Breathlessness can be very frightening and managing anxiety and fear is an important part of treatment.

Exclude important reversible causes, e.g. pleural effusion, severe anaemia, coincident heart failure.

Treatment depends on severity.

Breathlessness on exertion is not likely to respond to drug interventions.

Strategies such as information, adaptation, relaxation and plan of action for acute episodes which may include breathing exercises are likely to be advantageous.

Breathlessness at rest

• Ensure the room is well ventilated. Try using a fan, small handheld fans are particularly effective
• Give advice on posture, positioning, and focus on breathing out
• Give reassurance and a calm atmosphere and assess for anxiety
• If hypoxic, consider a trial of oxygen
• Use oral opioids - low dose oral morphine solution 2.5-5mg, 4 hourly
• Benzodiazepines, e.g. diazepam 2- 4mg orally at night or lorazepam 0.5mg-1mg sublingual (off-label use) for acute exacerbations and titrate according to response.
• If unable to swallow:
  • Single dose of morphine sulfate 2.5mg – 5mg SC, and as required (if the patient is not already on an opioid)
  • Consider adding midazolam 2.5mg – 5mg SC as required
  • If recurrent symptoms or 2 or more breakthrough doses, consider morphine sulfate 10mg-15mg over 24 hours via SC syringe driver, and consider adding midazolam 10mg over 24 hours too
• Trial of nebulised bronchodilators, particularly if wheeze e.g. salbutamol 2.5mg - 5mg +/- ipratropium 250 micrograms – 500 micrograms 4 times daily or nebulised saline for retained secretions may be considered.

Breathlessness in the terminal phase

• Opioid and benzodiazepine, continuous or intermittent use.

Established lymphangitic carcinomatosis may respond to oral steroids. Starting dose 6mg to 8mg of dexamethasone.

If symptoms persist – seek advice from the local specialist palliative care team