Synopsis
Assess breathlessness as a subjective multidimensional symptom, treat reversible emergencies and disease mechanisms, combine non-pharmacological measures with proportionate opioid or oxygen trials, and document goal-concordant escalation before crisis.
- Breathlessness is the patient's perception; respiratory rate, oxygen saturation and imaging help find mechanisms but do not measure distress completely.
- First-line assessment defines onset, triggers, positional and exertional pattern, associated pain, cough, haemoptysis, wheeze, fever and current treatment ceiling.
- Treat reversible causes when likely benefit matches goals: bronchodilator, antibiotic, diuretic, anticoagulation, drainage, transfusion, stent or radiotherapy may be appropriate.
- First-line non-drug care is upright positioning, cool facial airflow, calm coaching, loosened clothing, pacing, breathing control and rapid access to a trusted contact.
- A handheld fan directed across the central face can reduce breathlessness perception even when oxygen saturation is normal.
- Give supplemental oxygen for documented or strongly suspected hypoxaemia; in non-hypoxaemic breathlessness, oxygen is not routinely better than air and should be a time-limited trial only when benefit is demonstrated.
- Low-dose morphine can reduce refractory breathlessness after mechanism treatment and non-drug measures, with lower starting exposure in frailty and renal or hepatic caution.
- Benzodiazepines are not first-line for breathlessness itself; reserve them for severe associated anxiety or panic after safer measures and monitor combined respiratory sedation.
- The gold-standard plan records reversible causes, non-drug techniques, medicine and oxygen trials, rescue instructions, escalation ceiling and review of function and toxicity.
Key red flags
Stridor, facial or neck swelling, inability to speak, drooling or rapidly worsening upper-airway noise requires immediate airway and senior oncological assessment.
Sudden pleuritic pain, syncope, unilateral leg swelling or unexplained tachycardia suggests pulmonary embolism and needs goal-concordant urgent evaluation.
Acute unilateral chest pain with reduced breath sounds and instability suggests tension pneumothorax and requires emergency decompression assessment.
Fever, purulent sputum, shock or new focal chest signs may indicate infection requiring prompt antibiotics and sepsis care when consistent with goals.
Respiratory exhaustion, falling rate, confusion, cyanosis or rising carbon dioxide is more dangerous than visible tachypnoea alone.
Drowsiness and respiratory rate below 8 after opioid or sedative exposure suggests toxicity and requires airway support and proportionate reversal.
Major haemoptysis requires the catastrophic-bleed plan, presence and airway positioning rather than leaving the patient to fetch complex medicines.
Falling effort, silent chest
Investigation priorities
Measure rate, effort, speech, arousal, oxygen saturation, pulse, pressure and temperature and examine airway, chest, heart, legs and fluid status.
Management branches
Breathlessness has developed suddenly, intensified rapidly or is accompanied by instability or red flags.
- Use ABCDE, position and reassure, provide oxygen to the appropriate target when hypoxaemic and activate emergency support within known treatment limits.
- Treat the suspected mechanism promptly and obtain focused tests that can change antibiotics, diuresis, anticoagulation, drainage, airway treatment or ventilatory support.
- Give proportionate symptom relief, communicate uncertainty and document the current ceiling, location and next review rather than treating DNACPR as no treatment.