In Control of My Breathing:
Non-pharmacological Management of Breathlessness
Kirsty Hampson
Palliative Care Physiotherapist
[email protected]
Objectives
• ‘Total Breathlessness’: Model to guide
effective assessment and management of
breathlessness
• Non-pharmacological strategies and
techniques to support patients with
breathlessness and advanced COPD
• Alf
- Advanced
COPD and Lung
Cancer
- Refractory
breathlessness:
breathless
despite optimal
management
Effective management starts with
effective assessment…
• Highly subjective and can only truly be described and
interpreted by the person experiencing the sensation
Yorke 2008
 What is the lived experience of breathlessness
for each individual?
Subjective awareness of increased work of
breathing causing discomfort and sensations such as
fear and anxiety that are widely variable in intensity
Interactions between multiple causative factors;
physiological, psychological, social and environmental ,
producing secondary physiological and behavioural
responses
American Thoracic Society 1999
Total Breathlessness
Physical
Psychological
Spiritual
Social
Total Dyspnoea. Abernethy and Wheeler 2008
Total Breathlessness
Physical
Difficulty managing ADL’s
Mobility
Difficulty Speaking
Difficulty Eating
Spiritual
Difficulty expressing self/ wishes/
fears
Fear of dying gasping for breath
Loss of ‘self’/ Loss of meaning in life
Psychological
Decreased confidence in ability to
cope
Increased fear and anxiety
Feeling of being a burden on carers/
Guilt
Social
Dependence on others for support
Fear of going out/ Social Isolation
Decreased ability to communicate
and interact with others
Effective management of
breathlessness must consider the
‘Totality’ of the lived experience
of breathlessness for that
individual
Balance of Management Approaches
NonPh
NonPh
Pharm
Pharm
Dyspnoea on
exercise
Dyspnoea at
rest
NonPh
Nonpharmacological
Non-pharmacological
interventions are the most
effective interventions
Pharmacological
Pharmavailable
currently
to palliate
breathlessness in the mobile
patient
Booth et al 2011
Terminal
dyspnoea
Wilcock, 1998
Individualised intervention is key
for the person
• Functional status
• Choice and motivation for learning a new skill or
technique
• Level of cognition and ability to concentrate
And for the stage of disease and disease
trajectory
Booth et al 2011
Non-pharmacological Approaches
to support patients
To be in control of their breathing
AND
As independent as possible
Education
Intervention
•Anatomy and physiology of
breathlessness
•To patient and carer/ family
Rationale
•Promotes better understanding of their
illness, why breathlessness occurs
•Increases acceptance Decreases fear
•Empowers patients to be experts in their
condition
Evidence
•Insufficient Bausewein et al 2009.
•Await results of RCT’s for
Breathlessness Service
Positioning
Intervention
•Forward lean in standing or sitting to fix shoulder girdle and upper
limbs
•High sitting (30deg) in supine or sidelying
Rationale
•Increases efficient use of breathing
accessory muscles
•Positions abdominal contents forward
(down) to offload diaphragm and allow
greater lung expansion Buckholz and von Gunten 2009
•Improves ventilation/perfusion ratio
Evidence
•Limited. Recommended in clinical practice but further research
needed. Booth et al 2011
Hand Held Fan
Intervention
•Handheld fan directing current of air
against the face (Dermatome distribution of
Trigeminal Nerve)
Rationale
•Stimulates nasal receptors altering the signal to brainstem respiratory
complex and changing respiratory pattern
•? Relative benefits of reduced temperature versus air flow
Abernethey et al 2010
Evidence
•Strong evidence. Crossover RCT 51 patients with chronic breathlessness.
