Palliative Care Guidelines - NHS Lanarkshire

Palliative Care Guidelines: BreathlessnessBreathlessness in Palliative CareIntroductionBreathlessness is a common and distressing symptom in advanced cancer, chronic obstructivepulmonary disease, lung fibrosis and heart failure.Assessment• Clarify pattern of breathlessness, precipitating / alleviating factors and associated symptoms.• Is treatment of the underlying disease appropriate? Seek advice if in doubt.• Look for any reversible causes of breathlessness: infection, pleural effusion, anaemia,arrhythmia, pulmonary embolism, or bronchospasm.• Check oxygen saturation (if pulse oximeter available).• Ask the patient to rate symptom severity and level of associated distress/ anxiety.• Explore fears, impact on functional abilities, and quality of life.Management• Treat any reversible causes, if appropriate.• If stridor or signs of superior vena cava obstruction - emergency referral to hospital.• Give high dose steroids in divided doses: dexamethasone 16mg, or prednisolone 60mg.• Oxygen: careful individual patient assessment. Important to avoid psychological dependence.A fan or air from a window may be just as effective.If oxygen saturation is less than 90%, consider a trial of oxygen.• Nebulised sodium chloride 0.9%, 5ml as required may help loosen secretions.Medication• Bronchodilators: by inhaler or spacer: Stop if no symptomatic benefit.• Steroids: trial of dexamethasone oral 8-16mg daily for lymphangitis or airways obstruction thathas responded to steroids before.Unless starting emergency therapy, give steroids in the morning.Stop if no effect after a week, or reduce gradually to lowest effective dose.• Opioids: can reduce breathlessness, particularly at rest and in the terminal phase.Give as a therapeutic trial; monitor patient response and side effects.• No opioid before:o Immediate release morphine oral 2mg, 4-6 hourly or as required.Increase slowly in steps of about 30%, if tolerated.o If unable to take oral medication:morphine SC 2mg, 4-6 hourly and/or 2 hourly as required.or diamorphine SC 2.5mg, 4-6 hourly and/or 2 hourly as required.• Elderly, frail patient or impaired renal function:o Morphine oral 1-2mg, 6-8 hourly as required; monitor closely for side effects.• Opioid taken regularly for pain:o 25% of the 4 hourly breakthrough analgesic dose, given as required, may beadequate for breathlessness. Titrate according to response.• Continuous breathlessness:o Consider using modified release (long acting) morphine.o If the patient is dying, give morphine as a continuous SC infusion. Dose is basedon previous regular dose and any as required doses.Usually combined with midazolam SC in the infusion.• Second line opioid:o Second line opioids can be used for breathlessness if the patient is unable totolerate morphine due to side effects. (See: Choosing & Changing opioids)• Anxiolytics: Start with a low dose and increase gradually as required and tolerated.o Lorazepam sublingually 0.5mg, as required for episodic anxiety, panic attacks.o Diazepam oral 5mg, at night if more continuous anxiety.© NHS Lothian Issue date: January 2009 Review date: March 20121