Nonpharmacological therapy for chronic breathlessness in palliative care

A combination of nonpharmacological techniques, individualised to the patient, is key to managing chronic breathlessness. While many techniques are specific to the cause, overarching principles are similar. For fact sheets on some nonpharmacological techniques for breathlessness (including breathlessness action plans), see the NHS Breathlessness Intervention Service website and the Inspire: breathing better website.

Breathlessness can be eased with certain postures and positions that help accessory muscles involved in breathing. Sitting upright and leaning forward a little while resting the arms on pillows or knees, or on a table, is often helpful. No one position suits everyone, and experimentation is required.

Breathlessness can lead to inefficient breathing techniques, resulting in less comfortable breathing. Physiotherapists can provide advice on breathing training to reduce hyperventilation and accessory muscle use, and aid breathing recovery. For example, patients with COPD may find it helpful to use long breaths out, or a pursed lips exhale (can be described as trying to ‘blow out a candle’). Some patients may find gentle or relaxed breaths helpful.

Hand-held fansBarnes-Harris, 2019Swan, 2019 can reduce breathlessness. Airflow on the face, nose and upper airway alters central perception of breathlessness and decreases neural drive. Fans may be used in exercise recovery, during daily activities that cause breathlessness, and in severe acute breathlessness.

Improving airflow in the environment can help with breathlessness, and can be achieved by:

• increasing cool air movement around the person (eg by opening doors and windows, using bedside fans or cool face washers)
• using cooler shower temperatures and deflecting the shower stream away from the person’s face.

Breathlessness can trigger anxiety by activating the fight or flight response. Anxiety and panic increases dysfunctional breathing patterns of quick and shallow breaths, which increase muscle tension and effort of breathing. Anxiety about breathlessness can result in avoidance of activities that cause breathlessness, which can lead to deconditioning and exacerbation of breathlessness. Use of a mantra or positive prompt within a breathlessness action plan can reassure patients that the breathlessness has occurred before and that it will soon pass. Examples of mantras include:

• ‘I have had this feeling before and I know it will go away soon’.
• ‘This will pass’.
• ‘I am breathing’.

Relaxation and mindfulness can reduce stress and anxiety associated with breathlessness. These strategies are commonly employed within a broader intervention to address breathlessness, such as within a program of integrated respiratory palliative care or pulmonary rehabilitation. Examples of relaxation exercises may include visualisation, meditation, listening to music or reading.

Chronic breathlessness often leads patients to reduce their activity levels to avoid breathlessness. This causes deconditioning which further worsens breathlessness because weakened muscles use oxygen less efficiently. Reassure patients that moderate breathlessness while being active is not harmful. Encourage patients with chronic breathlessness to participate in tailored exercise programs (eg those provided by pulmonary rehabilitation), which can improve quality of life in many conditions including COPD, interstitial lung disease and advanced cancerDowman, 2021McCarthy, 2015Wang, 2016. Pulmonary rehabilitation services and occupational therapists can provide advice on how to focus on conserving energy, and educate patients on balancing rest with activity rather than using up energy all at once. Simple advice may include suggesting a process of planning, pacing and prioritising activities for the day. Occupational therapists can also provide advice on how to make everyday activities at home more manageable, such as using equipment and walking aids, bathroom modifications or handrails, or keeping regularly used objects (eg phone chargers) close at hand.