Dyspnea in Palliative Care
Kittiphon Nagaviroj, MD
Department of Family Medicine
• To increase the participants awareness of the prevalence
of this devastating symptom.
• To review the common causes of dyspnea in the palliative
• To summarize available etiologic and management for
What is “Dyspnea”?
• Subjective experience of discomfort in breathing
that consists of qualitatively distinct sensations
that vary in intensity.
American Thoracic Society (1999)
• It arises from interactions among physiological,
psychological, social and environmental factors
Multidimensional aspects of symptoms in palliative care
Assessment + Treatment
Ripamonti et al, JPSM 1997;13:220-232
• a Canadian study found that out of 923 cancer
out-patients, 46% reported breathlessness but
only 4% had lung cancer and 5.4% had lung
• Cancers in which at least 50% of patients reported
breathlessness included lung, lymphoma, head
and neck, genito-urinary and breast.
• 49-year-old gentleman was diagnosed with metastatic
non-small cell cancer of the lung two months ago.
• Hx: Increased shortness of breath over the last few days,
no cough, no fever, no hemoptysis, mild constant achy
pain in the middle of the chest (no radiation, no incident
pain, no neuropathic component)
• He received radiotherapy to right side of his chest as well
as the mediastinum two weeks ago.
• Previously he was healthy. No underlying diseases.
20-pack-year smoking Hx. No Hx of EtOH.
• Vital signs: T 37 c, P 100/min, RR 30/min, BP
110/70, Oxygen sat 88% (room air)
• alert and well cooperated, using accessory
muscles to breath, mild pallor, pitting edema 1+ in
both lower extremities, no signs of DVT
• CVS: JVP 2 cm above sternal angle, normal heart
sounds, no murmur audible
• RS: clear, no crackles or wheezing
• Abdomen: Shifting dullness and fluid thrill
negative, liver and spleen not palpable
How would you assess dyspnea in
• Most used in non cancer patients with chronic dyspnea.
• No single tool takes into account all the different
components of dyspnea.
• Choice of tool according to the purpose of the
• Should not worsen patient’s QOL (burdensome,
• VAS and NRS : useful in daily assessment
and assessment of therapies.
• No correlation between dyspnea and
objective measurements (PFT, oxygen
• No correlation with respiratory effort (use of
accessory muscles, respiratory rate, laboured
• ESAS: Pain 2/10, Tiredness 7/10, Depressed 6/10,
Anxiety 6/10, Appetite 5/10, Well-being 7/10, SOB
• MMSE 29/30
• PPS 40%
• He was a financial consultant before this illness.
• Married, 2 teenage sons ( 16 and 13)
• Very supportive wife and family
• He is having difficult time coping with his
• He also stated that he doesn’t want to “choke to
What are the possible causes
of the dyspnea in this
Conditions Resulting in Dyspnea
• Dyspnea Caused Directly by Cancer
• Dyspnea Caused Indirectly by Cancer
• Dyspnea From Cancer Treatment
• Dyspnea Unrelated to Cancer
Dyspnea Caused Directly by Cancer
• Pulmonary parenchymal involvement (primary or
• Lymphangitic carcinomatosis
• Intrinsic or extrinsic airway obstruction by tumor
• Pleural tumor
• Pleural effusion
• Phrenic nerve paralysis
Dyspnea Caused Indirectly by Cancer
• Electrolyte abnormalities
• Pulmonary aspiration
• Pulmonary emboli
• Neurologic paraneoplastic syndromes
Dyspnea From Cancer Treatment
• Radiation pneumonitis or fibrosis
• Chemotherapy-induced pulmonary toxicity
(Bleomycin, Methotrexate, Mtomycin, Busulfan)
• Chemotherapy-induced cardiomyopathy
(Doxorubicin, Daunorubicin, Mitoxantrone)
• Radiation-induced pericardial disease
Dyspnea Unrelated to Cancer
• Chronic obstructive pulmonary disease
• Congestive heart failure
• Interstitial lung disease
• Chest wall deformity
• Neuromuscular disorders
• Pulmonary vascular disease
• Usually forgotten as contributors to the
development of dyspnea.
• Treatment not always present/ maximized.
• Many irreversible but yet treatable.
• COPD a contributor in 50% of the lung and head
and neck cancer population.
• Therefore……Treat those contributing
What types of investigations will you
Lab & Investigation
• EKG: Normal
• CBC : Hb 85, WBC 7.6 (N 5.5, L 2.2), Plt 350
• Chemistry: Urea 4, Creatinine 44, Na 140, K
3.5, Cl 117, CO2 19, Albumin 30, Calcium 2.2
• Usually asymmetric and occasionally unilateral
• Chest radiographic manifestations
– Interlobular septal thickening
– reticular opacities
– Pleural effusion
What is your diagnosis?
