ABC of palliative care: Breathlessness, cough, and other respiratory problems

Radiograph of patient with malignant pericardial effusion and secondary pleural effusion causing breathlessness Respiratory problems are common in patients with advanced incurable disease. This article describes palliation of adult patients with malignant disease, but the principles can be applied to many types of non-malignant disease. A detailed history, examination, and appropriate investigations are needed to establish the most likely cause of any symptom. The history should cover factors that influence the severity of the symptom, including pre-existing diseases (such as chronic obstructive pulmonary disease, which is relatively common in patients with lung cancer), exacerbating factors (such as anaemia, ascites, or profound anxiety), and additional factors (such as pulmonary embolism, infection, or left ventricular failure). All of these will influence management. Breathlessness has non-physical as well as physical aspects and, like pain, can be defined by what a patient says it is. It is an unpleasant sensation of being unable to breathe easily. It is relatively common during the terminal stages of cancer: in one survey 70% of 1700 patients with cancer suffered breathlessness during their last six weeks of life. It is a particularly distressing and frightening symptom, not only for patients but also for carers. Activity, levels of anxiety, speed of onset, and previous experience may influence patients' perception of breathlessness and its severity. While there is often an obvious cause (such as pleural effusion or extrinsic bronchial compression), in some patients no cause is found despite thorough assessment. Little is known about the effects of cachexia on respiratory muscle function, and hyperventilation may account for breathlessness in some cases. #### General principles of managing breathlessness