Significant decrease in breathlessness measured on VAS when fan
directed to cheeks vs leg (p=0.003)
Galbraith et al 2010
Breathing Techniques
Breathing Control:
•‘normal tidal breathing encouraging relaxation of the upper
chest and shoulders’ BTS/ACPRC (2009)
•Promotes efficient breathing pattern, decrease distressing
symptoms of hyperventilation
Pursed Lip Breathing:
•‘generation of a positive pressure within the airways by
expiration against partially closed lips’ BTS/ACPRC (2009)
•Creates Positive end expiratory pressure to maintain patency
of unstable airways, increase expiratory airflow and decrease
dynamic hyperinflation
Recovery Breathing:
•‘patient focuses on blowing out while gradually and
deliberately increasing the length of the out breath as their
breathing recovers’ CBIS Manual (2011) .
•Allows maximum air movement for given lung capacity,
maximising gaseous exchange
Evidence
•Moderate quality evidence to support
Bausewein et al 2009 Cochrane
Systematic Review
•Compounded by variation in definition of techniques Booth et al
2011
Stop what you are doing
Sit in a comfortable, supported position
Relax shoulders and the muscles around the neck
Focus on slowly breathing out
Breath in comes spontaneously when ready
Don’t force it
Gently encourage patient to try and slow their breathing by focus
on slowly breathing out
Can get patient to breath out against against flow of air from
handheld fan
Speak calmly and reassure ++
Functional Exercise
Exercise in patients with advanced breathlessness is appropriate:
•
Promoted in a nonthreatening way
•
Individually prescribed
•
Related to functional tasks
Sachs & Weinberg 2009
Rationale
• Lower ventilation demand resulting in slowing of respiration. Longer
expiration reduces dynamic hyperinflation
Kamal et al 2012
• Prevents spiral of deconditioning and disability
• Essential for helping patients to maintain independence and dignity
Evidence
Some evidence to support effectiveness
Thomas et al 2011
Energy Conservation and Activity Modification
Intervention:
Education to influence behaviour change:
• Balancing periods of activity and periods of rest
• Prioritisation of what is important, letting others help with more strenuous
tasks
• Planning day according to how you are feeling
• Break down tasks into smaller more manageable ones
• Consideration of aids and adaptations to make tasks easier
Rationale:
Support to help individuals become aware of the energy they have available
and enable maximal use of this energy Booth et al 2011
Evidence:
• Lack of robust evidence. Bausewein et al 2009 Cochrane Systematic Review.
Walking Aids
Intervention
•Appropriate walking aid (suited to functional ability) allows forward leaning
position to be maintained during walking
Rationale
•Stabilisation of ribcage may improve accessory
muscle function and contribution to respiration
Probst 2004
•Minimises energy expenditure allowing
patients to carry O2 cylinder, shopping
•Increases confidence mobilising/
psychological reassurance (recovery station)
Evidence
•Strong evidence to support reduces exertion dyspnoea in COPD
Booth S, Moffat C, Burkin J. 2011
•May increase walking distance in those with COPD Ambrosino and Vagheggini 2006
Anxiety and Panic Management
• Identify triggers for anxiety – consider ‘Total
Breathlessness’
• Reinforce normal physiological response to anxiety
• Teach patients to recognise anxiety
• Have a clear plan:
Recovery Breathing
• Reassure patients: they always come through it
• Teach carers techniques to support and reinforce
with patient
• Consider referral for Psychological Support
Breathlessness Services
• Multi-professional to best address multi-dimensional impacts
of breathlessness Yates and Zhao 2011
• Aim to support patients with intractable breathlessness of
any diagnosis to self manage breathlessness
• ‘Total Breathlessness’ model: optimal medical management
alongside robust non-pharmacological strategies
Evidence:
• Lack of robust evidence to date. Show promise Booth et al 2006.
• 2 RCT’s currently underway employing MRC complex
intervention framework Booth et al 2011
ICon: In Control of My Breathing
Programme
Total Breathlessness
Physical
Psychological
In Control of
Breathing
Spiritual
Live well
alongside
Breathlessness
Social
Total Dyspnoea. Abernethy and Wheeler 2008