What are the treatment options for shortness of breath?

Treatment of Shortness of Breath

The treatment of shortness of breath depends critically on the underlying cause and must be directed at optimizing disease-specific therapy first, with supplemental oxygen reserved for hypoxemic patients and bronchodilators for obstructive airway disease. 1

Initial Assessment and Disease-Specific Treatment

The first priority is identifying and treating the underlying cardiopulmonary condition causing dyspnea, as symptomatic management alone without addressing the root cause provides limited benefit. 1

For Obstructive Airway Disease (Asthma/COPD)

• Bronchodilators are the cornerstone of acute treatment for patients with asthma or COPD experiencing shortness of breath, with inhaled beta-2 agonists providing rapid symptom relief. 1, 2

• For asthma patients aged 12 years and older, use combination inhaled corticosteroid/long-acting beta-agonist (ICS/LABA) therapy such as fluticasone/salmeterol 1 inhalation twice daily, approximately 12 hours apart. 2

• For COPD patients, the recommended dosage is fluticasone/salmeterol 250/50 mcg twice daily, with short-acting beta-2 agonists used for breakthrough dyspnea between doses. 2

• Improvement typically occurs within 30 minutes of bronchodilator administration, though maximum benefit may require 1 week or longer. 2

For Type 2 Respiratory Failure (Hypercapnic)

• Non-invasive ventilation (NIV) should be initiated when pH <7.35 and PaCO₂ >6 kPa (45 mmHg), particularly in COPD exacerbations with respiratory acidosis. 3

• Controlled oxygen therapy with target saturation of 88-92% is essential to avoid worsening hypercapnia in Type 2 respiratory failure. 3

• Monitor arterial blood gases after 1-2 hours of NIV and again after 4-6 hours if initial improvement is inadequate. 3

Oxygen Therapy: Evidence-Based Indications

Oxygen therapy should NOT be routinely administered to all patients with shortness of breath, as evidence shows no clear benefit for survival or symptom relief in non-hypoxemic patients. 1

Specific Situations Where Oxygen May Be Beneficial

• Advanced cancer patients with dyspnea AND documented hypoxia may benefit from supplemental oxygen. 1

• Patients with decompression injury should receive supplemental oxygen. 1

• Hypoxemic patients (SpO₂ <92%) with chronic respiratory disease may benefit from long-term oxygen therapy (LTOT) if they meet criteria (PaO₂ ≤7.3 kPa). 1

• During exercise in hypoxemic patients, oxygen reduces breathlessness (effect size -0.34 on standardized scales, translating to approximately 0.7 points on a 0-10 scale). 4

When Oxygen Should NOT Be Used

• Patients with cancer or end-stage cardiorespiratory disease who are non-hypoxaemic or mildly hypoxaemic (SpO₂ ≥92%) should NOT receive palliative oxygen therapy (Grade A recommendation). 1

• Short burst oxygen therapy (SBOT) should NOT be ordered for use before or after exercise in hypoxaemic or normoxic COPD patients (Grade A recommendation). 1

• No evidence supports oxygen for breathlessness in daily life settings outside of acute exercise testing. 4

Palliative Management of Refractory Breathlessness

Opioid Therapy

• Low-dose oral morphine is the only licensed pharmacological treatment for chronic breathlessness (licensed in Australia for COPD, heart failure, and cancer-related dyspnea). 1

• Starting dose is 10 mg oral morphine per day (2.5 mg immediate release four times daily, or 5 mg modified release twice daily, or 10 mg modified release once daily). 1

• 63% of patients experience clinically important improvement, with 67% of responders benefiting at the 10 mg/day dose. 1

• Dose titration should occur no sooner than one week after initiation, as the full magnitude of benefit may take up to a week to develop. 1

• Maximum dose is 30 mg/24 hours of oral morphine or equivalent, which appears safe without excess mortality or hospital admission in severe COPD. 1

• Avoid morphine in significant renal impairment (GFR <30 mL/min, Stages 4-5 chronic kidney disease), which is common in advanced heart failure and older adults. 1

Non-Pharmacological Interventions

• Opiates should be assessed by appropriately trained healthcare professionals for patients with cancer or end-stage cardiorespiratory disease experiencing intractable breathlessness (Grade A recommendation). 1

• Fan therapy directed at the face should be assessed as a non-pharmacological treatment for intractable breathlessness (Grade D recommendation). 1

• Breathing training, relaxation techniques, and psychological interventions can be tried for symptomatic relief. 1

• Appropriately tailored exercise and physiotherapy help improve functional capacity and skeletal myopathy in heart failure patients. 1

Special Considerations for Cluster Headache

• High-flow oxygen at 12 L/min via non-rebreather mask should be offered to treat acute attacks of cluster headache (Grade A recommendation). 1

Critical Pitfalls to Avoid

• Do not use oxygen as a blanket treatment for all dyspnea, as the 2015 International Consensus found insufficient evidence to recommend routine oxygen administration for shortness of breath without documented hypoxemia. 1

• Do not administer oxygen to COPD patients without monitoring CO₂ levels, as uncontrolled oxygen can worsen hypercapnia in Type 2 respiratory failure. 3

• Do not use LABA monotherapy without inhaled corticosteroids in asthma patients, as this increases risk of asthma-related death and hospitalization. 2

• Oxygen administration should be limited to individuals with specific training in oxygen delivery systems. 1

• Health-related quality of life is NOT improved by oxygen in mildly hypoxemic or non-hypoxemic COPD patients. 4