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Breathlessness - complex for clinicians, frightening for patients
Breathlessness (dyspnoea), is one of the most common symptoms experienced by people who are nearing the end of life.1 It
is reported as being the most debilitating symptom by 95% of people with Chronic Obstructive Pulmonary Disease (COPD),
and is also common in patients with lung fibrosis, heart failure and terminal cancer.2
Breathlessness is caused by a complex interaction of signals from the chest walls, lungs, upper airways and central
nervous system. Activity, anxiety level and previous experiences all influence a patient's perception of breathlessness.
While there is often an obvious reason, for some people no cause is found despite thorough assessment. Breathlessness
is described by patients as "hard work", "painful", "frightening" or a "continuous fight".3
The initial aims of management are to reduce the level of breathlessness and treat any underlying conditions that may
be aggravating the breathlessness. For example, furosemide can be given by several routes, including subcutaneously, to
reduce fluid overload occurring secondary to congestive heart failure or dexamethasone can be given for partial obstruction
of the airways. Referral for drainage of pleural effusions or abdominal ascites may also be considered where appropriate.8 However,
once all reversible causes have been addressed and pharmacological treatments are maximal, breathlessness, if still present,
is considered to be refractory.
Goals of care when treating refractory breathlessness
Once breathlessness is refractory, the goal of treatment becomes symptom relief. Treatment should begin with non-pharmacological
interventions, then consider low-dose morphine, and if appropriate, benzodiazepines (if anxiety is a factor) or oxygen
treatment (if hypoxaemic). However, clinicians should individualise their approach, as treatment effectiveness varies
between patients, and other interventions may be trialled on an individual basis.
Non-pharmacological treatments of breathlessness
Non-pharmacological treatments should be considered first-line for treating breathlessness in people with a terminal
condition. The acceptability and effectiveness of treatments will depend on individual patient circumstances and preference.
A Cochrane review found evidence supporting the use of physiotherapy in the treatment of breathlessness, e.g. pursed-lip
breathing training where the respiratory rate is decreased and vital capacity increased, as well as evidence for walking
aids for patients who are mobile.4 However, the number of studies was insufficient to conduct a meta-analysis.
Electrical muscle stimulation was also shown to be effective, although this is not widely available.4 A small
study of 50 patients found that a handheld fan directed at the face reduced the sensation of breathlessness.5
Cognitive behavioural approaches, where available, can provide some relief from breathlessness.6 This includes
relaxation and modification of negative thoughts.6
There is no strong evidence for recommending other non-pharmacological treatments for breathlessness, however, any intervention
that improves the patient's psychological state may provide some degree of symptom relief, e.g. acupuncture or music therapy.
Encouraging the patient to maintain a small level of activity (if able), may also be helpful.
Strategies aimed at improving patient comfort include:7
- Positioning the patient to maximise their comfort, e.g. elevating the head and torso, or lying with the affected lung
downwards if only one lung is dysfunctional
- Using a humidifier
- Reducing the room temperature
- Eliminating irritants such as smoke or allergens
- Opening a window to create a draft
- Providing a window view if possible
- Providing reassurance
The Asthma Foundation's "Breathe easier with COPD" booklets provide a
list of techniques and practical ways of dealing with the stress and limitations of breathlessness.
Morphine for breathlessness
Morphine is the most widely studied and extensively used medicine for the treatment of breathlessness in patients with
a terminal condition.1
How does morphine reduce breathlessness?
The exact mechanism by which morphine alleviates breathlessness is unknown, however, opioid-induced vasodilation in
pulmonary vasculature has been demonstrated in animal studies.1 Endogenous circulatory opioids (e.g. endorphins)
have been shown to improve breathlessness during exercise in people with COPD.1
Overcoming potential barriers to morphine use
Health professionals in primary care may be reluctant to use morphine in the management of breathlessness because of
concerns about respiratory depression.9 Opioids can relieve breathlessness by decreasing the respiratory rate
without causing hypercapnia or hypoxia.1 A study comparing the effects of morphine or hydromorphone on breathlessness
in 15 opioid-naive and 12 opioid pre-treated patients, found no higher risk of respiratory depression or hypercapnia in
the opioid-naive group.10 As of 2009, there were no reported cases of respiratory depression from the use of
oral, low-dose, strong opioids in patients with breathlessness.3
Lack of guidelines may make clinicians feel that treatment of breathlessness with morphine is more suited to a hospital
or hospice setting.9 In response, the American College of Chest Physicians released a consensus statement in
2010 recommending that opioids should be used and titrated for the relief of breathlessness in patients with progressive
lung or heart disease and a limited prognosis.11
Patients and their family/ whānau may be concerned about their ability to administer morphine, or about the presence
of narcotics in the home. Clear written and explained instructions regarding dose titration and regular phone follow-up
in the first weeks of treatment may provide reassurance. Safety concerns can be addressed by discussing the maximum ten-day
dispensing requirement and by suggesting patients request pharmacists use child resistant closures on tablet and liquid
Initiating opioids for breathlessness
First-line pharmacological treatment is oral morphine. Initially low doses may be given on an as-needed basis, e.g.
