Breathlessness in palliative care

Breathlessness is also called shortness of breath or dyspnoea. It can feel like:

• a tightness in your chest
• you can’t get enough air when you breathe in
• you’re having to work hard to take a breath
• it’s stopping you from moving or talking due to lack of air.

Breathlessness can last a little while, or it can come and go or be with you all the time. It can also make you feel very anxious about having problems while breathing. 

Being short of breath may mean you have problems staying active and doing all the things you need to do. It may also make you very tired and make you feel down or a bit hopeless.

When is it important to get help?

If your breathlessness comes on very suddenly or is very severe meaning you can’t get enough breath, get medical help.

It’s also important to get help if you have shortness of breath and:

• a headache or feeling of fullness in your head
• swollen veins in your neck or chest
• swollen arms, hands, neck or face
• dizziness
• changes to your vision.

There are many things that can contribute to the feeling of being short of breath. It may come and go quickly (acute) or may come on slowly and last for a longer time (chronic).

It can be caused by the terminal illness you're living with, eg, lung cancer, or other medical conditions that happen at the same time. Breathlessness can also be caused by, or made worse by, psychological factors such as anxiety and fear. It isn't always possible to find an exact cause. 

Common causes of breathlessness in people living with a terminal illness include:

• cancer and its complications, such as pleural effusion, pulmonary embolism or airway obstruction
• conditions affecting your lungs, such as COPD 
• heart conditions such as heart failure
• muscle weakness
• fatigue
• infection
• metabolic acidosis (when your body makes too much acid)
• low blood count (anaemia)
• smoking
• pain
• anxiety and fear.

Breathlessness may be managed or even taken away if the underlying cause can be treated (is reversible). Examples include infection, anaemia, asthma and anxiety.

Symptoms can range from mild shortness of breath to very fast gasping breaths. You may also feel:

• dizzy
• chest discomfort and/or tightness
• fatigue
• anxious or scared.

Your healthcare provider may ask you some questions to find out the possible causes of your breathlessness. You may need to complete a symptom diary to monitor the timing of your breathlessness, what triggers it and how it's affecting your daily life. 

Your healthcare provider may also do a physical examination to check for signs of illness or disease and carry out tests to rule out physical causes, such as blood and urine tests. 

Treatment aims to relieve your symptom of being short of breath and to make you feel better. You may have many healthcare providers involved in your care as it requires treatment from a multidisciplinary team. Your healthcare team could include doctors, nurses, a physiotherapist, an occupational therapist, a palliative care specialist or a cancer specialist.

If you have a medical condition or any obvious causes of breathlessness are found, treatment will focus on the condition or cause. 

There are 2 components of the treatment of breathlessness:

• non-medicines treatment
• medicines.

Non-medicine treatment

The non-medicine treatment of breathlessness includes:

• physiotherapy
• counselling
• relaxation techniques
• breath control techniques
• good positioning
• blood transfusion if you have anaemia 
• complementary therapies such as aromatherapy, music and art therapy.

You may be referred to a physiotherapist, an occupational therapist, a psychologist or a complementary therapist as part of your treatment. 

Medicines

Medicines may be used to treat and reverse an underlying condition if it's causing or contributing to your breathlessness. 

Examples include

• antibiotics if you have an infection
• diuretics for conditions such as heart failure
• chemotherapy or radiotherapy, eg, if you have lung cancer
• inhalers or nebulisers if you have asthma or COPD.

Other medicines may help with your breathlessness if the problem can't be reversed. Morphine is often used in this situation as a very effective and safe medication.

You may be given oxygen if your oxygen levels are low. However, oxygen on its own isn't useful if you're feeling breathless but your oxygen levels aren't low – this is common.

As you near the end of life, some of these medicines may be given to you as a subcutaneous injection (under your skin) or with a syringe driver. Read more about syringe drivers. 

There are several things you can do to help manage breathlessness. 

• Try sitting in an area that has good ventilation, eg, by an open window or using a small fan.
• Use a cool damp cloth or fine mist spray on your face.
• Plan activities in advance, break down tasks and do them one by one, taking frequent breaks in between.
• Practice mindfulness and relaxation exercises.
• Practice breath control techniques – a physiotherapist or occupational therapist can teach you how to do these.
• Wear loose-fitting clothes.
• Sit down to dress or do other tasks.
• Change your body position.
• Listen to music or turn on the TV to distract yourself – distraction helps.
• Use a walker if needed.
• If you smoke, get help to stop.
• If you're are on medication for your breathing, make sure you take it as prescribed.

Breath control techniques

There are some breathing techniques and exercises that can help you control your breathing.

A simple breathing exercise to try is as follows:

• Breathe in slowly for a count of 3: 1–2–3.
• Hold your breath for a count of 3: 1–2–3. 
• Breathe out slowly for a count of 3: 1–2–3
• Repeat 3 or 4 times until you start to feel relaxed.

Ask your healthcare provider about referring you to a physiotherapist to learn about breathing techniques and exercises. You can also look for a physiotherapist with a respiratory interest. Find a physio.(external link)

Body position

Changing the position of your body can also help when you are feeling breathless. Try the following:

• Put yourself in a position that supports your head and shoulders to relax comfortably.
• Try a range of positions such as sitting or standing up tall, or leaning forward resting your elbows on your knees or on a bench.
• Rest, breathing slowly and gently, in the position that is most comfortable for you.

Relaxation and mindfulness exercises

Learning how to relax can help prevent the breathlessness–anxiety loop.

• Feeling breathless can make you feel anxious and when you are anxious, your breathing tends to become more rapid and shallow.
• This can make you feel more breathless, which in turn can increase your anxiety.

Learning and practising relaxation techniques can help you become calm and slow your breathing. Mindfulness is a useful practice to help you feel more relaxed and calm. Read more about mindfulness.

Apps reviewed by Healthify

You may find it useful to look at some Breathing apps, Pain management apps, and Long-term condition apps.

Living with breathlessness can be frightening. It can also make it challenging to do things physically. Talk through your feelings with your family and friends to get the support you need. 

If you need extra help in daily activities such as washing, dressing or cooking, your doctor may be able to arrange this for you. 

Below are some support services and information for people affected by cancer and their family/whānau:

Emotions and cancer(external link) Cancer Society of NZ
How we can help(external link) Cancer Society of NZ
NZ cancer services – find a hospital/service near you(external link) Healthpoint, NZ
More cancer support groups