What is the initial management strategy for a patient presenting with breathlessness?

Initial Management Strategy for Breathlessness

The initial management of breathlessness should first identify and treat potentially reversible causes, then implement non-pharmacological interventions including positioning and breathing techniques, followed by pharmacological treatment with opioids for persistent symptoms. 1

Assessment and Identification of Causes

• Check oxygen saturation using pulse oximetry at rest and/or after exertion
• Assess severity using a numerical rating scale (0-10) with focus on treating patients with scores ≥4 1
• Identify potentially reversible causes:
  • Haemodynamic status (heart failure)
  • Skeletal myopathy and sarcopenia
  • Chronic or acute comorbidities
  • Hypoxemia
  • Urinary retention
  • Constipation

Non-Pharmacological Interventions

These should be offered before starting pharmacological interventions and should continue alongside them 1:

1. Positioning techniques:

   • Sitting upright to increase peak ventilation and reduce airway obstruction
   • Leaning forward with arms bracing a chair or knees to improve ventilatory capacity
   • Elevating the head of the bed (semi-Fowler position) 2

2. Breathing techniques:

   • Controlled breathing techniques including pursed-lip breathing
   • Breathing exercises and coordinated breathing training
   • Relaxation and dropping the shoulders to reduce hunched posture associated with anxiety 1

3. Other supportive measures:

   • Cooling the face, opening windows, using small ventilators
   • Respiratory training with physiotherapist guidance
   • Walking aids (frame or walker) if mobility is affected 1
   • Neuro-electrical leg muscle stimulation for those with severe limitations 1

Oxygen Therapy

• Provide oxygen therapy for hypoxemic patients (SpO₂ <90%)
• Not recommended for patients who are only mildly hypoxemic or normoxemic 1
• For patients with COPD or risk of hypercapnia, target SpO₂ 88-92% 2
• Initial oxygen therapy devices should be chosen based on severity:
  • Mild hypoxemia: Nasal cannulae (1-2 L/min)
  • Moderate hypoxemia: Simple face mask (5-6 L/min)
  • Severe hypoxemia: Reservoir mask (15 L/min) 2

Pharmacological Management

For persistent breathlessness despite optimal treatment of underlying causes:

1. Opioids (first-line pharmacological treatment):

   • For opioid-naive patients able to swallow: Morphine sulfate immediate-release 2.5-5 mg every 2-4 hours as required or morphine sulfate modified-release 5 mg twice daily (maximum 30 mg daily) 1
   • Starting dose: 10 mg per day (2.5 mg immediate release four times daily or 5 mg modified release twice daily) 1
   • Response should be assessed within 24 hours, with full effect potentially developing over a week 1
   • If estimated glomerular filtration rate (eGFR) is <30 mL/min, use equivalent doses of oxycodone instead 1

2. Adjunctive medications:

   • Consider concomitant use of an antiemetic (such as haloperidol)
   • Add a regular stimulant laxative (such as senna) to prevent constipation 1
   • For anxiety-related breathlessness, consider benzodiazepines (lorazepam 0.5-1 mg orally four times daily as needed) 1

Special Considerations

• For patients with COPD exacerbations, add bronchodilators like salbutamol, but use with caution in patients with cardiovascular disorders 3
• For heart failure, optimize volume status with diuretics and consider vasodilators if blood pressure permits 2
• For patients with anxiety contributing to breathlessness, address psychological factors and consider relaxation techniques 1

Common Pitfalls to Avoid

• Delaying recognition of respiratory failure
• Providing excessive oxygen to COPD patients (can worsen hypercapnia)
• Failing to continue non-pharmacological strategies when starting opioids
• Using opioid patches in opioid-naive patients (slow onset, high morphine equivalence) 1
• Neglecting psychological aspects of breathlessness which can worsen the symptom 1

By following this structured approach to breathlessness management, clinicians can effectively address this distressing symptom while improving patients' quality of life and functional capacity.