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Guided learning

Breathlessness in advanced disease 2: patient assessment and management 

  • Comment

Breathlessness is a common problem in advanced disease. This article looks at pharmacological and non-pharmacological ways to manage this symptom.

Author

Donna Barnes, PG Cert Health and Social Care (Palliative), RN, is a staff nurse in palliative care, Nightingale Macmillan Unit, Royal Derby Hospital.

Abstract

Barnes D (2010) Breathlessness in advanced disease 2: patient assessment and management. Nursing Times; 106: 44, early online publication.

This second of a two-part unit on breathlessness addresses patient assessment and management including common treatments.  Interventions that can be taught to and used independently by patients and carers are explored.

Keywords Breathlessness, Advanced disease, Palliative care

  • This article has been double-blind peer reviewed

Learning objectives

  • Understand the role of assessment in the management of breathlessness.
  • Be aware of the common treatments involved in management of breathlessness in advanced disease. 

Assessment

Effective treatment of breathlessness should begin with a comprehensive assessment, including a full medical history, examination and appropriate investigations (Davis, 1997).  This may help to identify causes of breathlessness - such as infection or anaemia – that can respond to treatment.  Patients with advanced disease may find investigations and clinical procedures difficult to cope with and the treatment plan is likely to focus on pharmacological and non-pharmacological measures which will cause minimal distress to the patient (Twycross et al, 2009). 

Measurement tools

Twycross et al, (2009) categorise dyspnoea into three types: on exertion, at rest and terminal breathlessness, with terminal breathlessness indicating a poor prognosis. 

The nurse can use a variety of tools to measure breathlessness but currently, no single scale incorporates the extensive impact that breathlessness has on those with advanced disease (Bausewein et al. 2007).  Ideally, assessment should include the characteristics of breathlessness such as frequency, severity, exacerbating and relieving factors, and associated symptoms, such as presence of wheeze and colour and consistency of sputum (Bausewein et al, 2007, Twycross et al, 2009).  Physical indicators such as cyanosis or oxygen saturations may be used to evaluate the effectiveness of oxygen therapy (Twycross et al, 2009).

Wider issues such as drug history, environmental factors and the course of the specific disease trajectory are important (Bausewein et al, 2007, Twycross et al, 2009).  The impact on physical, psychosocial and spiritual welfare of the patient and their carers should also be assessed (Bausewein et al, 2007, Twycross et al, 2009). 

Uni-dimensional tools are commonly used and are simple and quick to complete (Bausewein et al, 2007).  These include the visual analogue scale (VAS), numerical rating scale, and the Modified Borg Scale (Bausewein et al, 2007).  The Modified Borg Scale asks patients to rate the intensity of the sensation of breathlessness from 0 to 10 using verbal descriptors such as “very, very slight” and “very severe” (Dorman et al, 2009). 

More detailed and time-consuming breathlessness-specific tools help the nurse to assess the wider impact of dyspnoea such as functional ability and anxiety levels (Bausewein et al, 2007). Similarly, disease-specific tools, including the Chronic Respiratory Disease Questionnaire (CRQ) look at domains such as coping skills and social activity to assess impact on quality of life (Dorman et al, 2009).          

A systematic review (Bausewein et al, 2007), recommended combining assessment tools to measure breathlessness associated with advanced disease.  Bausewein et al, (2007) suggested using a uni-dimensional scale, such as the VAS, in conjunction with a disease-specific scale, such as the CRQ. This approach helps to identify the effects of breathlessness in advanced disease on patients and their family (Bausewein et al, 2007).  

Treatment

Management of breathlessness in advanced disease remains difficult, because there is a poor evidence base (Booth et al, 2004).  Problems with existing research includes a lack of standardised definitions (Renwick, 2001)difficulties measuring breathlessness specifically (Bausewein et al, 2007), and design flaws of many studies (Dorman et al, 2009). 

To be effective, management of breathlessness in advanced disease needs to involve both the patient and those close to them.  Carers in particular often lack support (Gysels and Higginson, 2009) and have reported needing information on breathlessness, guidance on how to manage severe episodes, reassurance and simple interventions to support the patient (Moody et al, 2004).  The ward nurse is well placed to identify the needs of carers when their relatives are admitted.  Giving individualised information and providing written notes for what to do during a severe attack can reduce anxiety and allow patients to take steps to regain control of their breathing (Twycross et al, 2009; Booth, 2006).      