2 mg of an oral solution pre-measured in a syringe or 2.5 mg immediate release tablet (one-quarter of a 10 mg tablet).
An example of a more structured regimen is: 2 - 2.5 mg, given four to six hourly.12 This dose can be increased
in steps of 30% if tolerated.12
Where patients require regular dosing of morphine for breathlessness, consider switching to a sustained-release formulation.
A study of 83 opioid-naive patients with breathlessness, found 10 mg of sustained-release oral morphine once daily was
safe and effective for 70% of patients who responded to morphine for the treatment of breathlessness.13 The
sustained-release dose can be calculated by summing all the morphine doses given over a 24 hour period. Oral morphine
solution can also be used for acute relief, as required.
If oral medication is unsuitable for the patient, then subcutaneous morphine is an alternative at a dose of 1
- 2 mg, given four to six hourly.12 A syringe driver may also be considered, depending on the required
dosing frequency. Patients who are concurrently taking regular opioids for analgesia can be given additional small doses
of morphine for breathlessness, as required, e.g. using one quarter of the patient's current four-hourly breakthrough
In practice, it is unlikely that patients will receive significantly more benefit by increasing the total morphine dose
for breathlessness over 20 mg in a 24 hour period.
Switching to another opioid. If morphine is unable to be used due to allergy or intolerable adverse effects, a different
strong opioid can be trialled. Oxycodone can be initiated at a dose equipotent to morphine, however, there is no evidence
that oxycodone is as effective as morphine for relief of breathlessness (although a major study is underway). Oxycodone
is between 1.5 and two times more potent than morphine due to its increased bioavailability. For example, if the patient
was taking 10 mg oral morphine, they would require approximately 5 mg of oxycodone.
Nebulised opioids are not recommended for the treatment of breathlessness in a community setting, due to a lack of evidence
supporting their efficacy.2
Benzodiazepines for breathlessness
There is no evidence that benzodiazepines reduce breathlessness, however, they can be very effective at reducing the
anxiety associated with breathlessness,12 and may be considered if non-pharmacological treatments and morphine
have not been effective.
Lorazepam 0.5 mg (half a 1 mg tablet), every four to six hours, as required, is an appropriate starting dose.12 Oral
diazepam, 2 - 5 mg given at night is appropriate where there is continuous anxiety.12 In some cases clonazepam,
e.g. 0.5 mg at night or as required, may also be considered. Clonazepam has a relatively long half-life which can result
in a cumulative effect occurring over time.
Intranasal midazolam (unsubsidised), a short-acting benzodiazepine, is rapidly absorbed and a useful alternative if
administration via other routes is not appropriate for treating breathlessness that is caused by anxiety, or for calming
a highly anxious patient.14 Peak plasma concentrations occur within ten minutes.14 The short-acting
nature of this medicine means that it is less likely to accumulate in the body and the rapid speed of onset reduces the
likelihood that multiple doses will be administered. The preparation is made in the pharmacy by pouring midazolam injection
(15 mg/3 mL) into a nasal spray bottle.14 It can be prescribed at one to two sprays in each nostril, per hour
as required. Each spray delivers 0.5 mg of midazolam.14
Bronchial secretions - The "death rattle"
In the last days and hours of a person's life, bronchial secretions can accumulate in the throat and cause a choking
sound referred to as the "death rattle". This can cause discomfort for the patient and distress for their family and
friends. First-line treatment for bronchial secretions in this circumstance is hyoscine butylbromide (buscopan), 20 mg
subcutaneously given hourly as required.12 This can be delivered via a syringe driver and is compatible with
most other medicines commonly administered via this route in palliative care. Subcutaneous hyoscine hydrobromide 400
mcg up to every two hours or glycopyrronium (not subsidised) 200 mcg up to every four hours are other treatment options.12,15
N.B. The reason these medicines are used are because of their anticholinergic properties, which dry secretions. However,
this also causes the discomfort of a dry mouth therefore the benefits need to be weighed with the adverse effects.
An article on using syringe drivers in palliative care will appear in
the next edition of Best Practice Journal.
Oxygen treatment for breathlessness
Oxygen treatment is not beneficial to most patients with breathlessness, and should only be considered for patients
with established hypoxaemia (PaO2 ≤ 55 mmHg).16
Oxygen treatment in a hypoxic patient aims to avoid hypercapnia and may reduce polycythaemia, improve sleep quality
and prevent right heart failure.16 Oxygen treatment in a community setting requires authorisation from a respiratory
In patients who are not significantly hypoxaemic, there is currently no evidence that oxygen reduces breathlessness.17 A
blinded study of 239 patients randomly assigned to either domiciliary oxygen or room air via a nasal cannulae for 16 hours
per day, found small improvements in breathlessness for both treatments, but no difference between the two.18 This
suggests that the movement of air across the face alone may provide symptom relief. A Cochrane review found no overall
improvement in breathlessness among patients with cancer using oxygen, however, some individuals felt better breathing
Patient attitudes may vary towards long-term oxygen treatment, as it is restrictive and impacts on patient and carer
routines. Some patients may also be concerned about the unhealthy appearance that cylinders and masks present to family,
or dislike the technical focus on the machines and oxygen readings.3 Other patients may find reassurance in
the potential 'life-line' of oxygen supply.
