing evidence for the non-pharmacological approach to dyspnoea in the palliative care setting. Non-pharmacological 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.
  • Guidelines for sedation for refractory symptoms at the end of life have been proposed. [28]

 

  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. 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.
  4. Brighton LJ, Miller S, Farquhar M, Booth S, Yi D, Gao W, et al. Holistic services for people with advanced disease and chronic breathlessness: a systematic review and meta-analysis. Thorax. 2019 Mar;74(3):270-281. doi: 10.1136/thoraxjnl-2018-211589. Epub 2018 Nov 29.
  5. Lovell N, Etkind SN, Bajwah S, Maddocks M, Higginson IJ. Control and context are central for people with advanced illness experiencing breathlessness: A systematic review and thematic-synthesis. J Pain Symptom Manage. 2019 Jan;57(1):140-155.e2. doi: 10.1016/j.jpainsymman.2018.09.021. Epub 2018 Oct 4.
  6. Afolabi TM, Nahata MC, Pai V. Nebulized opioids for the palliation of dyspnea in terminally ill patients. Am J Health Syst Pharm. 2017 Jul 15;74(14):1053-1061. doi: 10.2146/ajhp150893.
  7. Marsaa K, Gundestrup S, Jensen JU, Lange P, Løkke A, Roberts NB, et al. Danish respiratory society position paper: palliative care in patients with chronic progressive non-malignant lung diseases. Eur Clin Respir J. 2018 Oct 16;5(1):1530029. doi: 10.1080/20018525.2018.1530029. eCollection 2018.
  8. Strieder M, Pecherstorfer M, Kreye G. Symptomatic treatment of dyspnea in advanced cancer patients: A narrative review of the current literature. Wien Med Wochenschr. 2018 Oct;168(13-14):333-343. doi: 10.1007/s10354-017-0600-4. Epub 2017 Sep 18.
  9. 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. 
  10. Jansen K, Haugen DF, Pont L, Ruths S. Safety and Effectiveness of Palliative Drug Treatment in the Last Days of Life-A Systematic Literature Review. J Pain Symptom Manage. 2018 Feb;55(2):508-521.e3. doi: 10.1016/j.jpainsymman.2017.06.010. Epub 2017 Aug 10.
  11. Senderovich H, Yendamuri A. Management of Breathlessness in Palliative Care: Inhalers and Dyspnea-A Literature Review. Rambam Maimonides Med J. 2019 Jan 28;10(1). doi: 10.5041/RMMJ.10357.
  12. León Delgado M, Campos LR, Bastidas Goyes A, Herazo Cubillos A, Martin Arsanios D, Muñoz Ortíz J, et al. Opioids for the management of dyspnea in patients with heart failure: a systematic review of the literature. Colombian Journal of Anesthesiology. 47(1):49-56, Jan-Mar 2019.
  13. Pieper L, Zernikow B, Drake R, Frosch M, Printz M, Wager J. Dyspnea in Children with Life-Threatening and Life-Limiting Complex Chronic Conditions. J Palliat Med. 2018 Apr;21(4):552-564. doi: 10.1089/jpm.2017.0240. Epub 2018 Jan 9.
  14. Craig F, Henderson EM, Bluebond-Langner M. Management of respiratory symptoms in paediatric palliative care. Curr Opin Support Palliat Care. 2015 Sep;9(3):217-26. doi: 10.1097/SPC.0000000000000154.
  15. 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.
  16. 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.
  17. Collis SP. Literature review of clinical benefits and reasons to prescribe palliative oxygen therapy in non-hypoxaemic patients. Br J Nurs. 2018 Nov 22;27(21):1255-1260. doi: 10.12968/bjon.2018.27.21.1255.
  18. 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.
  19. 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.
  20. Booth S, Chin C, Spathis A, Maddocks M, Yorke J, Burkin J, et al. Non-pharmacological interventions for breathlessness in people with cancer. Expert Rev Qual Life Cancer Care. 2018. doi: 10.1080/23809000.2018.1524708. Epub 2018 Oct 19.
  21. Scottish Intercollegiate Guidelines Network (SIGN). Management of lung cancer. A national clinical guideline. 2014 Feb;SIGN publication no. 137.
  22. 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.
  23. 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.
  24. Steindal SA, Torheim H, Oksholm T, Christensen VL, Lee K, Lerdal A, et al. Effectiveness of nursing interventions for breathlessness in people with chronic obstructive pulmonary disease: A systematic review and meta-analysis. J Adv Nurs. 2019 May;75(5):927-945. doi: 10.1111/jan.13902. Epub 2019 Jan 17.
  25. Ripamonti C. Management of dyspnea in advanced cancer patients. Support Care Cancer. 1999 Jul;7(4):233-43.
  26. 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.
  27. 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.
  28. 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.
  29. 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.

Overview Articles

Guidelines

Link to Prescribing Information

Last updated 08 November 2019