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.
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.
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
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.
Causes of Dyspnea
Vena Cava (SVC) obstruction
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.
Nebulized local anesthetic
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.
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.
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.
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.
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)
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
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.
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.
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.
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.
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
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.
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)
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.
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.
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.)
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.