Catherine Moffat

Nonpharmacological interventions for breathlessness.

Purpose of reviewBreathlessness is difficult to palliate and nonpharmacological interventions are effective management strategies currently available for mobile patients. These are a diverse group of interventions, currently poorly defined and inconsistently used. This review concentrates on identifying and recommending the most effective nonpharmacological strategies for breathlessness, to aid clinical practice. Recent findingsMuch of the evidence presented is based on a Cochrane Review, which demonstrated that facial cooling, by handheld fan, mobility aids (e.g. rollators) and neuromuscular electrical stimulation all had evidence to support their use in breathlessness. Breathing exercises, pacing and positioning are frequently used to manage breathlessness, but need definition and further research. Anxiety reduction techniques and carer support are used in chronic disease management and applicable for breathlessness, but act indirectly. Exercise is a long established management strategy in both respiratory and other chronic diseases to maintain fitness (which reduces breathlessness) and increase psychological well being. SummaryAll patients with breathlessness should learn appropriate nonpharmacological interventions. Some can be taught by clinicians without specialist training, but others require specialist skills and high levels of engagement by cognitively intact and highly motivated people. Specialist breathlessness services may be more effective in delivering complex nonpharmacological interventions, but more research is needed.

The Breathing, Thinking, Functioning clinical model: a proposal to facilitate evidence-based breathlessness management in chronic respiratory disease

Refractory breathlessness is a highly prevalent and distressing symptom in advanced chronic respiratory disease. Its intensity is not reliably predicted by the severity of lung pathology, with unhelpful emotions and behaviours inadvertently exacerbating and perpetuating the problem. Improved symptom management is possible if clinicians choose appropriate non-pharmacological approaches, but these require engagement and commitment from both patients and clinicians. The Breathing Thinking Functioning clinical model is a proposal, developed from current evidence, that has the potential to facilitate effective symptom control, by providing a rationale and focus for treatment.

Positions to Ease Breathlessness

Positioning improves the efficiency and effectiveness of both primary and accessory muscles of breathing and therefore helps to ease breathlessness. Patients who are breathless take up a wide variety of positions and choice of position is often influenced by pathology. This chapter will review the variety of positions that help to ease breathlessness at rest and after exertion. Theories and mechanical basis regarding why such positions help reduce breathlessness will be explored. The use of walking aids, to enable positions of ease to be used during mobilising, will also be discussed.

Breathing Techniques for Breathlessness

Breathing techniques are most commonly used in combination with positioning and the fan to the face or other facial cooling. This chapter will focus on three different breathing techniques that can help reduce the feeling of breathlessness: Breathing Control Pursed-lips Breathing Recovery Breathing

Non-pharmacological interventions for breathlessness in people with cancer

ABSTRACTIntroduction: Breathlessness is a common and distressing symptom in people with advanced cancer of all etiologies, often co-existing with cough and fatigue. Its incidence and severity incre...

Pharmacological Management of Breathlessness

There are many similarities in the central neurophysiology of pain and breathlessness but the treatment strategies are different. The pharmacological treatment of breathlessness lags behind that of pain in both the number of drugs available and the effectiveness of current drug regimens. There is reason for hope as increasing research is being carried out in this area. In general drug treatment is most effective in those with the most severe breathlessness or at the end of life. Oral morphine is the drug with the greatest evidence base and is most widely used. Second line treatment is open to question as there is no high quality evidence currently to support the use of benzodiazepines which are certainly useful at the end of life when sedation is needed but can promote hazardous dependency in those with months or years to live. Mirtazapine may have a more substantial rationale for its use although it has not been researched rigorously yet. In mobile patients with a lengthy prognosis non-pharmacological, procentral approaches are likely to be best approach.

The Genesis and Assessment of Breathlessness

The successful management of any symptom requires an understanding of its cause. The aetiology of breathlessness is particularly complex, and pathophysiological and clinical models have been developed in an attempt to explain the underlying mechanisms. This chapter outlines two such models, including the Breathing, Thinking, Functioning model, which explains how breathlessness is perpetuated and can be helpful in guiding symptom assessment and management.

An Approach to the Breathless Patient

The practical management of chronic intractable breathlessness requires a multifaceted approach i.e. a complex intervention encompassing pro-central non-pharmacological interventions, and palliative drug therapy where necessary. Treatment of the underlying disease should always be optimised and referral to other specialists may be necessary to achieve this: palliation cannot take place without a diagnosis of the cause of breathlessness. At assessment, the patient’s goals are at the centre of the care and the action plan and broader strategy are decided with them. The needs of the patient’s carer require individual attention, again built round that person’s goals. Non-pharmacological, pro-central interventions can be usefully considered by their main mode of action i.e. whether they primarily affect breathing, thinking or functioning, accepting there is a degree of overlap. As well as symptom control for breathlessness the patient needs to be assessed comprehensively as other symptoms frequently co-exist, for example fatigue, cough and pain. The latter is particularly common in those with advanced cancer. Approaches which aim to build the patient (and carer’s) wellbeing and mental resilience are also important, as living with a chronic illness is always demanding. If you are uncertain how to help an individual with difficult symptoms and need advice or a consultation contact your local palliative care service.

Exercise and Activity Promotion

Regular exercise and activity has been proven to improve breathlessness however breathless patients often avoid exercise and activity due to the misguided fear that breathlessness is harmful. Some patients may avoid exertion simply just to avoid this unpleasant symptom. Carers may also re-enforce negative beliefs regarding exercise, therefore promoting a sedentary life style. Inactivity may cause the breathless patient to become deconditioned and their breathlessness may worsen as a result. The clinician’s role is to address barriers to exercise and promote regular, appropriate exercise and activity. This chapter will introduce and explore a stepwise process to exercise and activity promotion to help guide the clinician to empower the breathless patient to engage in lifelong exercise and activity.

Breathlessness; the Experience for the Patient, an Approach for the Clinician

Intractable breathlessness is the most common devastating symptom of advanced cardio-respiratory disease, both malignant and non-malignant in nature. It is a global problem affecting millions of people worldwide as the incidence or COPD, lung cancer and heart failure continue to grow. Intractable breathlessness occurs when the uncomfortable sensation of the need to breathe persists even when the underlying medical condition and any other known aetiological factors have been maximally treated. In the most severe form it can be present at rest or on the most minimal exertion such as talking or washing. The fear and physical limitations the symptom imposes affects those closest to the patient as well, and over a period of years social isolation and depression are common both in the sufferer and the carers. There has been significant progress in recent years in understanding both the pathophysiology of breathlessness and ways it might be helped. This chapter sets out to outline both the experience of intractable breathlessness for patients and families and current best practice in managing the symptom.