BREATHLESSNESS MANAGEMENT

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Byron Booker
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1 Guideline Name: Breathlessness BACKGROUND Breathlessness is a common symptom in patients with cancer, end-stage heart failure and end-stage chronic obstructive pulmonary disease (COPD). There are many subtle neuro-hormonal abnormalities and alterations in the skeletal and respiratory muscle structure and function which influence the sensation of breathlessness. The cause can be multi-factorial and research has failed to show a relationship between underlying pathophysiology, sensation or severity of breathlessness for the patient or effective treatments. Up to 70 % of patients with advanced cancer report dyspnoea during the last six weeks of life and this sensation tends to worsen as death approaches. BREATHLESSNESS MANAGEMENT Management of breathlessness is multi-factorial and is best done by the multi-disciplinary team. The principles of breathlessness management include: Assessment by Clinical Nurse Specialist (CNS) / Doctor Assessment by Physiotherapist and/or Occupational Therapist Teaching of relaxation exercises Teaching of breathing exercises Education about mechanics of breathing Pacing activities and fatigue management Distribution of printed materials about breathlessness ASSESSMENT Severity (0-5 on Dyspnoea Exertion Scale 1 ) Please refer to Appendix 1 Aggravating and alleviating factors Associated respiratory symptoms (cough, chest pain, sputum, haemoptysis) Chest examination Treatment should be considered for reversible causes, e.g. cardiac failure, arrhythmias, pericardial effusion, bronchospasm, pleural effusion, pneumothorax, pulmonary embolus, superior vena cava obstruction, infection. NON DRUG MANAGEMENT Advise use of fan Fatigue management and energy conservation techniques Breathing techniques Relaxation exercises Equipment especially walking aids 2 Therapies complementary to medicine e.g. acupuncture, TENS and chest wall vibration 2 Consider referral to Counselling Support Services (CSS) especially if anxiety is a major component Page 1 of 5

2 Consider referral to Day Therapy Centre for ongoing symptom control and consolidation of breathing exercises and fatigue management Support for Active Living Group DRUG MANAGEMENT OPIOIDS There is evidence that opioids can give a 15-20% improvement in dyspnoea with a number needed to treat of just 1.5. They seem to work better if patient s level of functioning is relatively good 3. If an opioid has not yet been prescribed, commence Oramorph 2.5mg 4 hourly and prn (can use lower dose e.g. 1mg if renal impairment or previous sensitivity). Assess effect and titrate with 30-50% dose increments. When stable, consider controlled release morphine. If an opioid is currently prescribed for pain management, encourage use for breathlessness and use current prn dose of opioid orally or subcutaneously. Assess effect and titrate against symptoms. BENZODIAZEPINES There is little evidence for the use of benzodiazepines in breathlessness but they should be considered if the patient is anxious or experiencing panic attacks 4, 5. Sublingual Lorazepam 0.5-1mg prn Diazepam 2-5mg orally, and, if effective, 2-5mg tds Midazolam 2.5mg subcutaneously PRN. If required this can be given via syringe driver starting dose 5-10mg/24 hours STEROIDS Consider trial of steroids if there is any reason to suggest a reversible obstructive component to the breathlessness (e.g. asthma or COPD that has previously responded to steroids) or lymphangitis carcinomatosis. Dexamethasone 4-8mg od, or Prednisolone 25-50mg od Reduce to lowest effective dose. Stop after 1 week if no benefit Avoid giving after hours to avoid possibility of insomnia NEBULISED MEDICATION OXYGEN Normal saline 0.9% (5 mls) prn for management of cough, breathlessness and expectoration Salbutamol 2.5-5mg qds or Ipratropium Bromide mg qds if bronchospasm is present Patients with severe COPD (FEV1 <30%), or (FEV %) with O 2 sats <92% on air, are at risk of CO 2 retention and should be considered for referral for oxygen testing. They should be referred to the Respiratory Nurse at the Tunbridge Wells Hospital Telephone The evidence for oxygen in breathlessness is not clear cut. Most trials have favoured oxygen over air but have not been statistically significant 6. The current advice for palliative care patients is to consider a trial of oxygen and to assess the patient s symptoms 7. The role of oxygen in palliative care is to improve symptoms and quality of life. As oxygen can be quite restrictive, its effect on the patient s quality of life is very important and mustn t be overlooked during an assessment period. Page 2 of 5

