Your browser is no longer supported

For the best possible experience using our website we recommend you upgrade to a newer version or another browser.

Your browser appears to have cookies disabled. For the best experience of this website, please enable cookies in your browser

We'll assume we have your consent to use cookies, for example so you won't need to log in each time you visit our site.
Learn more

A non-pharmacological approach to managing breathlessness

  • Comment

VOL: 97, ISSUE: 34, PAGE NO: 57

GILLIAN STENT, BSc, RGN, NDN, is a Macmillan clinical nurse specialist, Papworth Hospital, Cambridge

The experience of breathlessness is a difficult and frightening symptom that both patients and carers feel helpless to control. It can have a profound impact on the quality of life, affecting almost every activity of daily living. It is a challenging symptom to manage and one that requires a multidisciplinary, patient-centred approach. Where pharmacological methods are only partially effective, the need to identify alternative ways of helping patients cope is essential.

The experience of breathlessness is a difficult and frightening symptom that both patients and carers feel helpless to control. It can have a profound impact on the quality of life, affecting almost every activity of daily living. It is a challenging symptom to manage and one that requires a multidisciplinary, patient-centred approach. Where pharmacological methods are only partially effective, the need to identify alternative ways of helping patients cope is essential.

Breathlessness occurs when the demand for oxygen is greater than the body’s ability to supply it (Raynard and Ahmedzai, 1990). The physiological response to this demand is to increase the respiration rate, the emotional one to experience the fear of breathlessness.

Breathlessness is a common symptom of lung cancer, with as many as 65% of patients experiencing it to some degree at some time during their illness (Twycross and Lack, 1986). It may also be a powerful reminder for these patients that their illness is a threat to their existence, creating more distress and anxiety as their disease progresses and symptoms increase.

Higginson and McCarthy (1989) looked at the symptoms of 86 patients referred for terminal symptom control. They found patients with lung cancer most commonly complained of pain and breathlessness. While the symptom of pain improved with treatment, the breathlessness did not and they concluded that ‘existing methods to control dyspnoea are ineffective and that new interventions are needed’.

The work carried out at the Macmillan Practice Development Unit at the Institute of Cancer Research in London has done much to redress this. A pilot study (Corner et al, 1995) aimed to evaluate the effectiveness of a nursing intervention for breathlessness in patients with lung cancer. This intervention used non-pharmacological approaches and focused on maximising quality of life and functional ability.

The emotional experience of breathlessness was considered inseparable from its physical cause, and therefore the intervention strategy both acknowledged the emotional meaning of the symptom and offered breathing retraining for managing it. The result indicated a benefit in the intervention group.

Breathlessness can result from many different causes. A full medical assessment is essential to identify and treat all reversible causes before referral to the clinic (Box 1). Referrals are accepted from any medical/specialist nursing practitioner, but the GP must be aware and in agreement with the patient attending (Box 2). Patients accepted for management attend on four occasions; each visit is planned to last one hour. Carers are encouraged to attend each session. They hear what the patient hears and observe what is taught. This enables them to re-enforce the teaching at home and empowers them to help the patient.

The clinic is led by a clinical nurse specialist, a physiotherapist, occupational therapist and senior staff nurse, all sharing clinical input and patient management.

Visit one: physiotherapy

Breathlessness is a subjective sensation and difficult to quantify. A visual analogue scale or Borg score (Fig 1) can be used to help patients quantify their breathlessness. They are requested to record their best and worst score and their activity levels at the time. A Borg score uses a 0- 10 scale, with a high score correlating to increasing breathlessness.

