When every breath becomes a burden
The feeling of not getting enough air is not only physically exhausting but is often also associated with anxiety. In medical terms, this symptom is referred to as dyspnoea. In seriously ill people – for example, those with advanced cancer, heart failure or chronic lung disease – breathlessness is one of the most common and most distressing symptoms. Relieving breathlessness in palliative care therefore always means giving back quality of life.
It is important to note that breathlessness is a subjective experience. It cannot be assessed by measurements such as oxygen saturation alone. Patients with normal readings may still suffer severely from shortness of breath – and vice versa. Empathetic medical care therefore always takes the individual's experience into account.
Causes: Why breathlessness can occur in palliative situations
The triggers of dyspnoea are varied, and several factors often overlap. A careful assessment is the basis for targeted relief of dyspnoea.
Lung conditions
- Lung tumours or metastases that narrow the airways or lung tissue
- Pleural effusion, a build-up of fluid between the lung and the chest wall
- Pneumonia and chronic inflammatory lung diseases such as COPD
- Pulmonary embolism, which may occur more frequently in seriously ill people
- Pulmonary fibrosis, a progressive scarring of the lung tissue
Cardiovascular causes
- Heart failure with fluid congestion in the pulmonary circulation
- Pericardial effusion, a build-up of fluid in the pericardial sac
- Anaemia, leading to reduced oxygen-carrying capacity
General and systemic factors
- Muscle weakness and exhaustion, for example due to cancer or prolonged bed rest
- Ascites (abdominal fluid), which pushes the diaphragm upwards
- Metabolic disorders and electrolyte imbalances
- Pain, which prevents deep breathing
Psychological and social aspects
Anxiety, restlessness and a sense of losing control can considerably worsen breathlessness. Conversely, persistent shortness of breath can trigger anxiety – a cycle that is difficult to break without support. In palliative symptom control, the whole person is therefore always considered, not just the physical symptom.
What medical assessment provides
Before measures to relieve symptoms are introduced, a detailed conversation is central: When does the breathlessness occur? At rest or with exertion? Which accompanying symptoms are present? Depending on the situation, a physical examination, laboratory tests, an ultrasound or X-ray may also be useful. The aim is to identify treatable causes – for example, a pleural effusion that can be drained, or anaemia that can be specifically treated.
In palliative situations, however, the following principle always applies: Every diagnostic and therapeutic measure is weighed up with the patient. Quality of life and personal wishes take precedence, not maximum diagnostic effort.
Ways to relieve breathlessness
Palliative symptom control rests on several pillars, which are combined individually. It includes pharmacological, non-pharmacological and psychosocial approaches.
Non-pharmacological measures
These measures are often surprisingly effective and, for many, the first step towards relief:
- Fresh air and a fan: A cool stream of air, for example from an open window or a small desk fan, can noticeably reduce the sensation of breathlessness.
- Raising the upper body: Semi-seated positions ease the work of the diaphragm.
- Breathing-relief postures: The "coachman's posture" or supporting the arms makes breathing easier.
- A calm environment: Few stimuli, soft lighting and familiar people help to reduce tension.
- Breathing therapy and physiotherapy: Trained therapists teach techniques such as pursed-lip breathing or targeted breathing exercises.
- Relaxation techniques: Guided imagery, mindfulness exercises or gentle touch can release inner tension.
Pharmacological options
If non-pharmacological measures are not sufficient, various drug groups are available. The choice is made individually by the treating doctor.
- Opioids such as morphine are considered the treatment of choice for distressing dyspnoea in palliative situations. They can reduce the sensation of breathlessness without dangerously impairing breathing at the usual palliative doses.
- Benzodiazepines can be used as an addition if marked anxiety intensifies the breathlessness.
- Corticosteroids may be considered, for example, in cases of airway narrowing caused by tumours or in inflammatory processes.
- Diuretics help to relieve fluid congestion in the context of heart failure.
- Bronchodilators can be helpful for narrowed airways, such as in COPD.
Oxygen via a nasal cannula is frequently used, but is not always the most effective option. Studies show that for many palliative patients without pronounced oxygen deficiency, a simple airflow from a fan can provide comparable relief.
Treating the underlying cause
Where possible and appropriate, the underlying cause is also treated – for example by draining a pleural effusion, by a blood transfusion in cases of marked anaemia, or by antibiotic therapy for pneumonia. Here, too, the focus is on the benefit to quality of life.
The role of family members
Family members often experience breathlessness as particularly threatening. It can be helpful to know simple measures and to be able to apply them calmly:
- Open a window or switch on a fan
- Speak in a reassuring tone, hold the person's hand
- Keep as-needed medication available according to medical instructions
- In case of acute deterioration, contact the palliative care team or the on-call doctor
Good preparation – for example through an emergency-plan discussion with the palliative care team – can provide reassurance and ease crisis situations.
When professional support is helpful
Specialised palliative care teams, mobile hospice services and palliative care units support patients and families both at home and in inpatient settings. In Austria, there is an increasingly dense network of such services. Early involvement can help to address distressing symptoms such as breathlessness in good time and comprehensively.
Conclusion
Breathlessness in palliative situations is a common but well-treatable symptom. A careful assessment of the cause, combined with non-pharmacological measures, medication and psychosocial support, can noticeably reduce the burden. Palliative symptom control is not to be understood as a "last resort", but as active support that can already be helpful early in the course of an illness.
This article does not replace medical advice.