• Assess the person to find whether investigations are indicated and whether the cause of the dyspnoea is reversible.
• Determine what management interventions are appropriate for the person's stage of illness:
• Use simple measures to reduce dyspnoea.
• Consider symptomatic treatment (symptom control can be used in conjunction with treatment for the underlying condition).
• Depending on what is considered appropriate, treat identified known causes, refer, or admit to hospital.
• Consider management of other physical symptoms, and take into account the psychological, social, and spiritual needs of the person and their family. For more information, see the CKS topic on Palliative cancer care - general issues.

• Take a history and perform an examination and investigations as appropriate.
• Consider whether the cause of the dyspnoea is known and whether treatment of the cause is appropriate, or whether the emphasis should be on treatment of symptoms.
• The assessment must take the following factors into account:
• The stage of illness and the person's prognosis.
• The person's wishes and those of carers and family.
• The cause of the person's dyspnoea and whether it is reversible or untreatable.
• The severity of dyspnoea (e.g. oxygen saturation, level of anxiety and distress caused, and effect of dyspnoea on quality of life).
• The urgency with which treatment is required.
• The input of the multidisciplinary team.

• Management decisions can be made on the basis of the assessment:
• Simple measures should be considered for all people with dyspnoea in palliative care.
• If assessment reveals a known cause for the dyspnoea, treat if appropriate.
• Consider symptomatic treatment if appropriate.

• This recommendation is pragmatic advice based on expert opinion in the palliative care literature [Twycross and Wilcock, 2001; Doyle et al, 2004]:
• Assessment is important because correctable causes should be identified and corrected if appropriate for the person's stage of illness [Twycross and Wilcock, 2001].
• Multiple causes often account for dyspnoea in a person with advanced cancer [Doyle et al, 2004].
• History taking, examination, and investigations are needed to elicit underlying causes [Doyle et al, 2004].

• 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.

• 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.

• This recommendation is based on expert opinion from medical and palliative care textbooks [Munro, 1995; Doyle et al, 2004; Regnard and Hockley, 2004b; Booth and Dudgeon, 2006].

• Perform an appropriate examination for the stage of the person's illness, to attempt to determine the cause of the dyspnoea.
• This should include a general examination, examination of the person's respiratory and cardiovascular systems, assessment of the effectiveness of the person's breathing (e.g. depth of breathing and expectoration of secretions), and looking for features of a panic attack or hyperventilation.
• If appropriate, observe the person walking a set distance or carrying out a set task.

• General examination for dyspnoea may reveal pallor (suggestive of anaemia) or plethora and engorged veins of the neck and chest area (suggestive of superior vena cava obstruction) [Munro, 1995].
• Determine whether the person is breathing effectively (e.g. taking deep breaths, expectorating secretions).
• Chest examination may reveal findings suggestive of a cause of dyspnoea (see Table 1). Note: atypical presentations may occur.

• This recommendation is based on expert opinion from medical and palliative care textbook literature [Munro, 1995; Twycross and Wilcock, 2001; Warrell et al, 2003b; Doyle et al, 2004].

• Investigations should be guided by the:
• Clinical assessment.
• Stage of disease and person's prognosis.
• Risk-to-benefit ratio of the investigation.
• Wishes of the person and their family.
• The most useful investigations to consider in all people with non-acute dyspnoea in a palliative care situation in primary care include:
• Chest radiography (to assess lung disease and heart failure).
• Spirometry (to assess possible undiagnosed chronic obstructive pulmonary disease, however, spirometry can be difficult for people with cancer because of pain).
• Full blood count (to exclude anaemia).
• Pulse oximetry, if available (to assess hypoxia).
• Electrocardiography (to exclude arrhythmia).

• Investigations which may be done in secondary care include [Twycross and Wilcock, 2001; Doyle et al, 2004; Booth and Dudgeon, 2006]:
• Computed tomography of the chest.
• Investigations to rule out pulmonary embolism if suspected.
• Ultrasonography for a pleural effusion.
• Echocardiography, to assess cardiac function.
• More information on investigation of non-malignant causes of dyspnoea is found in the CKS topics on Asthma, Chest infections - adult, Chronic obstructive pulmonary disease, and Heart failure - chronic.

