Breathlessness

• Undertake a holistic assessment using a multiprofessional approach. 
• Ask the patient to rate symptom severity and assess the level of associated distress or anxiety. Use appropriate scales, eg modified MRC Dyspnoea Scale.
• Explore the patient's understanding of the reasons for breathlessness, fears, impact on functional abilities and quality of life.
• Clarify the pattern of breathlessness, precipitating, aggravating and alleviating factors, and associated symptoms.
• Check oxygen saturation levels using a pulse oximeter. Note that readings may be less accurate in people with dark skin tone, so this should not be used as the only assessment measure.
• Assess for any potentially reversible causes of breathlessness, such as infection, pleural effusion, anaemia, arrhythmia, pulmonary embolism and bronchospasm.
• Determine if treatment of the underlying disease is appropriate. Seek advice if in doubt.
• If there are signs and symptoms of superior vena cava obstruction or stridor refer to the specific guidance for those conditions.
• If in last days of life, refer to Care in the last days of life.

• Treat any potentially reversible causes if appropriate. Seek advice if in doubt.
• Optimise current therapy (both non-pharmacological and pharmacological management).
• Acknowledge the person’s fear and anxieties, and provide supportive care. For example, offer a verbal explanation of symptoms, and provide written information.
• Non-pharmacological measures should be considered before initiating pharmacological management.

Non-pharmacological management

• Consider a self-management plan (with or without support from other appropriate health professionals).
• If appropriate, provide smoking cessation advice and consider nicotine replacement therapy. Advise a smoke-free environment where possible.
• Support and encourage coping and breathlessness management techniques such as pursed lip breathing, using a handheld fan, opening a window, positioning and strategies to manage anxiety and fatigue.
• Advise on managing and trying to maintain physical activity levels.
• Consider the need for any supportive equipment and a package of care.
• Consider referral to allied health professionals for palliative rehabilitation and management of breathlessness and respiratory function
  • Refer to breathlessness support and rehabilitation services (such as pulmonary rehabilitation or hospice) as appropriate.
• Menthol cream applied to the face and chest may help to manage breathlessness, so may be considered when available.
• Acupuncture may be considered when available.
• Essential oils are contraindicated if oxygen is in use.

Pharmacological management

Opioids

• Can reduce breathlessness at rest, on exertion (taken 15–30 minutes before expected exertion) and in the last days of life.
• Give as a therapeutic trial; monitor patient response and side effects.
• When prescribing opioids, consider proactive prescribing for constipation, and nausea and vomiting.
• Doses above 30 mg oral morphine in 24 hours may not confer additional benefit in terms of breathlessness management, if the person is opioid naive.

For a person who is opioid naive

For a person already established on an opioid

• Use the existing immediate-release breakthrough analgesic dose (oral if able, or subcutaneous bolus injection equivalent) for the relief of breathlessness.
• If taking a weak opioid such as codeine or tramadol, (ie WHO Pain Ladder step 2) consider switching to oral morphine equivalent dosing.
• 3 or more breakthrough doses taken in 24 hours for all indications (pain, breathlessness and cough) should trigger a dose review.
• Titrate both regular and breakthrough dose according to response.

Clinical situations where a modified approach is needed

Corticosteroids

• Trial †dexamethasone 8 mg to 16 mg daily orally (or parenteral equivalent) for lymphangitis or tumour-associated airway obstruction. Consider gastric protection.
• Unless starting emergency therapy, give corticosteroids in the morning.
• Review after 1 week and reduce gradually to the lowest effective dose where appropriate.

If there is no effect, stop treatment by weaning as appropriate.

Benzodiazepines

• May relieve anxiety and panic associated with severe breathlessness but:

• are less effective than opioids for breathlessness
• should be a third-line treatment for patients with symptoms unresponsive to non-drug measures and opioids.

• The following can be considered:
  • lorazepam (scored tablet) sublingual 500 micrograms, given 4–6 hourly as required. Oral solution and 250 microgram tablets are also available
  • diazepam oral 2 mg to 5 mg at night, if there is continuous distressing anxiety
  • †midazolam subcutaneously 2 mg, given 4–6 hourly as required, if oral or sublingual routes are not appropriate.

Oxygen

• Should only be given after careful individual patient assessment, including if the patient or any cohabitors or visitors are smokers.
• Only use if the patient is hypoxic.
• If oxygen saturation is less than 90% and the patient is not known to have COPD or type 2 respiratory failure, consider a trial of 1–2 litres/min of oxygen for symptom relief. It is important to be aware that there may be a poor relationship between hypoxaemia, breathlessness and response to oxygen.
• If there are concerns regarding the risk of type 2 respiratory failure, oxygen therapy should only be considered if saturations fall below the patient’s target range (usually 88–92% but may be lower if advised by respiratory specialists).
• For Long Term Oxygen Therapy (LTOT) prescription or emergency oxygen treatment in hospital refer to local guidelines.

Inhaled therapy

• Reassess current inhaler technique and appropriateness of devices.
• Nebulised †sodium chloride 0.9%, 5 ml as required may aid expectoration.
• If the patient has wheeze or COPD, give 2.5 mg to 5 mg salbutamol nebules four times per day, regularly and up to another four times in 24 hours as required.
• If still wheezy, add ipratropium bromide 250 microgram to 500 microgram nebules four times per day.

Subcutaneous furosemide

• Patients with breathlessness or oedema related to heart failure, who are no longer able to take, or are not responsive to oral diuretics, may achieve symptom benefit through continuous subcutaneous infusion (CSCI) of furosemide.
• The dosing of subcutaneous furosemide is a 1:1 conversion from the oral dose (ie oral 120 mg daily would be 120 mg/24 hrs CSCI). However, maximum dosing may be limited by syringe pump volume.
• Furosemide injection can be diluted with sodium chloride 0.9%, if remaining syringe capacity allows, or administered without diluent if not. The solution should be protected from light. A yellow solution should be discarded.

Monitoring may include patients' weight, standard observations (blood pressure, pulse respiratory rate) and bloods (renal function) but only if appropriate, as indicated by the patient’s condition. Regular monitoring of the infusion site is advised.

• Non-pharmacological management techniques that help patients and families cope are essential. Using a self-management plan can help with symptom relief.
• Breathlessness can make eating and drinking more challenging. Eating little and often with high-protein or high-calorie foods can be helpful.
• As the illness progresses, medication to relieve breathlessness may be required.

Starting opioids at a low dose and titrating carefully is safe and does not cause respiratory depression in patients with conditions that may cause breathlessness, eg cancer, COPD or heart failure.

• NHS Inform: https://nhsinform.scot/care-support-and-rights/palliative-care/symptom-control/breathlessness 
• Asthma and Lung UK: http://www.asthmaandlung.org.uk
• Enhanced Palliative Care online learning module: https://learn.nes.nhs.scot/64382/pharmacy/enhanced-palliative-care-module