Dyspnea means a distressing difficulty in breathing. It is a symptom, not a sign. A patient may have difficulty breathing and yet have no abnormal physical signs.

Incidence – Shortness of breath is reported in about 40% of cancer patients on admission to a hospice, (and in 70% of those with lung cancer). Most of these patients have mild shortness of breath on exertion, which is part of the picture of increasing weakness. Only about 5% to 10% of patients have distressing dyspnea that severely limits their mobility.

Sudden onset of dyspnea suggests arrythmia, embolus or left ventricular failure due to a myocardial infarction. Onset over hours or days suggests infection or effusion. Gradual onset over weeks suggests tumor growth or anemia (or rarely multiple pulmonary emboli).

Episodic shortness of breath is usually due to hyperventilation. Any patient with both dyspnea and cancer is prone to episodes of anxiety or panic. However it can occasionally be due to arrythmias, broncho-esophageal fistula or pulmonary emboli.

Treatable Causes of Dyspnea Treatment
Anemia Blood transfusion
Cardiac failure Diuretics
Pleural effusion Aspiration

Pericardial effusion                      

Pneumothorax Chest drain
Bronchospasm Bronchodilators
Lung infection Antibiotics
Lobar collapse Radiotherapy

Superior Vena Cava (SVC) obstruction

Ascites Paracentesis
Pulmonary emboli Anti-coagulants

Management options:

  1. Morphine
  2. Bronchodilators
  3. Theophylline, aminophylline
  4. Nebulized local anesthetic
  5. High dose steroids
  6. Physiotherapy
  7. Reassurance
  8. Breathing exercises
  9. Relaxation therapy
  10. Anxiolytics
  11. (Oxygen)
  12. (Nabilone)
1. Morphine reduces the inappropriate and excessive respiratory drive which is a feature of dyspnea. A low dose is often sufficient in a patient who is not already taking morphine. A starting dose for treating dyspnea should be 2.5mg to 5mg of oral morphine every 4 hours. It reduces inappropriate tachypnea (rapid breathing) and over-ventilation of the large airways (dead space). It does not cause CO2 retention used in this way, and it can even reduce cyanosis by slowing ventilation and making breathing more efficient. Doses above 10mg to 20mg every 4 hours are unlikely to give further benefit. Morphine can be given via a nebulizer.

2. Bronchodilators are very important because many patients have an unexpected airway obstruction that can be reversed, improving if not abolishing dyspnea. Nebulized adrenergic drugs and/or anti-cholinergic bronchodilators every 4 hours may be much more effective for weak patients than metered-dose aerosols, and should always be considered for a patient with dyspnea which is not responding to other measures, even if expiratory wheeze is not clinically obvious.

3. Theophylline and aminophylline can reduce dyspnea in COPD, not just as a bronchodilator (having an additive effect with adrenergic stimulants), but also by improving ventricular function by peripheral vasodilation. The slow release oral preparations should be used.

4. Nebulized local anesthetic can reduce dyspnea (and cough) in some patients, particularly those with bilateral diffuse disease or lymphangitis carcinomatosa. It can be effective as a single night-time dose, or used every 4 hours if necessary. (An ultrasound or jet nebulizer can be used, but a mouthpiece should be used rather than a mask.) It causes pharyngeal numbness, and the patient should be warned not to eat or drink for 30 minutes after treatment, to avoid choking. It is a technique still being evaluated and the patient should be closely observed during treatment. (see Cough)

5. High dose steroids (dexamethasone 8mg per day) can improve breathing if there is airway obstruction and sometimes if there is lymphangitis carcinomatosa (when there may be no abnormal physical signs). SVC obstruction may respond, but radiotherapy should always be considered. A week’s trial of high dose steroids is also considered if dyspnea has not responded to other measures.

6. Appropriate therapies by a skilled physiotherapist, respiratory therapist and/or relaxation therapist are usually the key elements in managing patients with dyspnea, and can transform the life of these patients, enabling them to cope psychologically and to extend their range of day-to-day activities. Breathing exercises, relaxation techniques and teaching the patient (and family) how to clear secretions by gentle shaking of the chest wall may all be involved. (Most patients are too ill for a full program of postural drainage to be appropriate.) Nebulized saline can be helpful to loosen secretions prior to therapy. (see Physical Therapy)

7. Reassurance is effective if the patient feels trust (partly induced by a detailed assessment and examination prior to reassuring). Explanations from all team members need to be the same, so good communication is essential. Reassurance usually needs to be repeated. Common fears are of suffocating or choking to death, and these usually need to be discussed in detail.

