Dyspnoea

People with dyspnoea describe their experience in a number of ways, for example:

Dyspnoea is a debilitating symptom with significant negative affect on a person’s quality of life:

• physical – inefficient breathing, increased respiratory rate, difficulty moving, speaking, or eating, reduced function
• social – reduced social interactions, loneliness
• psychological – fear of not being able to breathe, low moods, depression, anxiety
• spiritual – seeking meaning and purpose to life as they are more disabled.

These factors should be included in comprehensive assessment and management of dyspnoea. When combined they can further worsen breathlessness. For example, a person’s fear of no longer being able to breathe can fuel increased breathlessness through their anxiety. A person’s progressive deconditioning from inactivity, perhaps from avoiding exercise to avoid breathlessness and/or anxiety, can lead to increased breathlessness with movement.

It is important to identify reversible (treatable) factors contributing to dyspnoea and to manage them. These include bronchospasm, infection, heart failure, pleural effusion, pulmonary embolism, anaemia, and large airway obstruction. Active treatment of these may be appropriate.

Dyspnoea can be managed while the cause(s) are being investigated.

Assessment should include physical, social, psychological, and spiritual factors.

Observe the person’s posture – trying to sit upright leaning forward with shoulders hunched up or leaning against something suggests the person is working hard to breathe.

Listening to the person’s experience of breathlessness can provide clues to triggers or predominant vicious cycle which can be addressed as a priority.

Tailor the assessment to the person’s ability to tolerate the assessment. Ask open-ended questions if you think that the person can answer them. If the dyspnoea is or becomes acute, use closed questions which can be answered with one word, a nod or a shake of the head. A family member or carer may provide more detail.

Asking the person about their breathing difficulties and how it is affecting them (physical, social, psychological, spiritual, function) is the best approach. As appropriate ask open questions such as:

Or closed questions:

Nurses might ask the carer:

Consider use of tools such as

• Modified Borg scale (mBORG) (181kb pdf) for a quick rating of dyspnoea
• The NCCN Distress Thermometer (167kb pdf)
• Functional Assessment of Chronic Illness Therapy – Spirituality subscale (FACIT-Sp)

The aim of care is to reduce the effect of breathlessness on the person’s life including activities of daily living and to improve their quality of life. Dyspnoea is a complex symptom. Its treatment often requires a multidisciplinary approach and a combination of non-pharmacological measures, and medicines (pharmacological measures). Chronic or distressing dyspnoea can serve as a trigger for referral to palliative care services.

Acknowledge the distress of the person, their family, and carers. Asking what concerns them most can help identify the priorities of care.

Assist the person and their family and carer(s) to manage dyspnoea so that they feel more in control, can best manage activities, and know what to do in acute episodes of dyspnoea.

Non-pharmacological management

Non-pharmacological strategies that can help depending on the context include:

• encouraging the person to listen to their own body. Physiotherapists and occupational therapists can show the person, carers, family, and care staff ways that the person can conserve energy, pace themself and use relaxation techniques and equipment to optimise function, quality of life and independence.
• planning care and other activities – this may also include good control of pain and anxiety, preparing any equipment used for care, and the use of equipment to reduce the person’s effort
• encouraging the person to prioritise activities that are most important to them
• the presence of someone who can calm and reassure the person
• hand-held fan which stimulates the nerves in the face and eases the feeling of breathlessness
• optimising air circulation around the person e.g. a fan or open window
• breathing-control techniques e.g. pursed-lip breathing, breathing around the rectangle and positioning
• upright positions:
  • supported sitting
  • leaning on a supportive table
  • lying in a reclining chair or electric bed with backrest and knee break.
• relaxation exercises
• identifying triggers and ways to mitigate them
• providing information of when and how to seek additional help from GP, community nurse or ED.

Pharmacological management

Opioids are the first line pharmacological management for dyspnoea in people with advanced disease or cancer. If they are used, monitor for any side effects such as drowsiness, Bowel problems or Nausea and vomiting. The medication may need to be adjusted to find the balance between person’s preferences around drowsiness/alertness and the severity of dyspnoea.

Oxygen therapy may be used if the person is hypoxic and a therapeutic trial indicates that oxygen therapy is beneficial.