Guideline sources The following summarized guidelines for the evaluation and management of dyspnea in palliative care are prepared by our editorial team based on guidelines from the Global Initiative for Chronic Obstructive Lung Disease (GOLD 2023), the American Society of Clinical Oncology (ASCO 2021), the American Thoracic Society (ATS 2020), the European Respiratory Society (ERS 2017), the British Thoracic Society (BTS 2015), and the Canadian Thoracic Society (CTS 2011). 1 2 3 4 5 6 Calculator Calculator Calculat BODE index for survival of COPD COPD assessment test CAT DECAF Guidelines 1. Diagnostic investigations Clinical assessment: Obtain a systematic assessment of dyspnea using validated patient-reported outcome measures at every inpatient and outpatient encounter in patients with advanced cancer. Use https://web.pathway.md/diseases/reclICyFduWEmymO1 1/5 6/29/23, 10:26 PM Dyspnea in palliative care Pathway a validated observation measure in patients unable to self-report. B Obtain a comprehensive assessment of the severity, chronicity, potential causes, triggers, associated symptoms, and emotional and functional impact in patients with dyspnea, whenever possible. B 2. Respiratory support Airflow interventions: As per GOLD 2023 guidelines, consider offering a fan blowing air onto the face to relieve dyspnea in patients with advanced COPD. C As per ASCO 2021 guidelines, offer airflow interventions such as directing a fan at the cheek (trigeminal nerve distribution) in patients with advanced cancer and dyspnea. B As per BTS 2015 guidelines, offer a fan therapy provided by an appropriately trained healthcare professional in patients with cancer or end-stage cardiorespiratory disease experiencing intractable breathlessness. B Supplemental oxygen: As per GOLD 2023 guidelines, consider administering oxygen supplementation in patients with advanced COPD. C As per ASCO 2021 guidelines: Ensure standard supplemental oxygen is available for patients with hypoxemia experiencing dyspnea (SpO 90% on room air). B Do not administer supplemental oxygen when SpO is > 90%. D As per BTS 2015 guidelines: Do not offer palliative oxygen therapy in patients with cancer or end-stage cardiorespiratory disease experiencing intractable breathlessness if they are non-hypoxemic or having mild levels of hypoxemia above current long-term oxygen therapy thresholds (SpO 92%). D Consider offering palliative oxygen therapy by specialist teams in patients with intractable breathlessness unresponsive to all other modalities of treatment. Obtain an individual formal assessment of the effect of palliative oxygen on reducing breathlessness and improving quality of life. E As per CTS 2011 guidelines: Consider offering continuous oxygen therapy in hypoxemic (at rest) patients with advanced COPD. C Insufficient evidence to support the routine use of supplemental oxygen to reduce dyspnea in non-hypoxemic patients with advanced COPD. I Noninvasive ventilation: As per ASCO 2021 guidelines: Consider offering a time-limited therapeutic trial of high-flow nasal cannula oxygen therapy, if available, in patients with significant dyspnea and hypoxemia despite standard supplemental oxygen. C Consider offering a time-limited therapeutic trial of noninvasive ventilation, if available and not contraindicated, in patients with significant dyspnea despite standard measures. C https://web.pathway.md/diseases/reclICyFduWEmymO1 2/5 6/29/23, 10:26 PM Dyspnea in palliative care Pathway As per ERS 2017 guidelines, consider offering noninvasive ventilation to relieve dyspnea in patients with terminal cancer or other terminal conditions. C 3. Medical management General principles: refer patients with advanced cancer and dyspnea to an interprofessional palliative care team where available. B Management of underlying conditions: provide goal-concordant treatment consistent with the patient's wishes, prognosis, and overall health status in patients with potentially reversible, common etiologies of dyspnea, such as pleural effusion, pneumonia, airway obstruction, anemia, asthma, COPD exacerbation, PE, or treatment-induced pneumonitis. B Show 2 more Opioids: As per GOLD 2023 guidelines, consider offering opioids to relieve dyspnea in patients with advanced COPD. C Consider offering low-dose long-acting oral or parenteral opioids in patients with severe disease. C As per ASCO 2021 guidelines, offer systemic opioids in patients with advanced cancer when nonpharmacologic interventions are insufficient to provide dyspnea relief. B As per ATS 2020 guidelines, consider offering opioid-based therapy, within a personalized shared decision-making approach, in patients with COPD experiencing advanced refractory dyspnea despite otherwise