What is Dyspnea in Palliative Care?
Shortness of breath, known medically as dyspnea, is a common distressing symptom among patients with severe diseases, and is often experienced towards the end of one’s life. The American Thoracic Society has defined it as a subjective feeling of discomfort when breathing, which the person can clearly define and narrate. It’s important to note that this discomfort while breathing can be caused not only due to physical reasons, but also psychological, social, and environmental factors. These root causes then lead to secondary changes in a person’s body and behavior.
What Causes Dyspnea in Palliative Care?
Feeling short of breath, often medically referred to as dyspnea, can be caused by many different factors. Treating it requires a careful examination and a tailored treatment plan. Quite simply, people typically feel short of breath when their body senses that it’s not getting enough oxygen.
This can happen because the body feels like it needs more oxygen than usual, because it doesn’t feel able to get enough oxygen, or a mix of both. This is often referred to as a “mismatch” between oxygen supply and demand.
Risk Factors and Frequency for Dyspnea in Palliative Care
Dyspnea, or difficulty breathing, is a common and serious symptom in advanced illnesses. It’s often seen in cases of advanced cancer, heart failure, and chronic lung disease, which combined account for over half of the deaths in the United States. Among cancer patients, 50% to 70% experience dyspnea, and this goes up to 90% in case of lung cancer specifically. Similarly, 90% of people with severe lung disease and 50% of those with heart failure suffer from significant dyspnea. Additionally, difficulty breathing is a frequent symptom in patients dealing with end-stage kidney disease, dementia, aging, and HIV.
- Dyspnea is often seen in advanced stages of cancer, heart failure, and chronic lung disease – these majorly lead to over 50% of deaths in the United States.
- In cancer patients, 50% to 70% experience dyspnea, and this jumps to 90% for lung cancer patients.
- 90% of patients with severe lung disease endure significant dyspnea.
- 50% of heart failure patients experience significant dyspnea too.
- Dyspnea is also common among patients with end-stage kidney disease, dementia, advancing age, and HIV.
In the final six months of a patient’s life, the intensity and frequency of these breathing difficulties tend to increase. In fact, during the last three days of life, 90% of patients experience dyspnea at some point.
Signs and Symptoms of Dyspnea in Palliative Care
When a person experiences dyspnea, or difficulty breathing, it’s important for doctors to understand the context. They will talk to the person about the specifics of their symptoms, like when it happens, how often it happens, how long it lasts, and whether it is a continuous problem or comes and goes. They’ll also want to know what the experience means for the person — for instance, how much it distresses or frightens them.
A wide range of factors can influence how a person experiences difficulty breathing. This concept is sometimes referred to as “total dyspnea,” and it acknowledges that the physical symptoms, psychological factors like anxiety, the person’s spirituality, and their social environment, including relationships and finances, can all play a part.
The doctor will also conduct a physical examination, and what they find can depend on what’s causing the person’s difficulty breathing. An examination may reveal something new that’s contributing to the problem, or it might show that everything appears normal. A key part of this examination is looking at the person’s breathing. The doctor may look for signs like a change in the rate of breathing, visible signs of effort, or abnormal patterns, such as the use of additional muscles or unusual stomach movements.
Listening to the person’s breath sounds can also provide valuable information. The doctor will listen for signals like grunting, wheezing, crackles, or a change in the person’s voice. They’ll also pay attention to the force of the air moving in and out of the lungs.
The doctor will also look at physical signs outside of the respiratory system to understand what might be causing the difficulty breathing. Important observations might include:
- Swelling in the hands or feet
- The pulse in the veins in the neck
- The heart’s rhythm
- The quality of the sounds the heart makes
- The position of the person’s windpipe
- The response of the liver when pressure is applied to the stomach
- Swelling in the abdomen
- The color of the person’s skin
In addition to the physical examination, doctors will also consider how a person’s mental well-being, social life, and spiritual beliefs might be contributing to their experience of difficulty breathing.
Testing for Dyspnea in Palliative Care
If you’re having trouble breathing, your doctor will do a thorough examination and ask about your medical history. They’ll focus especially on finding any underlying causes of your breathlessness that can be treated. Extra tests in a lab and scans using medical imaging can also be used to diagnose the problem and decide on the best treatment.
One of these tests is pulse oximetry, which measures how much oxygen is in your blood. Arterial blood gases are another test that can tell if there are imbalances in your blood’s pH, if you’re not getting enough oxygen, or if your carbon dioxide levels are not normal. A count of your red blood cells, or hemoglobin count, can reveal if you’re anemic. A count of your white blood cells can indicate if you have an infection.
X-rays and computed tomography scans can give your doctor a look at your lungs, the area around your lungs, the blood vessels in your lungs, and your large airway structures. They can also give information about the bones in your chest. The information from these tests and scans can help your doctor find the reason why you’re having trouble breathing, allowing them to decide on the best way to treat your symptoms.