Morphine

Althoughexpert opinion recommends that morphine can be used safely for the management of dyspnoea in malignant and non-malignant disease, health professionals are reluctant to use it (Borton, 2008).  The evidence for using morphine has been questioned and inone critical review, studies were found to be limited in terms of data collection, sample size and a lack of control groups (Jantarakupt and Porock, 2005).

Nevertheless, the studies consistently found the risk of respiratory depression was low when small doses of morphine were used (Jantarakupt and Porock, 2005).  This finding is supported by other research (Clemens and Klaschik, 2007) and by clinical experts (Twycross et al, 2009). 

The mechanism by which morphine palliates dyspnoea is not fully understood (Borton, 2008), but it is thought to:

  • decrease the response of central and peripheral chemoreceptors to hypercapnia and hypoxaemia;
  • reduce anxiety by acting on the receptors in the higher brain centres which respond to emotional distress;
  • have a hypotensive effect that reduces preload on the heart and decreases pulmonary oedema (Jantarakupt and Porock, 2005). 

Misconceptions about morphine are common (Jantarakupt and Porock, 2005).  Although the risk of respiratory depression is low, it should still be considered a potential side effect by practitioners and monitored appropriately (Borton, 2008). Carers may be concerned about side effects such as nausea, vomiting, constipation and dry mouth.  Time should be taken to explain the benefits and risks of morphine for breathlessness (Twycross et al, 2009).

Doses should start with a low dose and titrate upwards according to response and side effects (Jantarakupt and Porock, 2005; Borton, 2008).  For those already taking morphine, the overall dose may need to be increased by 30 to 50 per cent (Borton, 2008).  Doses are typically smaller than required for pain management and should take account of route of administration, age and renal function (Jantarakupt and Porock, 2005).  

Parenteral opioids are used when the oral route is not appropriate (Borton, 2008) and administration by continuous subcutaneous infusion avoids the “peaks and troughs” associated with oral medication (Twycross et al, 2009). 

Benzodiazepines

Although benzodiazepines are widely used for breathlessness, evidence regarding their effectiveness is unclear (Booth, 2006).  Simon et al (2010) found no evidence that benzodiazepines relieved breathlessness in advanced cancer or COPD.  However, a lack of well-conducted studies limited this small review.  Overall, benzodiazepines are recommended as a second or third-line treatment when opioids and non-pharmacological measures have failed (Simon et al, 2010).   

Benzodiazepines may:

  • be beneficial as they relieve anxiety (Twycross et al, 2009); 
  • encourage relaxation of the respiratory muscles, reducing respiratory drive by decreasing pulmonary ventilation (Davis, 2005);

Respiratory depression is a complication of benzodiazepines as well as opiates (Borton, 2008) and the risk of excessive sedation necessitates close monitoring with older adults and those with poor renal function (Simon et al, 2010).  Diazepam, lorazepam and midazolam are most commonly used drugs (Borton, 2008). 

Midazolam can be given parentally and Navigante et al, (2006) notes that it works more rapidly than other benzodiazepines with a shorter duration of action.   Navigante et al, (2006) suggest that midazolam may improve the efficacy of morphine used to manage dyspnoea when the two drugs are used together.   

Oxygen and fans

Oxygen is commonly used to treat breathlessness in advanced disease without evidence that it is effective (Uronis et al, 2008) and its place in palliative care remains controversial (Booth et al, 2004).  In the author’s experience, failing to use oxygen or withdrawing it can raise concerns for patients and carers. 

Booth et al, (2004) found oxygen is beneficial for dyspnoea in advanced cancer and COPD, but noted a lack of evidence for heart failure. More recently, Cranston et al, (2008) failed to demonstrate consistent benefit for oxygen over piped air in advanced cancer. 

There is consensus that it is more beneficial to offer oxygen in short bursts as required, rather than continuously (Booth, 2006) and that oxygen should not be used when resting oxygen saturation is normal (Borton, 2008).  Jantarakupt and Porock (2005) argue that even if oxygen does not actually diminish the sensation of dyspnoea, the fact that patients report less breathlessness with its use provides sufficient rationale.  However, oxygen is not a benign treatment.  Negative associations include:

  • drying effects on the oral and nasal mucosa (Borton, 2008);
  • complications associated with hypercapnic respiratory failure (Uronis et al, 2008); 
  • psychological dependency; 
  • physical restriction;   
  • fire hazards (Booth et al, 2004).

