Breathlessness in palliative care

Key points

1. Breathlessness is a common and distressing symptom for people living with a terminal illness. Multiple factors can contribute to the feeling of being short of breath.
2. Treatment aims to relieve the symptom of being short of breath and to make you feel better.
3. You may have many health professionals involved in your care as breathlessness requires treatment from a multidisciplinary team. 
4. There are several things you can do to help manage breathlessness, including taking medicine, using breathing techniques, changing your position and doing relaxation exercises.
5. Living with breathlessness can be frightening, so make sure you get enough support from your family/whānau and friends.

What are the causes of breathlessness?

There are many causes that can contribute to the feeling of being short of breath. It may come and go quickly (acute) or may come on slowly and last for a longer time (chronic).

It can be caused by the terminal illness you are living with, eg, lung cancer, or other medical conditions that happen at the same time. Breathlessness can also be caused by psychological factors such as anxiety and fear. Sometimes, it's not possible to find out an exact cause. 

Common causes of breathlessness in patients living with a terminal illness include:

• cancer and its complications, such as pleural effusion, pulmonary embolism or airway obstruction
• conditions affecting your lungs, such as COPD 
• heart conditions such as heart failure
• muscle weakness
• fatigue
• infection
• metabolic acidosis (your body makes too much acid)
• low blood count (anaemia)
• smoking
• pain
• anxiety and fear.

What are the symptoms of breathlessness? 

Symptoms can range from mild shortness of breath to very fast gasping breaths. You may also feel:

• dizzy
• chest discomfort and/or tightness
• fatigue
• anxious or scared.

How is breathlessness diagnosed?

Your doctor may ask you some questions to find out the possible causes of your breathlessness. You may need to complete a symptom diary to monitor the timing of your breathlessness, what triggers it and how it is affecting your daily life. 

Your doctor may also do a physical examination to check for signs of illness or disease and carry out tests to rule out physical causes, such as blood and urine tests. 

How is breathlessness treated?

Treatment aims to relieve your symptom of being short of breath and to make you feel better. You may have many health professionals such as doctors, nurses, a physiotherapist, an occupational therapist, a palliative care specialist or a cancer specialist involved in your care, as it requires treatment from a multidisciplinary team. 

If you have a medical condition or any obvious causes of breathlessness are found, treatment will focus on the condition or cause. 

There are 2 components of the treatment of breathlessness:

• non-medicines treatment
• medicines.

Non-medicine treatment

The non-medicine treatment of breathlessness includes:

• physiotherapy
• counseling
• relaxation techniques
• breath control techniques
• good positioning
• blood transfusion if you have anaemia 
• complementary therapies such as aromatherapy, music and art therapy.

You may be referred to a physiotherapist, an occupational therapist, a psychologist or a complementary therapist as part of your treatment. 

Medicines

There are also some medicines that can help relieve your breathlessness.

Common medicines that may be prescribed include:

• opioids such as morphine
• benzodiazepines such as midazolam and lorazepam
• steroids such as dexamethasone or prednisone
• nebulisers
• bronchodilators such as salbutamol 
• antibiotics if you have an infection
• diuretics for conditions such as heart failure
• anticholinergics such as hyoscine or glycopyrrolate
• chemotherapy or radiotherapy
• oxygen. 

Nearing the end of life, some of these medicines may be given to you via subcutaneous injection (under your skin) or a syringe driver. Read more about syringe drivers. 

You may receive both non-medicine and medicine treatment together, depending on your condition. 

How can I care for myself with breathlessness?

There are several things you can do to help manage breathlessness. 

• Try sitting in an area that has good ventilation, eg, by an open window or using a small fan.
• Use a cool damp cloth or fine mist spray on your face.
• Plan activities in advance, break down tasks and do them one by one, taking frequent breaks in between.
• Practice mindfulness and relaxation exercies.
• Practice breath control techniques – a physiotherapist or occupational therapist can teach you how to do these.
• Wear loose-fitting clothes.
• Sit down to dress or do other tasks.
• Change your body position.
• Listen to music or turn on the TV to distract yourself – distraction helps.
• Use a walker if needed.
• If you smoke, get help to stop.
• If you are on medication for your breathing, make sure you take it as prescribed.

Breath control techniques

There are some breathing techniques and exercises that can help you control your breathing.

A simple breathing exercise to try is as follows:

• Breathe in slowly for a count of 3: 1–2–3.
• Hold your breath for a count of 3: 1–2–3. 
• Breathe out slowly for a count of 3: 1–2–3
• Repeat 3 or 4 times until you start to feel relaxed.

Ask your doctor about referring you to a physiotherapist to learn about breathing techniques and exercises. You can also look for a physiotherapist with a respiratory interest. Find a physio Physiotherapy NZ.

Body position

Changing the position of your body can also help when you are feeling breathless. Try the following:

• Put yourself in a position that supports your head and shoulders to relax comfortably.
• Try a range of positions such as sitting or standing up tall, or leaning forward resting your elbows on your knees or on a bench.
• Rest, breathing slowly and gently, in the position that is most comfortable for you.

Relaxation and mindfulness exercises

Learning how to relax can help prevent the breathlessness–anxiety loop.

• Feeling breathless can make you feel anxious and when you are anxious, your breathing tends to become more rapid and shallow.
• This can make you feel more breathless, which in turn can increase your anxiety.

Learning and practising relaxation techniques can help you become calm and slow your breathing. Mindfulness is a useful practice to help you feel more relaxed and calm. Read more about mindfulness.

What support is available with breathlessness?

Living with breathlessness can be frightening. It is also challenging to do things physically. Talk through your feelings with your family and friends to get the support you need. 

If you need extra help in daily activities such as washing, dressing or cooking, your doctor may be able to arrange this for you. 

Below are some support services and information for people affected by cancer and their family/whānau:

Emotions & cancer Cancer Society of NZ
How we can help Cancer Society of NZ
NZ cancer services - find a hospital/service near you Healthpoint
More cancer support groups

Learn more

Breathlessness Mercy Hospice, NZ
Coping with breathlessness St Christopher's, UK
Breathlessness Marie Curie, UK
Managing the symptoms of cancer Macmillan Cancer Support, UK

References

1. Dyspnoea in palliative care Auckland HealthPathways
2. Breathlessness – management in the palliative patient Starship Clinical Guidelines, 2015
3. Managing breathlessness in palliative care Hammond Care, Australia 
4. Dyspnoea in palliative care Patient Info, UK
5. Breathlessness Scottish Palliative Care Guidelines, UK
6. Breathlessness Marie Curie, UK