• This recommendation is based on palliative care guidelines [International Association for Hospice and Palliative Care, 2004; ICSI, 2007] and expert opinion from the palliative care literature [Twycross and Wilcock, 2001; Doyle et al, 2004; Booth and Dudgeon, 2006].

• Simple measures to relieve symptoms include:
• Keeping the room cool.
• Improving air circulation with a fan (directed towards the face, especially over the nose and mouth) or open window.
• Trying relaxation and breathing techniques.
• Providing reassurance that pain and distress will be controlled and explaining dyspnoea and its underlying cause, if known, to the person and their family.
• Encourage exercise within the person's capabilities.

• Controlled breathing techniques include positioning, pursed-lip breathing, breathing exercises, and coordinated breathing training [Doyle et al, 2004]:
• Relaxing and dropping the shoulders reduces the 'hunching' that comes with anxiety [Regnard and Hockley, 2004a].
• Sitting upright increases peak ventilation and reduces airway obstruction [Regnard and Hockley, 2004a].
• Leaning forward with arms bracing a chair or knees with the upper body supported has been shown to improve ventilatory capacity [Doyle et al, 2004].
• In pursed-lip breathing, people inhale through their nose for several seconds with their mouth closed, then exhale slowly through pursed lips for 4–6 seconds. This can help to relieve perception of dyspnoea during exercise or whenever dyspnoea is triggered [Doyle et al, 2004].
• Breathing retraining aims to help the person regain a sense of control and improve respiratory muscle strength. It is facilitated by physiotherapists and clinical nurse specialists [Regnard and Hockley, 2004a].
• For more information on techniques to help breathing, see Patient information on breathlessness.
• Encourage exertion to the point of breathlessness to increase tolerance and maintain fitness:
• The level of physical activity that is realistically achievable will vary from person to person. For example, people with very limited mobility may be able to stand up only once every hour or move their feet a few times an hour [Booth, 2006].
• Consider management of other physical symptoms and the general psychological, social, and spiritual needs of the person and their family. See the CKS topic on Palliative cancer care - general issues.
• Consider multidisciplinary assessment of the person and their family [Lothian Palliative Care Guidelines Group, 2004a].
• Discuss adaptations in activities of daily living and lifestyle expectations and involve other professionals to identify where additional support is required [Davis, 1997; Twycross and Wilcock, 2001]:
• Help the person adapt to their new respiratory capacity (e.g. review demands on mobility) [Regnard and Tempest, 1998].
• Suggest pacing of activities by doing the same things, but at a much slower rate [Booth, 2006].
• Offer access to patient groups, day care facilities, and respite admissions, depending on the needs of the person and their family [Twycross and Wilcock, 2001].

• This recommendation is based on palliative care guidelines [International Association for Hospice and Palliative Care, 2004; ICSI, 2007] and expert opinion from the palliative care literature [Davis, 1997; Regnard and Tempest, 1998; Twycross and Wilcock, 2001; Doyle et al, 2004; Regnard and Hockley, 2004b; Booth, 2006; Booth and Dudgeon, 2006].

• In all cases, consider simple measures to relieve dyspnoea.
• Determine what management interventions are appropriate for the underlying cause of dyspnoea and stage of illness, involving the person and their carers and family.
• Based on this, consider symptomatic measures if appropriate (e.g. an opioid, a benzodiazepine, a corticosteroid, a bronchodilator, or oxygen).

• This recommendation is pragmatic advice based on expert opinion from palliative care specialists.

• Consider using a strong opioid in people who need symptomatic treatment of dyspnoea, especially those with shortness of breath who are near the end of life.
• Continue with non-pharmacological strategies when initiating an opioid. See Simple measures to help dyspnoea.
• For more information see the section on opioids in Prescribing information.