The nurse and doctor must examine, explain and reassure. (“You are noticing your breathing, a bit like after running very hard, but parts of your lungs are working well, and the air is going out and in normally. The medicines will help the breathing.”) This sort of explanation usually needs to be repeated many times over. Most patients with dyspnea fear that their breathing will get worse and worse, but a peaceful end can be guaranteed, even though in extremely severe cases it has to be by heavy sedation.

8. Breathing exercises focus on exhaling completely, lowering the shoulders, and inhaling by moving lower ribs as well as breathing abdominally with the diaphragm. Performed correctly they slow respiration, making it more efficient. The patient often feels more in control by having something he can do about the situation during episodes of breathlessness.

9. Relaxation therapy is an essential part of management. Most patients with dyspnea have episodes of panic which tend to cause hyperventilation and worsening dyspnea. Relaxation therapy can reduce the incidence of hyperventilation. It is also helpful during episodes. One patient who was markedly improved said, “Now, when I feel breathless, I know what to think.” (see Relaxation)

10. Anxiolytics can be very helpful, but should be used in conjunction with relaxation therapy and breathing exercises. Diazepam 2mg 3 times a day is often helpful without causing excessive sedation. If the patient already feels drowsy, consider haloperidol 3mg to 5mg 2 times a day.

11. Oxygen therapy is rarely helpful in chronic dyspnea. Blood gases are often normal, and relatively few patients are breathless due to hypoxia (end-stage fibrosing alveolitis and COPD can be exceptions). If the patient wants oxygen for psychological reasons, nasal prongs are definitely preferable to a mask which makes talking and eating difficult and cuts the patient off from others (and severely dries out the mouth if not humidified). Most patients should be weaned off oxygen once other methods are instituted.

12. Nabilone is a synthetic derivative of cannabis with both bronchodilator and sedative properties, which has been used as a second-line drug to morphine for control of chronic dyspnea. It has to be started at low doses (0.1mg 2 times a day) and gradually increased. There is a risk of arrythmias. It remains experimental.

Severe dyspnea – In severe dyspnea even at rest, the patient needs to know that he will not be left alone. An electric fan or humidifier at the bed is often psychologically helpful. Nursing care involves careful positioning (45 degrees usually feels most comfortable), and helping the patient to achieve as much independence as is compatible with his dyspnea. The patient usually prefers people not to crowd around. If the patient remains very distressed despite all possible measures, it may be necessary to give morphine and diazepam in high enough doses to relieve distress, even if this causes drowsiness or unconsciousness.

Terminal bubbling – Secretions in the large airways are occasionally distressing to the patient. More commonly the patient is unconscious and the bubbling “death rattle” distresses the family. Scopolamine 0.4mg IM every 3 to 4 hours, or by continuous subcutaneous infusion, often helps. Sucking out secretions is effective only for a short time. Turning the patient sometimes reduces the bubbling noise. (see Terminal Phase)

Note on nebulizer therapy  – The jet nebulizer works by a stream of compressed air or oxygen which draws the liquid up through a capillary by the venturi effect and then atomizes it into an aerosol of tiny droplets of variable size. 4ml to 6ml of drug solution should be combined with an oxygen flow rate of 6L to 8L/min. During nebulization the solution cools by about 120C which can cause bronchospasm in some individuals.

The ultrasonic nebulizer depends on the high frequency vibration of a piezo-electrical crystal (which vibrates when an electric current is passed across it). The crystal is focused on the surface of the liquid to create a fountain of droplets. Particle size tends to be larger (4 to 10 microns) than with jet nebulizers. Some of the energy from the crystal is converted into heat so that the aerosol is warmer.

Droplets between 1 to 5 microns in diameter reach all parts of the lung right down to the alveoli in normal individuals. Most particles above 8 microns are deposited in the oropharynx. (Droplet size can be measured by collecting the nebulized mist on a thin film of oil on a microscope slide.)

About 12% of the nebulized drug actually reaches the lungs; the rest is either exhaled or stays in the apparatus. In a metered dose inhaler, about 9% of the drug reaches the lungs.

The author and publisher have taken precautions to ensure that the information in this book is error-free. However, readers must be guided by their own personal and professional standards of good practice in evaluating and applying recommendations made herein. The contents of this book represent the views and experience of the author, and not necessarily those of the publisher.

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