Assessing and managing chronic breathlessness
A blog post written by Professor of Palliative Care David Currow
Chronic breathlessness is highly prevalent across the community. One in 100 Australians have significant impairment of their activities of daily living and one in 300 people are housebound because of breathlessness.
Chronic breathlessness is systematically under-recognised by health professionals. When taking a history about breathlessness, the question ‘are you breathless?’ is not going to elicit the problem nor its magnitude. ‘What do you have to avoid in order to minimise breathlessness?’ is a far more important question, or this can also be phrased as ‘what have you given up in order not to be breathless?’ With these questions, we start to get a picture of the net impact of breathlessness on individual patients.
Assessing breathlessness requires an excellent history, examination, and judicious use of investigations. The basis of this approach is to ensure that any underlying, reversible causes have been treated optimally. Most people have more than one contributing cause to chronic breathlessness, particularly as it advances. It cannot be assumed that another clinician has looked for the reversible causes.
Having established that chronic breathlessness is being caused by underlying conditions that are refractory to further disease-modifying treatment, the management then shifts to symptom control.
There are a range of non-pharmacological symptomatic interventions that have been shown to reduce the impact of breathlessness on people on a day-to-day basis. This includes things such as breathing retraining, relaxation, and, where appropriate, the use of walking aids. Recent work has also again confirmed that the use of neuro-electrical muscle stimulation does help to break the deconditioning cycle for people with advanced disease causing breathlessness. It is also important to encourage people to exercise knowing that they will get breathless. People with advanced disease often try and avoid all breathlessness and this worsens the ongoing cycle of decline.
The pharmacological intervention with a strong evidence base is the use of regular, low dose, extended release morphine. This has been shown to reduce breathlessness safely in a wide range of people. The largest population studied are those with chronic obstructive pulmonary disease (COPD) with no evidence of respiratory depression or obtundation. Importantly, it appears that people’s worse breathlessness is the aspect of the symptom for which there is most symptomatic benefit.
Importantly, the goal of care is to reduce the impact of breathlessness. Very few people with established chronic breathlessness are going to be without breathlessness, particularly on exertion. The aim of any intervention is to reduce breathlessness. Even predicably reducing breathlessness a small amount will deliver a benefit patients will notice.
There is an increasing evidence base to suggest that oxygen may have more ability to reduce the symptom of breathlessness in people with advanced COPD than air alone delivered at two litres per minute using nasal prongs. Despite a recent meta-analysis that suggests that there may be benefit, patients also identify the burden of being attached to a machine and the concern of being reliant on a machine in order to feel well.
Ultimately, chronic breathlessness can be improved markedly, with careful attention to reversible causes and the judicious use of evidence-based interventions including non-pharmacological interventions and, in selected patients, the use of low dose extended release morphine regularly to reduce the burden of breathlessness.
David Currow is Professor of Palliative and Supportive Services at Flinders Universityand is the principal investigator for the Palliative Care Clinical Studies Collaborative (PaCCSC). David has published more than 380 peer-reviewed articles, editorials and books.
Editor's note: You can find evidence-based information about chronic breathlessness in the following places on the CareSearch website: