6 Managing breathlessness

6 Managing breathlessness

We will review and update these recommendations on a regular basis.

6.1 Be aware that severe breathlessness often causes anxiety, which can then increase breathlessness further.

6.2 As part of supportive care the following may help to manage breathlessness:

  • keeping the room cool

  • encouraging relaxation and breathing techniques and changing body positioning (see table 3 for techniques to help manage breathlessness)

  • encouraging patients who are self-isolating alone, to improve air circulation by opening a window or door (do not use a fan because this can spread infection)

  • when oxygen is available, consider a trial of oxygen therapy and assess whether breathlessness improves.

Table 3 Techniques to help manage breathlessness

Controlled breathing techniques include positioning, pursed-lip breathing, breathing exercises and coordinated breathing training.

In pursed-lip breathing, patients inhale through their nose for several seconds with their mouth closed, then exhale slowly through pursed lips for 4 to 6 seconds. This can help to relieve the perception of breathlessness during exercise or when it is triggered.

Relaxing and dropping the shoulders reduces the 'hunched' posture that comes with anxiety.

Sitting upright increases peak ventilation and reduces airway obstruction.

Leaning forward with arms bracing a chair or knees and the upper body supported has been shown to improve ventilatory capacity.

Breathing retraining aims to help the patient regain a sense of control and improve respiratory muscle strength. Physiotherapists and clinical nurse specialists can help patients learn how to do this (bearing in mind that this support may need to be done remotely).

6.4 Identify and treat reversible causes of breathlessness, for example pulmonary oedema.

6.5 Consider an opioid and benzodiazepine combination (see tables 4 and 5) for patients with COVID-19 who:

  • are at the end of life and

  • have moderate to severe breathlessness and

  • are distressed.

    Consider concomitant use of an antiemetic and a regular stimulant laxative.

    At the time of publication (April 2020), opioids and benzodiazepines did not have a UK marketing authorisation for moderate to severe breathlessness. See support for decision-making for off-label prescribing during the COVID-19 pandemic, produced by the General Medical Council (GMC) and Care Quality Commission (CQC), and the GMC's COVID-19 ethical hub. [amended 17 April 2020]

Table 4 End-of-life treatments for managing breathlessness for patients aged 18 years and over

Clinical scenario

Treatment

Higher doses may be needed for symptom relief in patients with COVID-19. Lower doses may be needed because of the patient's size or frailty

The doses are based on the BNF and the Palliative care formulary

Opioid naive (not currently taking opioids) and able to swallow

Oral treatment

Morphine sulfate immediate-release 2.5 mg to 5 mg every 2 to 4 hours as required or

morphine sulfate modified-release 5 mg twice a day, increased as necessary (maximum 30 mg daily)

Already taking regular opioids for other reasons (for example, pain relief)

Oral treatment

Morphine sulfate immediate-release 5 mg to 10 mg every 2 to 4 hours as required or

one twelfth of the 24-hour dose for pain, whichever is greater

Unable to swallow

Parenteral treatment

Morphine sulfate 1 mg to 2 mg subcutaneously every 2 to 4 hours as required, increasing the dose as necessary

If needed frequently (more than twice daily), a subcutaneous infusion via a syringe driver may be considered (if available), starting with morphine sulfate 10 mg over 24 hours

Special considerations

Seek specialist advice for patients under 18 years old

See BNF for more details on formulations and dosages of morphine sulfate. If breathlessness is not continuous, intermittent opioid dosing may be appropriate

If estimated glomerular filtration rate (eGFR) is less than 30 ml per minute, use equivalent doses of oxycodone instead of morphine sulfate (see Prescribing in palliative care in the BNF for more details)

Consider concomitant use of an antiemetic and a regular stimulant laxative

Continue with non-pharmacological strategies for managing breathlessness when starting an opioid

Opioid patches should not routinely be used in patients who are opioid naive because of the time it takes for the medicine to get to steady state for clinical effect and the high morphine equivalence (see Prescribing in palliative care in the BNF for more details)

Add a benzodiazepine if required

For breathlessness and anxiety: lorazepam 0.5 mg sublingually when required (maximum 4 mg daily)

Reduce the dose to 0.25 mg to 0.5 mg in elderly or debilitated patients (maximum 2 mg in 24 hours)

For associated agitation or distress: midazolam 2.5 mg to 5 mg subcutaneously when required (see BNF for more details on dosages)

Sedation and opioid use should not be withheld because of a fear of causing respiratory depression

Notes: At the time of publication (April 2020), opioids and benzodiazepines did not have a UK marketing authorisation for this indication or route of administration. See support for decision-making for off-label prescribing during the COVID-19 pandemic, produced by the General Medical Council (GMC) and Care Quality Commission (CQC), and the GMC's COVID-19 ethical hub.

[amended 22 April 2020]

Table 5 Treatments in the last days and hours of life for managing breathlessness for patients aged 18 years and over

Treatment

Dosage
Higher doses may be needed for symptom relief in patients with COVID-19. Lower doses may be needed because of the patient's size or frailty

The doses are based on the BNF and the Palliative care formulary

Opioid

Morphine sulfate 10 mg over 24 hours via a syringe driver, increasing stepwise to morphine sulfate 30 mg over 24 hours as required

Benzodiazepine if required in addition to opioid

Midazolam 10 mg over 24 hours via the syringe driver, increasing stepwise to midazolam 60 mg over 24 hours as required

Add parenteral morphine or midazolam if required

Morphine sulfate 2.5 mg to 5 mg subcutaneously as required

Midazolam 2.5 mg subcutaneously as required

(See BNF for more details on dosages)

Special considerations

Seek specialist advice for patients under 18 years old

Consider concomitant use of an antiemetic and a regular stimulant laxative

Continue with non-pharmacological strategies for managing breathlessness when starting an opioid

Sedation and opioid use should not be withheld because of a fear of causing respiratory depression

Notes: At the time of publication (April 2020), opioids and benzodiazepines did not have a UK marketing authorisation for this indication or route of administration. See support for decision-making for off-label prescribing during the COVID-19 pandemic, produced by the General Medical Council (GMC) and Care Quality Commission (CQC), and the GMC's COVID-19 ethical hub.

[amended 22 April 2020]