The physiotherapy aims to focus on teaching the patient breathing control, to slow the respiratory rate and focus on relaxed breathing (Box 3). Posture is important and a good shoulder-down position is taught to encourage breathing using the lower part of the chest and upper abdomen. Exercise tolerance is measured by distance walked or functional activity - for instance, climbing stairs. While mobilisation and activity is encouraged, patients are taught to pace themselves in order to keep their Borg scale at or below five and maintain more control. When very breathless patients are given the following advice:

- As you breathe out, let the air come out in its own time. Don’t force it. Try to take at least twice as long to breathe out as it took to breathe in. This should slow the breathing and help you breathe a little deeper each time;

- Try to keep your shoulders down and relaxed. Someone standing behind you resting their hands on your shoulders may help;

- Place your hands on both sides of your lower chest: as you breathe out, feel your ribs sink. Breathe in and feel your ribs move out and up. Gently breathe out and repeat, breathing in and out as deeply as you can. Do this five times;

- Try to be aware of what is normal for you and pace yourself so that your rate of breathing remains under your control. Carry out activities as slowly as necessary to keep your breathing rate under control

Visit two: nurse practitioner

Breathlessness is a frightening and disabling symptom. Many patients fear they will not regain control and that they will die during an episode of breathlessness. Carers can be equally frightened and feel helpless.

The techniques of relaxation and visualisation are explained and practised. Visualisation can be an effective means of deepening relaxation and relieving the anxiety of a real-life situation. Patients are encouraged to identify their own imagery and to use whichever of their senses they feel are most acute to enrich their experience.

Patients and carers are encouraged to talk about their fears, which we try to dispel with information and discussion. Some patients prefer relaxation to visualisation, some like both and some find both difficult. Patients are given relaxation scripts and loaned tapes to encourage practice at home. It is essential to practise both techniques - they cannot be ‘learnt’ during a breathless episode. The following are tips that may be useful:

- Avoid bending as much as possible; put items on low stools and tables;

- If eating makes you breathless, try having smaller meals more often and snack between meals if you are losing weight. If you are on oxygen, change to a nasal speculum even if it is just at meal times;

- Try not to become overweight - it makes breathing more difficult;

- Create a calm quiet environment rather than a noisy, busy one;

- Using a fan to blow air across the face can relieve the feeling of not having enough air.

Visit three: occupational therapy

The focus here is energy conservation. These techniques are used to ensure that a measured level of activity is achieved without overstressing the patient’s breathing, using energy wisely and efficiently for day-to-day activities. Home visits for assessment can be arranged and the loan of small items of equipment to try before buying is possible.

The aims in Box 4 are achieved by pre-planning and pacing activities, separating tasks into manageable stages and by organising work and living space to conserve energy. The use of labour- and energy-saving equipment is discussed.

Patients are encouraged, if possible, to sit to carry out tasks, to push objects - not to pull them - and to slide things along, not to lift them. Many breathless patients find activities of daily living increase their symptoms.

Simple techniques that may help include:

- Not having the bath/shower too hot and avoiding steamy atmospheres;

- Using a bathrobe rather than towelling dry;

- Avoiding unnecessary trips up and down stairs by planning activity;

- Using a cordless telephone and keeping it close by;

- Having a folding wheelchair to use if unable to walk back;

- Using a supermarket trolley to lean on;

- Using a trolley to move items in the house;

- Raising chairs, beds and toilet seats to make getting up and down easier.

Active teaching takes place on the first three visits. Each practitioner follows up with a short interview at the next visit when re-enforcement or correction to techniques can be made.

Visit four

This takes place several weeks after visit three, when patients are asked to return for review. They meet each practitioner again and progress/achievements are discussed. Following this, patients are discharged from the clinic but are able to self-refer again in the future if they feel this would be beneficial.

At each visit the patient is given written information to re-enforce teaching. Not everyone benefits from attending this clinic - patients have to be prepared to practise the techniques taught to be able to benefit when they need them most. It is hoped that this structured approach enables patients to feel that they can regain some control over this often intractable problem and thereby improve their quality of life.

  • Comment

Have your say

You must sign in to make a comment

Please remember that the submission of any material is governed by our Terms and Conditions and by submitting material you confirm your agreement to these Terms and Conditions. Links may be included in your comments but HTML is not permitted.