• Develop in as many as 5-15% of patients with thoracic
• Acute radiation pneumonitis occurs within 1-6 months
• Symptoms can include low-grade fever, cough, and
fullness in the chest
• The radiographic hallmark of radiation pneumonitis is a
diffuse infiltrate corresponding to a previous radiation
What is your plan of management for
this patient? Why?
• Treat underlying causes of dyspnea –
including co-morbid conditions!!!
• Pharmacologic treatment
• Non-pharmacologic treatment
• Central airway obstruction • Endoscopic interventions;
debulking and stent placement,
• Pleural effusion • Thoracentesis, Indwelling
pleural catheter, Pleurodesis
after lung re-expansion
• Pneumonia • Appropriate antibiotic, relief of
CAO if present
• Lymphangitis • Chemotherapy + Steroid
• Pulmonary embolism • Anticoagulation; if not
anticoagulation candidate, IVCF
• Pulmonary edema • Diuresis
• Drug toxicity • Stop presumed offending drug,
steroids if significant respiratory
• Pericardial effusion • Pericardiocentesis
• Both chemoRx and RT can reduce dyspnoea but
the response rates are variable and often less
than those for palliating cough and haemoptysis
• Mainstay of the treatment of dyspnea since the
late nineteenth century
• a Cochrane systematic review have shown the
benefit of opioids in managing the
breathlessness of cancer, COPD and heart failure
• Relieve the sensation of breathlessness
• Reduce pain which may be contributing to the
restriction of chest wall or diaphragmatic
• If patient is opioid naïve, can start opioids PRN or
ATC at same doses used for pain management.
• Class benefit, no evidence that any opioid is
superior for dyspnea management.
• Titrate slowly!!!.
• If already on opioids for pain increase regular opioid
by 25-50% of the 4 hourly dose.
(Allard et al, JPSM1999;17:256-265)
Respiratory depression from opioids: depends
on the rate of change of the dose, previous
opioid exposure and route of administration
• Although there are opioid receptors in the airways,
systematic review has found no benefit of nebulised
opioids for this symptom.
A systematic review of the use of opioids in the management of dyspnoea. Thorax
• The inhalation of furosemide has been shown in
several small, single-dose studies to result in
bronchodilatation and reduction of breathlessness
• Effective dose is from 20-40 mg
• Mechanism of action stimulation of lung airways
stretch receptors and parencyhmal j-receptors,
which modulates afferent signalling to the brain.
• Need further large RCT!!!
• Midazolam plus morphine was found to be
more effective than Morphine or Midazolam
alone in one trial. Navigante et al, JPSM 2006;31(1):38-47.
• Neuroleptics more widely studied than
• Chlorpromazine was found to be effective for
relief of dyspnea in advanced cancer patients in
an open-labeled trial. McIver et al, JPSM 1994;9:341-5.
• Effective to treat bronchospasm in asthma.
• Useful in respondent COPD patients and in acute
exacerbations of COPD.
• Used in cancer patients with SVCS, Radiotherapy-
induced fibrosis, lymphangitic carcinomatosis,
• Empiric, no RCT in cancer patients.
• Best agent and appropriate dose not identified yet.
• Indicated in cancer patients with evidence of air
• Beta-2 agonists produce less bronchodilation in
COPD as compared to asthma.
• Combination of a Beta-2 agonist and an
anticholinergic agent commonly used.
• ATC and PRN dosing.
• To reduce the incidence of respiratory
secretions and the so-called “death rattle”.
• Two agents available:
-Glycopyrrolate 0.3 mg sc ATC and PRN (does
not cross blood-brain barrier).
-Scopolamine 0.4 mg sc ATC and PRN (does
cross blood-brain barrier).
• Scopolamine slightly more effective according
to one trial.
• Patients who have significant (<90%) de-saturation at rest
or on exertion should be offered a trial of oxygen
• Little evidence for giving supplementary oxygen unless
the patient desaturates to below 90%, or is very anaemic
• Be careful in COPD risk of hypercapnic respiratory
• Best delivered by nasal cannulae, unless high flow rates
• Breathing through pursed lips.
• Breathing retraining.
• Open window.
• Fan aimed at the face.
Modalities supported by RCT:
• Relaxation techniques.
• Teaching of coping strategies.
• Last resort!!!.
• Provides relief for patient, families and staff.
• Exhaust treatment options first.
• Agent selection varies according to centers.
• Midazolam subcutaneous continuous infusion
used by Edmonton Palliative Care Program.
• Drug association may be necessary in some
• Dyspnea is frequently seen in our population.
• Is a “Multidimensional symptom”.
• Poor correlation between severity and
• Although subjective, can be measured with
• Treat pre-existing conditions that may
contribute to the development of dyspnea
• Interventional procedures or aggressive
treatments may be indicated.
• Opioids are SAFE and are the mainstay
of the symptomatic treatment of dyspnea.
• RCT support the use of Alternative/
• When dyspnea becomes refractory, Palliative
Sedation is an appropriate option.