GPAtlas🧭 When to suspect
Dyspnoea (breathlessness) is a subjective, uncomfortable awareness of breathing. It is one of the most common and frightening symptoms in advanced illness, and its severity is consistently underestimated by clinicians and 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. It may be continuous or episodic (coming and going, often triggered by exertion, lying flat or anxiety), and 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 / fluid overload | Orthopnoea, raised 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 / 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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