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Understanding Palliative Care: Breathlessness

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
  • 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)