optimal therapy. C As per BTS 2015 guidelines, offer a trial of opioids in patients with cancer or end-stage cardiorespiratory disease experiencing intractable breathlessness. A As per CTS 2011 guidelines, offer oral (but not nebulized) opioids for the treatment of refractory dyspnea in individual patients with advanced COPD. B Benzodiazepines: consider offering short-acting benzodiazepines in patients experiencing dyspnea-related anxiety and continuing to experience dyspnea despite opioids and other nonpharmacologic measures. C Corticosteroids: consider offering systemic corticosteroids in selected patients with airway obstruction or when inflammation is likely a key contributor to dyspnea. C Bronchodilators: offer bronchodilators for palliation of dyspnea in patients with established obstructive pulmonary disorder or evidence of bronchospasm. B Sedation: offer continuous palliative sedation in patients with dyspnea refractory to all standard treatment options and all applicable palliative options, with an expected life expectancy of days. B Therapies with no evidence for benefit: As per ASCO 2021 guidelines, insufficient evidence to recommend for or against the use of antidepressants, neuroleptics, or inhaled furosemide for dyspnea. I As per CTS 2011 guidelines, do not use anxiolytics and antidepressants routinely for the management of dyspnea in patients with advanced COPD. D https://web.pathway.md/diseases/reclICyFduWEmymO1 3/5 6/29/23, 10:26 PM Dyspnea in palliative care Pathway 4. Nonpharmacologic interventions Breathing techniques: As per ASCO 2021 guidelines, consider offering breathing techniques for dyspnea in patients with advanced cancer. C As per CTS 2011 guidelines, advise patients with advanced COPD of the potential benefits of pursed-lip breathing and instruct them in its use. B Walking aids: advise patients with advanced COPD of the potential benefits of walking aids and obtain a professional assessment for choosing a suitable device. B Nutritional support: provide nutritional supplementation to improve respiratory muscle strength and overall health status in malnourished patients. B Alternative and complementary therapies: As per ASCO 2021 guidelines: Consider offering other nonpharmacologic measures for dyspnea, such as posture, relaxation, distraction, meditation, self-management, physical therapy, and music therapy, in patients with advanced cancer. Consider offering acupressure or reflexology, if available. C Insufficient evidence to recommend for or against pulmonary rehabilitation in patients with advanced cancer and dyspnea. I As per CTS 2011 guidelines, insufficient evidence to recommend the routine use of acupuncture, acupressure, distractive auditory stimuli (music), relaxation, handheld fans, counseling and support programs, and psychotherapy in patients with advanced COPD. I 5. Therapeutic procedures Neuromuscular electrical stimulation: As per GOLD 2023 guidelines, consider offering neuromuscular electrical stimulation in patients with advanced COPD. C As per CTS 2011 guidelines, consider offering neuromuscular electrical stimulation and chest wall vibration to reduce dyspnea in patients with advanced COPD. C Studies 2022 BEAMS (morphine 16 mg) In adult patients with COPD and chronic breathlessness, morphine was not superior to placebo with respect to reduction in intensity of worst breathlessness at week 1. Magnus Ekstr m et al. JAMA. 2022 Nov 22. 2022 BEAMS (morphine 8 mg) In adult patients with COPD and chronic breathlessness, morphine was not superior to placebo with respect to reduction in intensity of worst breathlessness at week 1. https://web.pathway.md/diseases/reclICyFduWEmymO1 4/5 6/29/23, 10:26 PM Dyspnea in palliative care Pathway Magnus Ekstr m et al. JAMA. 2022 Nov 22. Show 3 more References 1. Darcy D Marciniuk, Donna Goodridge, Paul Hernandez et al. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline. Can Respir J. 2011 Mar-Apr;18 2 69 78. Open 2. Hardinge M, Annandale J, Bourne S et al. British Thoracic Society guidelines for home oxygen use in adults. Thorax. 2015 Jun;70 Suppl 1:i1 43. Open 3. David Hui, Kari Bohlke, Ting Bao et al. Management of Dyspnea in Advanced Cancer: ASCO Guideline. J Clin Oncol. 2021 Apr 20;39 12 1389 1411. Open 4. Alvar Agusti, Richard Beasley, Bartolome R. Celli et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease: 2023 Report. GOLD. 2023. Open 5. Linda Nici, Manoj J Mammen, Edward Charbek et al. Pharmacologic Management of Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2020 May 1;201 9):e56-e69. Open 6. Rochwerg B, Brochard L, Elliott MW et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug 31;50 2 . pii: 1602426. Open https://web.pathway.md/diseases/reclICyFduWEmymO1 5/5