GPAtlas🧭 When to suspect
Breathlessness (dyspnoea) is a subjective, uncomfortable awareness of breathing.
• Breathlessness is one of the most common and frightening symptoms in advanced illness.
• Its severity is consistently underestimated by clinicians.
• Its severity correlates poorly with oxygen saturation – a comfortable saturation does not mean a comfortable patient.
Think of it as "total dyspnoea": the sensation is shaped by physical, psychological (anxiety, fear of suffocation), social and spiritual factors, not by hypoxia alone.
• Breathlessness may be continuous or episodic (coming and going, often triggered by exertion, lying flat or anxiety).
• Breathlessness is common in advanced cancer, end-stage chronic obstructive pulmonary disease (COPD), interstitial lung disease, heart failure and motor neurone disease (MND).
The two core clinical skills are: identify and treat any reversible cause, and never miss a palliative emergency. Where the cause is fixed, the task shifts to relieving the symptom itself.
| Reversible cause to look for | Typical pointer & first step |
|---|---|
| Chest infection | Fever, purulent sputum, focal crackles → antibiotics if appropriate to goals of care |
| Pleural effusion | Stony-dull base, reduced breath sounds → consider drainage |
| Heart failure or fluid overload | Orthopnoea, raised jugular venous pressure (JVP), oedema, bibasal crackles → diuretic (e.g. furosemide) |
| COPD/bronchospasm | Wheeze, known airways disease → bronchodilator (e.g. salbutamol) ± steroid |
| Anaemia | Pallor, fatigue → transfuse if proportionate to goals of care |
| Pulmonary embolism | Sudden pleuritic pain, tachycardia → anticoagulate if appropriate |
| Malignant airway obstruction, lymphangitis or superior vena cava obstruction (SVCO) | Dry cough, rapid progression, facial swelling → dexamethasone + specialist referral |
| Anxiety/panic | Episodic, situational, hyperventilation → non-drug measures ± benzodiazepine |
Source: Scottish Palliative Care Guidelines · NICE NG31
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