• Normal-release oral morphine is the usual opioid of choice:
• Routes of administration other than oral may be considered, but use of nebulized opioids is not recommended for symptomatic relief of breathlessness [Jennings et al, 2002; Kvale et al, 2003; Doyle et al, 2004; Brown et al, 2005; Fraser Health, 2006; ICSI, 2007].
• Intermittent opioid dosing is appropriate if dyspnoea is not continuous.
• If the person cannot take oral medication, use a subcutaneous bolus of diamorphine when required or a subcutaneous continuous infusion of diamorphine delivered through a syringe driver [Lothian Palliative Care Guidelines Group, 2004b; Pan-Glasgow Palliative Care Algorithm Group, 2005].
• Concomitant use of an anti-emetic should be considered and treatment with regular laxatives commenced.

• This recommendation is based on palliative care guidelines [Lothian Palliative Care Guidelines Group, 2004b; NHMRC, 2004; ICSI, 2007] and expert opinion from the palliative care literature [Kvale et al, 2003; Doyle et al, 2004; Booth, 2006].
• Opioids can influence a person's perception of dyspnoea, and central mediation of breathing occurs in the brainstem respiratory centre, an area rich with opioid receptors [Booth and Dudgeon, 2006].
• Two systematic reviews using the same data investigated the effectiveness of opioid drugs given by any route in relieving breathlessness in people who are being treated palliatively:
• Eighteen studies were identified, of which nine involved the non-nebulized route of administration and nine the nebulized route. A small but statistically significant positive effect was found when opioids were administered orally or subcutaneously [Jennings et al, 2001; Jennings et al, 2002].
• Evidence was insufficient to conclude whether nebulized opioids were effective or any better than nebulized normal saline.
• A more recent systematic review investigated the effectiveness of nebulized morphine in the management of dyspnoea due to chronic lung disease:
• Results from nine small studies do not support the use of nebulized morphine for treatment of dyspnoea, although several positive case reports have been published [Brown et al, 2005].

• Consider short-term use of a benzodiazepine:
• If dyspnoea is associated with acute anxiety and benefit from simple measures has been insufficient.
• At the end of life.
• Note: anxiety may contribute to dyspnoea, or anxiety may result from breathlessness.

• Anxiolytics can relieve dyspnoea by depressing hypoxic or hypercapnic ventilatory responses and altering the emotional response to dyspnoea [Doyle et al, 2004].
• Commonly recommended benzodiazepines include:
• Diazepam
• Lorazepam
• Midazolam
• Benzodiazepine selection depends on the stage of terminal disease, the severity of anxiety, and the desired onset of action. For more information, see the section on benzodiazepines in Prescribing Information.
• In people at the end of life or those with severe anxiety, combining an oral opioid and benzodiazepine treatment may be beneficial, but monitoring for sedation is necessary.

• This recommendation is based on palliative care guidelines [International Association for Hospice and Palliative Care, 2004; Lothian Palliative Care Guidelines Group, 2004b; NHMRC, 2004; Pan-Glasgow Palliative Care Algorithm Group, 2005; NCCN, 2006] and expert opinion from the palliative care literature [Doyle et al, 2004; Regnard and Hockley, 2004b].
• Anxiety and agitation are often associated with dyspnoea [NHMRC, 2004] because they cause an increase in oxygen consumption.
• Experts often recommend benzodiazepines to help relieve anxiety, but no evidence is available on their benefit in people with advanced cancer.
• Evidence is insufficient to support the use of benzodiazepines in people with advanced cancer who have dyspnoea. Nonetheless, experts often recommend benzodiazepines to help relieve anxiety, and a trial of a benzodiazepine may be considered on an individual basis [NHMRC, 2004; Booth, 2006].

• Initiation of a corticosteroid (e.g. dexamethasone) in primary care may be necessary in emergency situations involving airway obstruction (see Managing dyspnoea of known cause), but in other situations it should ideally be done only by, or on the advice of, a specialist.
• However, if specialist advice is not available when needed, the decision should be based on the cause of the breathlessness, the likelihood of benefit, and the risk of adverse effects. Local guidelines should be followed, the person should be closely monitored, and specialist advice should be sought as soon as possible with early review by a specialist.

• This recommendation is pragmatic advice, based on expert opinion from medical and palliative care specialists.

