Chronic breathlessness is a major symptom of lung and cardiac diseases and may also be a significant symptom in cancer and other non-cardiorespiratory chronic disease. In severe or late-stage cardiac and respiratory disease, it is often a disabling symptom.
The experience of breathlessness can vary between patients even though they may have the same apparent severity of disease.
In the patient with severe or late-stage lung disease (e.g. COPD or ILD) or heart failure, the severity of breathlessness can have a massive impact on quality of life. The approach and management of this symptom in these patients can be challenging. Usually by this point, disease-specific treatment has been maximised but the symptom of breathlessness remains or progresses.
A first step in the management is for the patient, and also the doctor, to acknowledge that this is going to be a persisting and likely progressive symptom. Understanding that, management will be to ease the symptom rather than resolve it, which allows everyone to focus on what is realistic. In this situation, management of severe breathlessness is about easing the symptom, improving quality of life and perhaps the patient’s level of function.
The feeling of dyspnoea arises from a complex interplay between the physiological requirement for ventilation and the cortical responses of the individual to the work of breathing. The breathing control centre in the medulla receives inputs from the airways, respiratory muscles, the lung parenchyma, the chest wall and the central and peripheral chemoreceptors. It then sends outputs to the respiratory system to drive ventilation.
Unique to the respiratory system is a corollary discharge from the medulla to the cortex giving a conscious component to this otherwise automatic response. This allows conscious control of breathing but also means there is a conscious sensation of breathing.
It is this cortical component that can lead to the feeling of dyspnoea and the emotional response that has an impact on the person. Severe dyspnoea in an otherwise well person who has undertaken a significant physical effort will have a different emotional overlay to a patient with severe lung disease who is breathless walking around their house.
The management of this aspect of breathlessness is starting to receive some attention from research groups and is already being looked at in the management of chronic pain.
The practical management of chronic breathlessness is challenging – it does not resolve it. The approach is more about easing the feeling and trying to improve quality of life. As mentioned, disease-specific management is important and has usually already been optimised. The management of chronic breathlessness can be divided in to pharmacological and non-pharmacological strategies which can be applied regardless of the aetiology.
Low-dose opiates have been investigated the most in the management of breathlessness. The recent withdrawal from the Australian market of liquid morphine has caused some challenges. Low-dose sustained-release morphine (Kapanol 10mg) does provide some benefit by reducing the baseline level of breathlessness. Short-acting agents are useful either as pre-treatment before an activity (e.g. showering) and/or post-activity to manage symptoms. The risk of respiratory depression with this use is low. However, constipation is a common side effect.
Benzodiazepines, especially those with anxiolytic properties, have shown minimal benefit and may be more harmful due to sedation, but they may have a role in the patient with higher levels of anxiety driving breathlessness.
Even in the patient with very severe lung disease, exercise and pulmonary rehabilitation programs still offer value. The degree and duration of exercise may be limited, but maintaining physical condition helps with breathlessness management. Pursed-lipped breathing can help with exercise as well.
Improved lung emptying reduces the degree of dynamic hyperinflation. Recovering from exertion with a posture that supports the shoulders (e.g. tripod) can help ease breathlessness. This allows the accessory muscles of respiration to function more effectively.
Oxygen therapy can improve exercise capacity and reduced breathlessness in some patients. Often severe lung disease is associated with exertional hypoxia, but this is not necessarily the cause of the breathlessness. In some patients, the benefit may come from the sensation of airflow in the upper airway.
A similar response can be elicited with a handheld fan. This can provide some relief to the feeling of dyspnoea. In some preliminary work from a Japanese group, inhalation of menthol can induce a cooling sensation in the airways which can reduce some of the more unpleasant feelings associated with breathlessness.
Breathlessness in the patient with chronic severe disease is a distressing and challenging symptom. Some strategies for management do exist, but there is a need for further work in this area.
Key messages
- Chronic breathlessness has many causes and is very disabling
- Management is focused on improving symptoms and not cure
- Exercise and pulmonary rehabilitation programs still offer value in even severe cases.
Author competing interests – nil