Breathlessness in the palliative care patient can be due to a variety of reasons and as a result management depends on what the underlying cause is.
- Lungs
- Exacerbation of COPD – nebulized bronchodilators
- Pleural effusion – therapeutic aspiration
- Pneumothorax – thoracostomy and chest tube drainage
- Empyema – thoracostomy and chest tube drainage with antibiotics
- Pulmonary embolism – anticoagulation with LWMH
- Pneumonia – antibiotics
- Heart
- Pericardial effusion and tamponade
- Pre-existing heart conditions (heart failure, arrhythmias)
- Blood
- Symptomatic anemia – RBC infusion, EPO
- Occlusions/Obstructions/Tumor mass effect
- Lymphangitic carinomatosis – steroids
- Pulmonary artery/vein occlusion – external beam radiotherapy
- Superior vena cava syndrome – steroids and palliative radiotherapy
- Chest wall/pleural invasion – external beam palliative radiotherapy
On the other hand there are also more general treatment options available regardless of the underlying cause
- Opioids
- Low dose PO and parenteral opioids have been proven beneficial (especially short-acting opioids)
- Reduces breathlessness through
- Decreased anxiety and perception of breathlessness
- Reduced sensitivity to hypercapnia (which typically is the trigger for increasing breathing rate)
- Typical dose 2.5 mg morphine q6h prn
- Compared to morphine for pain, the dose is lower and given more infrequently
- Benzodiazepines
- Particularly useful when SOB is due to underlying anxiety
- Typical dose lorazepam 0.5 – 1 mg or diazepam 2-5 mg prn
- Oxygen
- Typically psychological but not physiological benefit
- Indications for long term continuous O2 therapy in COPD patients include:
- PaO2 less than 55 mmHg or O2 sat less than 88 %
- Corticosteroids
- Useful for
- Bronchospasm
- Partial obstruction like in lymphangitic carcinomatosis
- Useful for
- Bronchodilators and inhaled steroids
- Nebulized albuterol (short acting bronchodilator i.e. ventolin)
- Longer acting bronchodilators may be beneficial
- Nebulized steroids are also available
Non-pharmacological measures include
- Sitting upright
- Allowing air flow through the room
- Avoid crowding the room
- Have a fan blow air across the face (stimulation of branch of trigeminal nerve has central inhibitory effects on breathlessness)
- Pursued lip breathing
- Reassurance to ease anxiety (which may contribute to breathlessness)