Decision tree designed in collaboration with Gloucestershire Community and Hospital Respiratory and Palliative Care Teams and in
consultation with GHT Cardiac Team. Version 2 Updated 2016
Intractable Dyspnoea
Breathlessness that does not improve despite optimisation of medicines
All clinical causes of breathlessness need to be excluded and treated first. On-going
assessment of hypoxia should continue at all stages
Non pharmacological
Treatment Options
Clinical Assessment
of hypoxia for Oxygen Treatment
Fan Therapy – Air flow across
OXYGEN THERAPY
Check SpO2
Ensure patient is a non-smoker
face is usually preferred. Cool flannel
on face also helps
Open windows - reduces air
hunger. Over chilling of head and
neck can lead to exacerbations
Keep rooms cool and un-crowded
Pacing –
Planning ADL reduces O2 needs
Adapted washing and dressing activity
If SpO2 > 90%
There is no evidence to support O2 use in
non-hypoxic breathlessness. However;
Consider 1-2 LPM nasal oxygen short burst
Refer to HOAS to create and send HOOF,
assess patient safety, CBG if required and
provided ongoing advice and support for
oxygen therapy
Breathing Control – Low, slow
breathing supports effective use of
respiratory system and muscles.
Positions of Ease – Reduces
Consider
support from
Physio and
OT
work of breathing, oxygen demands of
muscles, aids relaxation and reduces
pain caused by muscle spasm/fatigue
Chest Clearance – Active Cycle
Of Breathing Technique, postural
drainage, adequate hydration and
adjuncts assist in the clearance of
retained secretions.
If SpO2 <90%
Rule out treatable causes
Refer to HOAS
If out of hours provide 1-2 LPM oxygen to
bring SpO2 above 90%
4 hour delivery reserved for last few
days/week of life
Oxygen therapy
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Home Oxygen is contraindicated in smokers
Prescriber to refer all patients to HOAS, unless last
days/few weeks of life, to rule out hypercapnia
Hypercapnia is uncomfortable and avoidable ( severe
headaches, dizziness, facial flushing and induced
coma)
Please email HOOF to HOAS
[email protected]
Psychological therapies such
as CBT support all the above.
Use music & relaxation CDs
Consider referral to other services
Using more than one of the
above is advised
Consider Advance Care Planning tool
End of Life Wishes and Plans
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Oxygen Masks
Nasal oxygen is preferable for comfort, and
eating/drinking. Please seek advice from HOAS if mask
required for high flow as humidified oxygen may be
necessary at higher flow rates to provide comfort
Trial of Saline Nebuliser
Moistens airways in LTOT users or mouth breathers
- Saline nebules 0.9%/2.5mls PRN
Use in-between nebulised bronchodilators if required
in respiratory patients
Humidification of O2 of <6L/min is not advised as
endpoint oxygen flow rates may be reduced
Decision tree designed in collaboration with Gloucestershire Community and Hospital Respiratory and Palliative Care Teams and in
consultation with GHT Cardiac Team. Version 2 Updated 2016
Dyspnoea Decision Tree
Exclude Reversible Causes and Treat as Appropriate
e.g.
(Pulmonary oedema, bronchospasm, anaemia, pleural effusion, hyperventilation)
If dyspnoea persists consider non pharmacological management options
See below (page 2)
If dyspnoea persists consider pharmacological management options
Check Oxygen Saturation levels (Normal SpO2 >90%)
Trial of Opioids
Opioid Naive: Check eGFR:
eGFR ≥30 Oramorph® –2 - 2.5mgs up to hourly
eGFR <30 OxyNorm® liquid PRN 1 – 1.25mg up to hourly
Consider starting at low doses and titrating especially in patients who do not have cancer or frail/elderly
Can consider Zomorph®/Longtec® if benefiting from immediate release preparations or struggling with
regular dosing. Consider low dose buprenorphine BuTec® patch 5mcg/hr if the oral route is unsuitable.
Please contact Specialist Palliative Care Team for more advice on opioid dosing
On Background Opioid: Use patient’s normal breakthrough dose for episodes of dyspnoea (usually 1/6th
of background dose)
.
Trial of benzodiazepine
Use when high anxiety is suspected
Lorazepam 0.5-1mg Sublingual PRN 6hrly
(Maximum 4mg per 24 hours)
Symptomatic Trial of Oxygen
If patient is hypoxic or becomes hypoxic after
exercise
(<90% SpO2)
Diazepam is not usually advised
Using oxygen for non-hypoxic breathlessness is
not advised
Midazolam 2.5-5mg SC PRN up to hrly
Review oxygen use regularly and refer to home
oxygen team
These interventions should be tried in turn so that efficacy of each intervention can be better
assessed
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