However, breathlessness is a personal experience and can be caused by many different things. Because of this, there may not be any identifiable abnormalities in your tests or scans even if you’re having trouble breathing.
Treatment Options for Dyspnea in Palliative Care
Dyspnea, or shortness of breath, can be managed in several ways. Different treatments can be aimed at improving lung pathologies, decreasing the work of the muscles used in respiration, regulating the sensation of breathlessness in the brain, and managing emotional aspects, like anxiety, associated with breathlessness.
The treatment can include both drug and non-drug methods. Medications can either manage the underlying condition causing dyspnea, or they can lessen the impact of symptoms.
Treatment options include:
Disease-Modifying Medications
- Diuretics help manage fluid overload in conditions like congestive heart failure, kidney failure, and liver failure.
- Beta-adrenergic agonists and muscarinic antagonists can reduce symptoms in advanced chronic obstructive pulmonary disease (COPD).
- In patients with low levels of oxygen in the blood, giving additional oxygen can ease dyspnea.
Symptom-Based Medications
- Opioids, particularly immediate-release morphine, significantly help manage breathlessness by reducing the discomfort it causes. They work by decreasing spontaneous respiratory drive and affecting how the brain processes the sensation of breathlessness.
- Benzodiazepines lessen the anxiety associated with shortness of breath, but do not directly affect the sensation of breathlessness.
- In COPD patients, nebulized furosemide (a type of diuretic) has shown effectiveness. It works by activating lung receptors.
- No evidence exists to support the use of nebulized lidocaine or morphine.
- Dexamethasone might be useful for lung cancer patients or those with COPD.
- Mirtazapine has shown beneficial effects for chronic dyspnea patients.
Non-Drug Therapies
- Non-invasive ventilation provides symptom relief for those experiencing increased work of breathing, but may not help cases with certain types of oxygen or air exchange problems.
- Cold air or fans blowing on the face can remarkably improve breathlessness. These methods work by triggering certain nerves in the face. Supplementary oxygen is useful only in cases where oxygen levels in the blood are low.
- Physical therapy for the lungs has been proven beneficial, especially exercise.
- Approaches such as cognitive-behavioral therapy and anxiety-reduction techniques can help manage the emotional aspects of breathlessness.
- Educating caregivers about patient positioning, crisis planning, and both drug-based and non-drug therapies can help reduce anxiety and provide an increased sense of control. They can also join dedicated support groups to help them cope with the situation.
What else can Dyspnea in Palliative Care be?
When a doctor is trying to figure out what is wrong with a patient, they consider many different diseases and conditions that might be causing the patient’s symptoms. In the case of heart or lung related symptoms, these might include:
- Acute coronary syndrome (sudden, reduced blood flow to the heart)
- Decompensated congestive heart failure (a worsening condition where the heart can’t pump enough blood to meet the body’s needs)
- Acute respiratory failure (when the lungs can’t release enough oxygen into the blood or remove carbon dioxide from the blood)
- Cardiomyopathy (a disease of the heart muscle making it harder for your heart to pump blood)
- Exogenous allergic alveolitis (inflammation of the tiny air sacs in the lungs due to an allergic reaction to dusts breathed in)
- Hemorrhage (heavy bleeding)
- High output failure (the heart works harder to pump blood, but the body’s organs still aren’t receiving enough blood flow)
- Lung contusion (bruising of the lung)
- Lung cancer
- Pulmonary edema (fluid buildup in the lungs)
- Pneumonia (lung infection caused by bacteria, viruses or fungi)
- Pleural effusion (excess fluid that builds up in the pleural space, the area between the lungs and the chest wall)
All these possibilities have to be considered and adequate tests should be carried out to achieve a correct diagnosis.
What to expect with Dyspnea in Palliative Care
Predicting the outcome for someone with difficulty breathing who is in end-of-life care can be tough. This is because the individual is nearing the end of their life, and the focus is on easing their symptoms and boosting their quality of life in the time they have left.
Possible Complications When Diagnosed with Dyspnea in Palliative Care
Possible negative effects of Opioids can include problems with breathing. Additionally, if surgical interventions are attempted, there may be complications. It’s also important to know that without proper treatment, the patient’s quality of life can be significantly impacted.
Possible Risks:
- Opioid side effects, such as breathing difficulties
- Complications from surgery
- Significant drop in the patient’s quality of life without treatment
Preventing Dyspnea in Palliative Care
It’s important for patients in the late stages of illness and their families to understand that treatments for shortness of breath are typically meant to provide comfort, not to cure the condition. In most cases, these treatments focus on the breathing difficulty or its cause, not on improving the overall terminal condition.
