Principles of managing chronic breathlessness in palliative care
Management of chronic breathlessness is individualised and depends on comprehensive assessment, potential benefits and burdens of treatment, and the patient’s prognosis, preferences and goals of care—see Principles of symptom management in palliative care. However, management of all patients with chronic breathlessness should include the general measures outlined in General measures for all patients with chronic breathlessness.
Identify reversible causes of breathlessness and manage as appropriate
Optimise management of underlying conditions and comorbidities
Use nonpharmacological therapy
Create a written breathlessness action plan to help patients and carers confidently manage acute-on-chronic breathlessness, including breathlessness crisis
Discuss and create an advance care plan to help reassure patients that appropriate interventions will be offered and withdrawn when no longer providing benefit
Educate patients on how to manage both the acute and chronic nature of their breathlessness
If breathlessness remains problematic despite the use of general measures, consider the addition of an opioid.
For anxiety and distress associated with breathlessness that does not respond to nonpharmacological therapy and opioid therapy, consider the addition of a benzodiazepine—see Benzodiazepines for anxiety associated with chronic breathlessness in palliative care for discussion on the role of benzodiazepines in breathlessness.
Oxygen therapy may provide symptomatic relief for patients with hypoxia (partial pressure of oxygen [PaO2] less than 55 mmHg, or oxygen saturation measured by pulse oximetry [SpO2] less than or equal to 88%). However, breathlessness does not necessarily indicate hypoxia, and even if a patient is hypoxic, oxygen may not improve breathlessnessMcDonald, 2016.
Noninvasive ventilation (eg bilevel positive airway pressure [BPAP]) may be considered for long-term community use in patients with palliative care needs who have chronic hypercapnic respiratory failure (eg chronic obstructive pulmonary disease [COPD]), obesity hypoventilation syndrome, or neuromuscular and chest wall disorders. Seek specialist advice (eg from a respiratory or neurology specialist). Before starting noninvasive ventilation in patients with palliative care needs, discuss advance care planning and make a plan for withdrawal.
Consider referring patients with chronic breathlessness to an integrated respiratory and palliative care service, breathlessness service, or specialist palliative care service to help support patients and carers with disease-specific management, alongside breathlessness action plans, nonpharmacological therapy, opioid therapy and advance care planning discussionsBausewein, Schumacher, 2018Broese, 2021McDonald, 2022Smallwood, Currow, 2018Smallwood, Gaffney, 2018Smallwood, Thompson, 2018.
For management of severe acute breathlessness (breathlessness crisis), see Severe acute breathlessness in palliative care.
For management of breathlessness in the last days of life, see Breathlessness causing distress in the last days of life.