• Scenario: Assessment of dyspnoea: covers the assessment of people with dyspnoea in a palliative care setting, in order to determine the cause of dyspnoea and manage the person appropriately.
• Scenario: Symptomatic treatment: covers the management of people with dyspnoea in a palliative care setting who require treatment of symptoms.
• Scenario: Known cause of dyspnoea: covers the management of people with dyspnoea of known cause in a palliative care setting.

• The terms dyspnoea and breathlessness are commonly used interchangeably. However, breathlessness is physically apparent in a person, whereas dyspnoea is the sensation of difficulty in breathing.
• Like pain, dyspnoea is subjective and involves the perception of breathlessness and the person's reaction to it. Anxiety is often a major component of 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.

In depth

• 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).
• Looking for features of a panic attack or hyperventilation.
• If appropriate, observe the person walking a set distance or carrying out a set task.

In depth

• 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).

In depth

• Keep the room cool, improve air circulation with a fan or open window, and encourage relaxation and breathing techniques.
• Provide reassurance and an explanation of dyspnoea and its underlying cause.
• Encourage exercise within the person's capabilities.

In depth

• For symptomatic treatment of dyspnoea, especially in people nearing the end of life.

In depth

• If not taking an opioid: start oral morphine 2 mg or 2.5 mg. Most people can take this dose every 4 hours and as required, although people with breathlessness may not need as frequent dosing (e.g. just as required 30 minutes before exercise for dyspnoea on exertion).
• If taking a weak opioid (e.g. codeine): only continue the weak opioid if appropriate. Start oral morphine 2.5 mg to 10 mg every 4 hours and as required (or just as required 30 minutes before exercise for dyspnoea on exertion).
• If taking regular analgesic morphine: increase regular morphine dose by around 30% every 2–3 days until symptoms controlled or adverse effects prevent further dose increases.
• Reassess every 2 days and increase the dose until dyspnoea is controlled without adverse effects and the dose is stable. If regular morphine is needed throughout the day, convert to a modified-release preparation. If only one or two doses are needed each day, continue as-required doses of standard-release morphine.
• If benefit once on a stable dose and no adverse effects, calculate the total dose given over 24 hours (new total daily dose). The new 4-hourly dose is one sixth of this.

In depth

• For dyspnoea associated with acute anxiety and benefit from simple measures has been insufficient, or the person is at the end of life.

In depth

• Use diazepam (chronic anxiety-related dyspnoea symptoms), lorazepam (acute scenario), or midazolam (for intractable breathlessness when required or by continuous subcutaneous infusion).
• Dose: consider the person's age, general condition, previous benzodiazepine use, intensity of distress, and the urgency of relief. In general, start low doses for elderly and debilitated people.

In depth

• Corticosteroids may be necessary in emergency situations involving airway obstruction (see Scenario: Known cause of dyspnoea), but otherwise should ideally be initiated only by, or on the advice of, a specialist.

In depth

• If wheeze thought to be due to partial airway obstruction from a tumour, refer for definitive treatment (e.g. radiotherapy or stenting) if appropriate to the person's stage of illness. If definitive treatment is inappropriate, or there is a delay to treatment, consider a trial of bronchodilator and assess benefit. Seek specialist advice if unsure.
• For emergency management of severe airway obstruction, see Scenario: Known cause of dyspnoea.

In depth

• Consider in people with chronic dyspnoea who need symptomatic treatment despite having tried simple measures.
• Clinically assess in primary care if possible, taking into account benefit from simple measures, degree of hypoxia, underlying cause, and risk/benefit of oxygen.
• If appropriate, a trial of short-burst oxygen therapy may be initiated in primary care following assessment. Tailor to the person's needs. Long-term oxygen therapy should be initiated by a respiratory specialist.

In depth

• The terms dyspnoea and breathlessness are commonly used interchangeably. However, breathlessness is physically apparent in a person, whereas dyspnoea is the sensation of difficulty in breathing.
• Like pain, dyspnoea is subjective and involves the perception of breathlessness and the person's reaction to it. Anxiety is often a major component of dyspnoea.

• Keep the room cool, improve air circulation with a fan or open window, and encourage relaxation and breathing techniques.
• Provide reassurance and an explanation of dyspnoea and its underlying cause.
• Encourage exercise within the person's capabilities.

In depth

• In all cases:
• Consider simple measures to relieve dyspnoea.
• Consider symptomatic treatment if appropriate. See Scenario: Symptomatic treatment.
• 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.
• For immediate emergency management:
• 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.

In depth