Respiratory symptoms

Key messages

• The prevalence and severity of respiratory symptoms will vary depending on the patient but between 50 and 70 per cent of patients with cancer, 50 per cent of patients with heart failure and 95 per cent of patients with lung disease will have breathing issues of some kind. [1]
• Assessing patient’s respiratory function includes identifying the potential causes of respiratory issues. Routine assessment of patients 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. [2]
• Management of respiratory symptoms can include pharmacological and non-pharmacological interventions.
• Opioids, either oral or parenteral, are effective in relieving the symptom of breathlessness (dyspnoea) from both cancer and non-malignant causes. [3-5]
• Nebulised opioids have not been shown to have any significant benefit for breathlessness. [5]
• The role of benzodiazepines in managing dyspnoea is not well researched, although the reduction of anxiety in dyspnoea is a common treatment goal. [6-8]
• While oxygen has not been shown to be better than air for breathless patients with chronic terminal illness, [9] there may be a sub-population who benefit. Oxygen prescription should therefore be individualised, based on the presence of hypoxia and a formal assessment of benefit after a therapeutic trial in the individual patient and treatment of any other contributing factors. [10]
• Medications for respiratory secretions have not so far been shown to be more effective than placebo, although they are widely used. [11]
• It is recognised that noisy breathing can be distressing to carers and family and therefore it may be necessary to initiate treatment based on individual needs.

Evidence summary

Definition and prevalence

Respiratory symptoms are a significant issue for many palliative care patients and occur with increasing frequency in the terminal stage of most life-limiting conditions. Although the prevalence and severity of respiratory symptoms will vary depending on the condition between 50 and 70 per cent of patients with cancer, 50 per cent of patients with heart failure will have breathing issues of some kind. [1] The rates increase to 95 per cent in patients with lung cancer or COPD. [1]

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 e.g. Motor Neurone Disease, imminently dying people.

Assessment and treatment

Potentially treatable factors that contribute to respiratory issues should be sought and treated if appropriate. These include:

• Pulmonary embolus
• Co-morbid lung diseases (e.g. 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.

The main respiratory symptoms likely to be encountered in a palliative care context are dyspnoea and obstruction. Synthesis of the evidence relating to these and other respiratory symptoms is provided separately in the corresponding sub-sections. See:
Cough
Dyspnoea
Haemoptysis
Obstruction
Respiratory secretions

Practice implications

See individual sub-sections for more on practice implications in Cough, Dyspnoea, Haemoptysis, and Obstruction. In brief:

• Based on current low level evidence, the recommendations are to consider disease-directed treatment as appropriate, to attend to potentially reversible causes of cough, and to offer a simple cough linctus.
• 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.
• Patients with significant haemoptysis from a lung malignancy should be offered radiotherapy and / or antifibrinolytics as clinically appropriate.
• Chemotherapy should be considered, where clinically appropriate, as the first line treatment for chemosensitive tumours causing obstruction.

Evidence gaps

• 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. [2,12]
• It is unclear which patients with breathlessness experience relief from therapy with either oxygen or air. [9] 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. [13-15]
• Episodic dyspnoea appears to be a common but poorly understood aspect of dyspnoea. An agreed definition and further research is needed. [16]
• A range of non-pharmacological strategies for management of breathlessness are being investigated, and have been shown to be effective in advanced cancer and advanced pulmonary disease. [17-20]
• Studies are under way to establish a strategy for dose titration of morphine and fentanyl for dyspnoea.
• Further research is needed to assess the potential benefits of nebulised frusemide for breathlessness. [21]
• Further studies are needed to clarify the role of medications in managing respiratory secretions at the end of life. In the absence of evidence to guide recommendations there is some uncertainty as to the need to treat secretions.
• Research into the management of cough is developing and new medications, such as gabapentin are being trialled. [22]
• Breathlessness Intervention Services are identified as a strategy to manage the multiple factors associated with breathlessness, and provide both pharmacological and non-pharmacological treatment. [17,19,20]
• No studies of interventions for cough in palliative care patients have been reported.
• Brachytherapy shows promise as a treatment for cough in patients with lung cancer. Based on current evidence, the lowest effective dose should be used. [11,23] There is also some promising research on the use of gabapentin in persistent cough. [22]