Advanced Care Planning - communicating with the patient before hospital admission
Despite the best efforts of carers and clinicians in the community, patients with terminal conditions often require
hospital or hospice admission in the final days of their life. Admitting staff may have had no previous contact with
the patient and may be unaware of the patient's wishes. Health professionals in primary care, who have a long-standing
relationship with the patient, can enable continuity of care by initiating Advanced Care Planning. This involves proactive
discussions about the expected course of the patient's disease and its prognosis, including the patient's preferences
for care at the end of life - both medical and spiritual. A folder containing information about the patient's medicines,
contacts, decisions and wishes can then be left with the patient. This allows admitting staff to ensure that the treatment
and care they provide are consistent with the patient's values and goals.
"A Good Death" is a thirty minute documentary, produced by Professor
Robin Taylor and Dr Paul Trotman, following a patient with COPD, and his family, during the last months of his life.
The film focuses on end of life care and Advanced Care Planning, and is available at:
ACKNOWLEDGEMENT: Thank you to Dr Rachel Wiseman, Senior Respiratory Registrar and
Palliative Medicine Physician, Christchurch Hospital, Canterbury DHB for expert guidance in developing this article.
- Kamal AH, Maguire JM, Wheeler JL, et al. Dyspnea review for the palliative care professional: treatment goals and
therapeutic options. J Palliat Med 2012;15(1):106-14.
- Uronis HE, Currow DC, Abernethy AP. Palliative management of refractory dyspnea in COPD. Int J Chron Obstruct Pulmon
- Rocker G, Horton R, Currow D, et al. Palliation of dyspnoea in advanced COPD: revisiting a role for opioids. Thorax
- Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages
of malignant and non-malignant diseases. Cochrane Database Syst Rev 2008;(2):CD005623.
- Galbraith S, Fagan P, Perkins P, et al. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled,
crossover trial. J Pain Symptom Manag 2010;39(5):831-8.
- Howard C, Dupont S, Haselden B, et al. The effectiveness of a group cognitive-behavioural breathlessness intervention
on health status, mood and hospital admissions in elderly patients with chronic obstructive pulmonary disease. Psychol
Health Med 2010;15(4):371-85.
- Tyler L. Dyspnea in palliative care patients. J Pharmaceut Care Pain Symptom Contr 2000;7(4):109-27.
- Macleod A, MacLeod R, Vella-Brincat J. The palliative care handbook. 5th ed. NZIJ Hospice Charitable Trust; 2011.
- Young J, Donahue M, Farquhar M, et al. Using opioids to treat dyspnea in advanced COPD: attitudes and experiences
of family physicians and respiratory therapists. Can Fam Physician 2012;58(7):e401-7.
- Clemens KE, Quednau I, Klaschik E. Is there a higher risk of respiratory depression in opioid-naïve palliative care
patients during symptomatic therapy of dyspnea with strong opioids? J Palliat Med 2008;11(2):204-16.
- Mahler DA, Selecky PA, Harrod CG, et al. American College of Chest Physicians consensus statement on the management
of dyspnea in patients with advanced lung or heart disease. Chest 2010;137(3):674-91.
- National Health Service (NHS) Lothian. Breathlessness in palliative care. NHS, UK 2010. Available from:
- Currow DC, McDonald C, Oaten S, et al. Once-daily opioids for chronic dyspnea: a dose increment and pharmacovigilance
study. J Pain Symptom Manag 2011;42(3):388-99.
- Canterbury DHB (CDHB). Intranasal midazolam in palliative care patients. CDHB, 2011. Available from:
- New Zealand Formulary (NZF). NZF v4. NZF; 2012. Available from: www.nzf.org.nz (Accessed
- McDonald CF, Crockett AJ, Young IH. Adult domiciliary oxygen therapy. Position statement of the Thoracic Society
of Australia and New Zealand. Med J Aust 2005;182(12):621-6.
- Clark AL, Johnson MJ, Squire I. Does home oxygen benefit people with chronic heart failure? BMJ 2011;342:d234.
- Abernethy AP, McDonald CF, Frith PA, et al. Effect of palliative oxygen versus room air in relief of breathlessness
in patients with refractory dyspnoea: a double-blind, randomised controlled trial. Lancet 2010;376(9743):784-93.
- Cranston JM, Crockett A, Currow D. Oxygen therapy for dyspnoea in adults. Cochrane Database Syst Rev 2008;(3):CD004769.