Twycross et al, (2009) suggest that it is the sensation of airflow, possibly with a cooling effect, that provides relief.  Consequently, cool air from an open window or fan may also reduce the sensation of dyspnoea (Jantarakupt and Porock, 2005), and should be offered before oxygen is prescribed (Twycross et al, 2009, Booth, 2006).

Fans reduce the severity of breathlessness by cooling the face in the area of the trigeminal nerve (Booth, 2006)However Bausewein et al (2008) could not judge the evidence for their use as there is insufficient research data.  Anecdotal evidence from work in one breathlessness clinic suggests that fans are a very useful cheap intervention, have no side effects and offer patients a degree of control over their symptoms (Booth, 2006).

Non-pharmacological measures

There appears to be little research into the role of non-pharmacological  treatments for breathlessness despite the integral part that they play in patient care (Booth, 2006).

Pulmonary rehabilitation (PR) is one example of a non-pharmacological approach that offers benefit to those with even severe disease, particularly patients with end-stage COPD (Clini and Ambrinoso 2008, Thomas et al, 2010). PR is an evidence-based multidisciplinary intervention including education, psychological support and techniques such as walking exercises, work simplification and breathing strategies (Clini and Ambrinoso 2008, Thomas et al, 2010).      

Breathing strategies, positioning and relaxation are techniques commonly used in the in-patient setting. 

Breathing strategies

Bausewein et al (2008) noted in their review that “breathing training” was supported by moderate strength evidence but a specific definition of the term was not given.  Breathing techniques, positioning and relaxation were all included under the heading.      

A more relaxed, controlled breathing pattern can minimise the work of breathing and produce more effective ventilation than the shallow, rapid pattern of dyspnoea (Twycross et al, 2009). It can also re-establish a sense of control for the patient and break the cycle of increasing dyspnoea and panic (Jantarakupt and Porock, 2005).  Similarly, deep inhalation through the nose followed by pursed-lip exhalation increases lung expansion and improves gas exchange (Twycross et al, 2009). 

Positioning

There is little research regarding the effect of positioning on breathlessness (Jantarakupt and Porock, 2005).  However, anecdotal evidence supports the beneficial effects of careful attention to positioning even in the terminal phase of illness (Davis, 2005).  Leaning forward, for example sitting on the edge of the bed with arms folded on the bedside table is a comfortable position can reduce dyspnoea (figure 1).   In this position less transdiaphragmatic pressure occurs and the abdominal wall can move outward more easily (Jantarakupt and Porock, 2005).  This provides more space for lung expansion and gas exchange.

Relaxation

Relaxation is generally achieved through verbal instructions regarding progressive muscle relaxation or guided imagery.  Complete muscular relaxation can decrease oxygen consumption, carbon dioxide production and respiratory rate (Jantarakupt and Porock, 2005).  A lack of data means that the evidence for relaxation therapies cannot be judged (Bausewein et al, 2008) however, given the role that anxiety plays in precipitating and exacerbating breathlessness, interventions that interrupt the escalation of anxiety can be useful.    

Nurses can discuss the benefits of a peaceful environment with patients and carers.  Relaxation tapes or compact discs and complementary therapy are often available in palliative care units. 

These non-pharmacological measures are cost-efficient strategies that can be easily explained by nurses (Jantarakupt and Porock, 2005) and implemented by patients and carers. They provide simple, practical tips that are especially helpful during acute exacerbations.

Conclusion

The current management of breathlessness is unsatisfactory due to a limited understanding of its complex pathophysiology, its subjective nature and numerous research difficulties.  The result is a lack of evidence which prevents a consistent approach to treating breathlessness in practice and ultimately hampers the service received by patients and carers.

The evidence–based information provided in this article can be useful to both general nurses and those in palliative care settings.  Management advice can be discussed with patients and carers to increase their ability to self-manage this distressing symptom of advanced disease. 

Preventing or reducing the severity of an acute attack

Written advice on how to prevent or reduce the severity of an acute attack may include the following practical tips.   

  • Keep the room well ventilated, with a cool draft directed towards the breathless person using an open window or fan.
  • Encourage better positioning, such as leaning forward with arms resting on the bed table, to provide some relief.
  • Encourage more relaxed breathing by focusing on the person breathing out slowly through pursed lips.
  • A peaceful environment can aid relaxation.
  • Anxiety can be reduced by family and friends providing support, distraction and reassurance. Ward staff can refer patients to the complementary therapist for additional relaxation techniques.

Patients at home should be given a direct telephone number of the ward or community team who can offer support and advice. 

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