• If a person has wheeze thought to be caused by partial airway obstruction from a tumour:
• Refer for more definitive treatment (e.g. radiotherapy or stenting) if appropriate to the person's stage of illness. Seek specialist advice if unsure.
• If more definitive treatment is not appropriate, or the person has to wait for treatment, consider a trial of bronchodilator while waiting, and assess benefit.
• For emergency management of severe airway obstruction, see Managing dyspnoea of known cause.

• If nebulized bronchodilator is used then monitor for adverse effects, such as bronchospasm, after the first dose.

• This recommendation is pragmatic advice, based on medical and palliative care textbooks [Warrell et al, 2003a; Doyle et al, 2004] and expert opinion from palliative care and medical specialists.

• Consider oxygen therapy in people with chronic dyspnoea who need symptomatic treatment despite having tried simple measures, such as improving air circulation by using a fan.
• When selecting people for oxygen therapy, carefully consider the potential risks and benefits in each case.
• The person's need for oxygen therapy should be clinically assessed by the palliative care team in primary care if possible, taking into account, for example:
• The person's response to simple measures.
• If pulse oximetry indicates the person is hypoxic, or whether the person has to make a constant physical effort to avoid hypoxia.
• The underlying cause of the dyspnoea.
• The risks from oxygen use (e.g. does the person or any other member of the household smoke?).
• A trial of short-burst oxygen therapy may be initiated in primary care if considered appropriate following assessment (preferably after discussion with a specialist), and should be tailored to a person's needs.
• Long-term oxygen therapy should be initiated by a respiratory specialist.
• Oxygen therapy may also be appropriate in people with cancer who have dyspnoea of non-malignant causes. For more information, see Managing dyspnoea of known cause.
• For more information see the section on oxygen in Prescribing information.

• Breathlessness with and without oxygen therapy, at rest or on exertion, may be measured using:
• Exercise tests (e.g. in which people exercise at a fixed rate for as long as possible, until they are limited by symptoms).
• Objective measurement of oxygenation (e.g. pulse oximetry, in which a convenient, non-invasive device measures peripheral haemoglobin oxygen saturation by fluctuations of light absorption in well-vascularized tissue).
• However, pulse oximetry is not as accurate as blood gas measurement, so should be used as a guide, to monitor change in levels pre- and post-exertion, to ensure improvement with oxygen therapy, and to titrate dose of oxygen (e.g. to prevent under- or over-dosing).
• Assessment tools (e.g. visual analogue scale, on which people self-report symptom severity).
• Little evidence supports the use of short-burst oxygen therapy immediately before and after exercise.

[Booth and Dudgeon, 2006]

• However, expert opinion suggests that short-burst oxygen therapy may also be useful for pre-planned activity which triggers breathlessness (e.g. washing).
• Short-burst oxygen therapy should be initiated at 2 L/minute. Some experts suggest an initial duration of treatment of between 15 and 30 minutes, but other experts suggest continuing until the person feels benefit.
• Specialist initiation of long-term oxygen therapy (15 hours or more a day) can be considered in people with severe disabling breathlessness due to cancer or other progressive, life-threatening diseases [Twycross et al, 2002].

• Appropriate use of oxygen therapy is recommended for people with dyspnoea and cancer in palliative care guidelines [International Association for Hospice and Palliative Care, 2004; Lothian Palliative Care Guidelines Group, 2004b; NHMRC, 2004; Pan-Glasgow Palliative Care Algorithm Group, 2005; NCCN, 2006] and by published palliative care literature [Doyle et al, 2004; Regnard and Hockley, 2004b; Booth and Dudgeon, 2006]. Recommendations were also based on the expert opinion of palliative care specialists.
• When assessing people, focus on the relevance of oxygen therapy in the clinical context rather than on assessment tools used in research [Booth and Dudgeon, 2006].
• It is very difficult to select people who will benefit significantly from oxygen therapy:
• Oxygen does not relieve breathlessness in all people, and evidence indicates that the people who gain acute benefit from oxygen are not necessarily those who experience an increase in quality of life by using oxygen therapy at home [Booth and Dudgeon, 2006].
• CKS found no studies that identified which people are most likely to benefit significantly from short-burst oxygen therapy. Short-burst oxygen therapy can relieve symptoms in people with cancer and dyspnoea at rest (oxygen saturation =< 90%), although it is uncertain whether oxygen is better than air in people with advanced cancer [Doyle et al, 2004; Gallagher and Roberts, 2004].
• A recent randomized controlled trial (n = 51) investigated the effect of oxygen on dyspnoea in people with advanced cancer and found that symptoms improved with both air and oxygen, and that the treatments did not differ significantly [Philip et al, 2006]. This supports the suggestion that the sensation of airflow is an important determinant of benefit [Twycross et al, 2002].
• In people with oxygen saturation greater than 90%, the role of oxygen is controversial because response to oxygen therapy varies greatly [Twycross et al, 2002].
• Not all breathless people are hypoxaemic, and not all hypoxaemic people benefit from oxygen therapy. Therefore, a simple trial of oxygen is often the best guide to therapy [Booth and Wade, 2003], particularly when pulse oximetry is not available.

