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Palliative cancer care - dyspnoea - Management
What should I ask about the dyspnoea?
- Ask about:
- Features of the dyspnoea (e.g. severity, timing, onset, and precipitating and exacerbating factors).
- Associated physical symptoms.
- Associated psychological symptoms (e.g. anxiety).
- Drug history (e.g. nonsteroidal anti-inflammatory drugs, beta-blockers, chemotherapy).
- Quality of life.
- Role of carers.
Clarification / Additional information
- Dyspnoea can be difficult to quantify. Use of a visual analogue scale may be helpful in the initial assessment of severity and monitoring of response to treatment:
- The person marks how breathless they feel on a line which has at one end 'no breathlessness' and at the other end 'maximum breathlessness' [Doyle et al, 2004].
- Enquiry about the time course of dyspnoea should include whether the dyspnoea is chronic or intermittent, when it occurs, the duration and frequency of each episode, and the interval between episodes [Doyle et al, 2004]:
- Dyspnoea is usually chronic in people with cancer [Booth and Dudgeon, 2006].
- If onset is more acute, consider other causes (e.g. pneumothorax, pulmonary embolism, anxiety, pneumonia, asthma, heart failure).
- Precipitating or exacerbating factors include physical activity, posture, environmental factors (e.g. pollen), and emotional factors (e.g. anxiety, excitement, fear) [Doyle et al, 2004].
- Quality-of-life issues include mobility, effect of the dyspnoea on the person's usual role, coping strategies (behavioural and emotional), and social isolation. Various quality-of-life measures are available, but these may be more applicable to research than to clinical practice [Doyle et al, 2004; Booth and Dudgeon, 2006].
- Assess any changes in the person's level of functioning because of their dyspnoea.
- Questions which can be asked in primary care to help elicit the functional impact of dyspnoea include [Munro, 1995]:
- Does it disturb sleep?
- Does it occur at rest?
- Does it interfere with normal conversation?
- Does it occur with washing or dressing?
- How far can you walk on the flat without stopping for a rest?
- How many stairs can you climb without stopping?
- Are there things you cannot do because of breathlessness?
- Associated symptoms include cough, sputum, haemoptysis, wheeze, stridor, pleuritic pain from pulmonary embolism, pneumothorax or pleural effusion, fatigue, and panic [Doyle et al, 2004; Booth and Dudgeon, 2006].
- See Table 1 for typical symptoms that can be useful in suggesting a diagnosis. Note: atypical presentations are common.
Table 1. Typical symptoms associated with dyspnoea and possible diagnoses.
No chest pain, no cough or wheeze | Central, non-pleuritic chest pain | Lateralized pleuritic chest pain | Cough or wheeze, but no pain |
|---|
Pulmonary embolism | Myocardial infarction | Pneumonia | Asthma |
Tension pneumothorax | Massive pulmonary embolism | Pulmonary infarction | Pulmonary oedema |
Hypovolaemic shock | Pericardial effusion | Rib fracture | Pneumothorax |
Metabolic acidosis | — | Pneumothorax | — |
|
Basis for recommendation
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