Breathlessness in advanced disease

Breathlessness is a distressing symptom that arises in many diseases. It has several pathophysiological causes involving peripheral and central receptors and modulated by cortical processing. Older people and patients with cachexia are more susceptible to breathlessness on exertion. Most patients can be assessed by physical examination, and simple investigations including haemoglobin concentration, oxygen saturation, electrocardiography and imaging (X-ray, ultrasound). Research has shown that careful use of opioids can reduce the sensation of breathlessness without compromising ventilatory control. Benzodiazepines also help, probably by their anxiolytic and sedative actions. The combination of an opioid and short-acting benzodiazepine is especially useful. Nebulized furosemide is a new approach that requires further research. Oxygen is indicated if oxygen saturation falls, but increased airflow around the face (e.g. with a fan) can also help. The combination of helium and oxygen can be more effective than oxygen alone. Non-invasive ventilation can be necessary in severe cases, such as neuromuscular disease. Non-medical approaches, including breathing training and relaxation, can also help. Infusions of carefully titrated opioid and midazolam can be used in the dying patient, together with an anticholinergic agent if there are noisy upper airways secretions (‘death rattle’).