Palliative care - breathlessness

🔍 When to Suspect

Patient reports a subjective experience of uncomfortable awareness of breathing, which can be persistent or intermittent and associated with anxiety

From the full topic in The Ocean Library: Palliative care - breathlessness

🧭 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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