Assessing breathlessness in palliative care

When assessing breathlessness in patients with palliative care needs:

For principles of symptom assessment in palliative care, see Symptom assessment in palliative care.

Figure 1. Common or important causes of breathlessness in palliative care

acidosis

anaemia

anxiety and associated disorders

cachexia

Cancer complications (eg airway obstruction, pleural effusion, pericardial effusion, superior vena cava obstruction, lymphangitis carcinomatosis, radiation- and drug-related pneumonitis)

decompensated heart failure [NB1]

deconditioning

exacerbations or progression of respiratory disease (eg COPD)

neuromuscular conditions (eg myopathy, motor neurone disease)

pneumothorax

pulmonary embolism

respiratory tract infections (eg pneumonia)

Note:

COPD = chronic obstructive pulmonary disease

NB1: See also Acute cardiogenic pulmonary oedema in the Cardiovascular guidelines.

New and acute-onset breathlessness is more likely to be reversible than progressive longstanding breathlessness. The following investigations may assist in determining reversible causes of breathlessness:

  • blood tests, including full blood count, electrolytes and D-dimer (eg for infection, anaemia or pulmonary embolism)
  • chest X-ray (eg for pneumonia, pleural effusions, pulmonary oedema or pneumothorax)
  • electrocardiogram (ECG) (eg for acute coronary syndrome)
  • pulse oximetry
  • venous blood gases.

If a specific cause of breathlessness is suspected, consider other investigations as indicated, depending on the potential benefits, burdens and availability of investigations and resultant treatment, and the patient’s prognosis, preferences and goals of care. Example investigations include:

  • echocardiography (eg for pericardial effusion or acute right heart strain)
  • computed tomography (CT) (eg for pulmonary embolism, superior vena cava obstruction or progressive airway obstruction)
  • respiratory function tests and 6-minute walk test (eg for obstructive lung disease or hypoxia).

Arterial blood gases can determine the risk of hypercapnic respiratory failure but are more uncomfortable for patients than venous blood gases—avoid taking arterial blood gases unless noninvasive ventilation is being considered. For further information, see Arterial blood gases and Venous blood gases in the Respiratory guidelines.