Breathlessness in palliative care – general review
Last November, the Association of Supportive and Palliative Care hosted a virtual conference that included an exceptional talk called ‘Taking your Breath Away’ by Dr Helen Meynell, Consultant Pharmacist in Respiratory and Palliative Care in Doncaster and Bassetlaw NHS foundation trust.
This article is based on the various interesting points discussed in that presentation and aims to summarise current approaches and options to manage breathlessness towards the latest stages of life.
Dyspnoea is defined as a subjective sensation of difficulty in breathing, and may be caused by a variety of medical conditions, including COPD, cystic fibrosis, lung cancer and other types of malignant disease, severe fibrotic lung disease, and idiopathic pulmonary fibrosis. It is especially prevalent in post COVID patients. Respiratory muscle disorders such as motor neurone disease or muscular dystrophy also play a part.
Breathlessness is the most common respiratory problem in palliative care and a key trigger for acute admissions. Its prevalence is around 90% to 95% in COPD, 60% to 88% in heart failure and 22% to 58% in cancer.
Reversible causes producing dyspnoea should always be ruled out first and reversed if possible. Causes include: anaemia, broncho-constriction, hypoxia, heart failure, pulmonary embolism or blockages due to malignant disease.
Non-pharmacological approaches may be used to improve breathlessness and these should ideally be tried first and in conjunction with pharmaceutical interventions later on. Some of the current non-pharmacological strategies followed are: reducing levels of fear and anxiety through breathing exercises and calming strategies, improving respiration control through breathing retaining – pursed-lip breathing, activity-pacing advice, cool temperature, body positioning (upright), pulmonary rehab (particularly useful in post-COVID patients), use of fans, and complimentary therapies such as acupuncture, massage or hypnosis. It is worth noting that fans are not recommended to treat dyspnoea associated with COVID-19 due to the high risk of transmission, unless the patients are isolated in their own homes.
There are a few pharmacological options available to help patients with breathlessness; however, in line with most drug treatments in palliative care, the scientific evidence behind medication used to treat the symptoms of dyspnoea is usually poor and based on clinical practice and small case studies rather than RCTs.
First-line treatment for breathlessness is usually an opioid drug, with morphine being the drug of choice. Initial morphine doses should be based on current opioid usage (if a patient is already on morphine titrate the dose up by 25% in the first instance), and the patient’s opioid tolerance and preferences, always starting towards the lower dose range. It is generally accepted that a maximum daily 30mg dose of oral morphine should be used for this purpose. Some improvement may be seen within 24 hours of starting opioid treatment, but the patient’s full response should be evaluated five days after commencing morphine therapy.
Corticosteroids can also play a role in managing breathlessness. These are often ineffective when dyspnoea is linked to a chronic condition, such as COPD. But steroids may help if breathlessness is due to inflammatory lung conditions or is COVID related.
Benzodiazepines, usually lorazepam, are widely used in hospices to ease breathlessness, particularly when associated with anxiety. Pathological anxiety may be present in around 60% of COPD patients. Ideally, lorazepam should be given orally when possible, reserving the unlicensed sublingual route for those patients unable to swallow. The buccal cavity should be moisturised as lack of saliva will prevent the tablet from dissolving under the tongue.
Antidepressants could also have a role in preventing breathlessness. Mirtazapine or trazodone may be used, both are sedatives and usually help to improve appetite too. SSRIs, like citalopram or sertraline, may be used as well as duloxetine. Nevertheless, the risk of hyponatraemia should always be considered before prescribing antidepressants in palliative care. Tricyclic antidepressants, like amitriptyline, may also help with neuropathic pain, although the comprehensive side-effect burden of TCAs including dry mouth, constipation and potential for cardiovascular toxicity, among others, should always be taken into account before initiating treatment.
Lastly, note that when treating breathlessness towards the very end of life, the patient’s comfort is always the main priority: oxygen masks may be removed and anticipatory use of medication is key at this stage. If a patient is on a syringe driver, a morphine dose of 10mg plus midazolam 10mg every 24 hours may provide that extra comfort. Maximum 24-hour doses up to 30mg of morphine and 60mg of midazolam should usually be used to treat breathlessness in the dying patient.