• In all cases:
• Consider simple measures to relieve dyspnoea.
• Consider symptomatic treatment if appropriate.
• With the person and their carers and family, determine what management interventions are appropriate for the underlying cause of the dyspnoea and the stage of illness. These may include:
• Treatment of reversible causes in primary care, such as asthma or chronic obstructive pulmonary disease (COPD).
• Referral for treatment of the underlying cancer if needed (e.g. radiotherapy to a tumour, drainage of a pleural effusion).
• Referral if the cause of dyspnoea is not directly related to the underlying cancer but is more appropriately managed in secondary care (e.g. worsening COPD).
• Emergency treatment or admission to hospital (e.g. acute airway obstruction due to tumour or superior vena cava obstruction).
• If in doubt as to whether treatment of the underlying illness is appropriate, seek specialist advice.

• The management of malignant causes of dyspnoea (e.g. tumour) should usually involve a specialist because treatment must be tailored to the person's underlying cancer and co-existing problems and because there are a large variety of treatments available. Treatment options include radiotherapy, aspiration or pleurodesis of a pleural effusion, corticosteroids, or stent when appropriate.
• Management of severe, acute dyspnoea should be based on the cause, or symptoms should be palliated, as appropriate.
• For immediate emergency management [Regnard and Hockley, 2004c]:
• Sit the person upright.
• Ensure a flow of cool air to the face.
• Stay with the person.
• Check oxygen saturation if a pulse oximeter is available. Start 24% oxygen if the saturation is 90% or less.
• If the person develops stridor due to acute airway obstruction by a malignant cause, or superior vena cava obstruction, corticosteroid use may be beneficial in this situation but initiation should ideally be discussed with a palliative care consultant.
• However, if specialist advice is not available, when needed, CKS have reviewed the feedback from expert reviewers and palliative care literature and suggest:
• Giving a single oral dose of dexamethasone 16 mg immediately if the person can swallow. If they are unable to take oral medication, administer the dose via the intramuscular, subcutaneous (not licensed), or intravenous (IV) route (IV administration may be more difficult in primary care and should be given as a slow injection over 2 minutes).
• If dexamethasone is not available, giving prednisolone 60 mg orally.
• Arranging immediate admission to hospital if appropriate. However, if hospital admission is not appropriate, discuss ongoing management with an appropriate specialist.
• Separate CKS topics deal with the management of common non-malignant causes of dyspnoea. These can often be managed in primary care, but in some cases admission to hospital or secondary care advice may be necessary. For more information, see the CKS topics on:
• Anaemia - iron deficiency
• Angina
• Asthma
• Atrial fibrillation
• Chest infections - adult
• Chronic obstructive pulmonary disease
• Heart failure - chronic

• This recommendation is pragmatic advice based on palliative care guidelines [International Association for Hospice and Palliative Care, 2004; Lothian Palliative Care Guidelines Group, 2004b; NHMRC, 2004; Pan-Glasgow Palliative Care Algorithm Group, 2005], palliative care textbook literature [Twycross and Wilcock, 2001; Regnard and Hockley, 2004b], and expert opinion from specialists in palliative care.