3 Start the flow rate at 2L/min and titrate as needed The use of nasal cannulae should be first choice Patients should be asked to keep a weekly diary recording the frequency and intensity of the breathlessness using a visual analogue scale, without and with oxygen therapy. This should be reviewed at the end of the trial. Domiciliary oxygen should be prescribed according to local guidance. This is done via the patient s GP in liaison with the respiratory nurses. Forms and guidance can be found on the common server under Forms/HOOF forms. Alternatively they are available at Dolby Vivisol ( telephone , fax MANAGEMENT OF BREATHLESSNESS IN TERMINAL PHASE For patients who are no longer able to swallow: Convert morphine to sc dose of Diamorphine via syringe driver over 24 hours (divide 1/3) Convert benzodiazepines to sc Midazolam 5-10mg/24 hours via syringe driver Titrate dose according to prn doses and effect If there are excessive secretions commence syringe driver with: Glycopyrronium 1.2mgs/24hours, and sc 0.4mg prn (the dose can be increased to 2.4mgs if needed in some circumstances) 8 or Hyoscine Hydrobromide 1.2-2mgs, and sc 400mcgs prn If there are excessive secretions due to an infection then consider one dose of Ceftriaxone 1gram IM/IV as palliation. MANAGEMENT OF SUPERIOR VENA CAVA OBSTRUCTION NB this is considered a palliative care emergency Give high dose oral Dexamethasone 16mg daily, or oral Prednisolone 60mg daily Make an urgent referral to Interventional Radiologist / Oncologist (for consideration of stenting and/or palliative radiotherapy) RELATED GUIDELINES Oxygen Administration Antisecretories REFERENCES 1. Heyse-Moore LH. On dyspnoea in advanced cancer. DM: Southampton University, Bausewein C, Booth S, Gysels M, Higginson IJ. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of Systematic Reviews 2008, Issue Jennings AL, Davies AN, Higgins JPT, Broadley K. Opioids for the palliation of breathlessness in terminal illness. Cochrane Database of Systematic Reviews 2001, Issue 3 4. Viola R et al. The management of dyspnoea in cancer patients: a systematic review. Support Care Cancer (2008) 16: Simon ST, Higginson IJ, Booth S, Harding R, Bausewein C. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database of Systematic Reviews Issue 1 Page 3 of 5

4 6. Cranston JM, Crockett A, Currow D. Oxygen Therapy for dyspnoea in adults. Cochrane Database of Systematic Reviews 2008, Issue Booth S et al, Oxygen or air for palliation of breathlessness in advanced cancer, J R Soc Med 2003; 96: Dickman, A. The Syringe Driver. 2 nd Edition Chapter 3 pages & Date Originated: April 2008 Original Author: Unknown Date of Review: April 2013 Reviewed By: Sally Willis, Clinical Nurse Specialist Next Review Due: June 2016 Issuing Authority: Dr Helen McGee, Consultant Page 4 of 5

5 Appendix 1 Dyspnoea Exertion Scale Grade 0 Degree of breathlessness I am able to walk at my own pace on the level without getting breathless over any distance 1 I become breathless if I walk more than 100 yards on the level at my own pace 2 I become breathless if I walk around the house or on the ward on the level at my own pace 3 I become breathless if I move around in bed or get out of bed 4 I become breathless on talking 5 I am breathless at rest Page 5 of 5

Regional Breathlessness Audit - Case Note Survey. 1. Introduction. Regional Breathlessness Audit - Case Note Survey. 2.

Regional Breathlessness Audit - Case te Survey 1. Introduction Please complete this form for your case note review. Cases used may be PROSPECTIVE AND/OR RETROSPECTIVE. Please log as many cases as you can.