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Ovid: Oxford Handbook of Respiratory Medicine

Authors: Chapman, Stephen; Robinson, Grace; Stradling, John; West, Sophie Title: Oxford Handbook of Respiratory Medicine, 1st Edition Copyright ©2005 Oxford University Press > Table of Contents > Part 3 – Supportive care > Chapter 59 – Palliative care of the chest patient Chapter 59 Palliative care of the chest patient P.650
Pain and dyspnoea Palliative care is defined as the total care of patients whose disease is not responsive to curative treatment. It aims to provide the best possible quality of life for patients, their carers, and families. It includes control of pain and other physical symptoms, as well as care for psychological, social, and spiritual problems. Within chest medicine, palliative care is most commonly considered for patients with lung cancer and mesothelioma; many other patients with progressive, end-stage respiratory disease (such as COPD, CF, and UIP) also benefit from specific palliative interventions.

  • Involve the specialist palliative care team early
  • Recognize that delirium, dyspnoea, and decreased mobility often herald the terminal phase of cancer.


  • Aim to determine cause, type, and site
  • Start with simple analgesia and increase according to the WHO analgesic ladder, moving from non-opioid analgesia through weak opioids to strong opioids
  • Prescribe analgesia as required for breakthrough pain
  • Give drugs a chance to work at appropriate doses
  • The addition of an anti-inflammatory drug can be effective for bony pain
  • Treat drug side-effects, e.g. constipation, nausea. Prescribe prophylactic laxatives with morphine
  • Consider radiotherapy for localized pain in the chest related to cancer
  • Pain from bony metastases may be treated with bisphosphonates, e.g. 90 mg of pamidronate every 4 weeks
  • Neuropathic pain can be treated with specific antidepressants (e.g. amitriptyline 10–50 mg) or anticonvulsants (e.g. carbamazepine or sodium valproate 200 mg/day)
  • Consider referral to pain clinic for further intervention such as a nerve block, transcutaneous electrical nerve stimulation (TENS), or complementary therapies.


  • Consider possible causes (see box). Dyspnoea may be due to the underlying lung disease, or due to an additional pathology
  • Dyspnoea is made worse by anxiety and panic
  • Lung cancer and pulmonary metastases are associated with the sensation of shortness of breath, often due to stimulation of receptors by malignant infiltration or lymphangitis carcinomatosis
  • Optimize treatment of any underlying lung disease with bronchodilators and steroids if appropriate
  • Treat concurrent chest infections
  • Opioids (e.g. 2.5–5 mg oramorph 4 hourly) relieve the sensation of dyspnoea without affecting respiratory function
  • Oxygen cylinders for intermittent use may help symptoms
  • Consider the need for an airway stent in a patient with lung cancer experiencing dyspnoea due to bronchial obstruction or compression with tumour.

Causes of breathlessness in patients with lung cancer

  • Pneumonia
  • Underlying chronic lung disease (e.g. COPD, UIP)
  • Lobar collapse
  • Pleural effusion
  • SVCO
  • Upper airway obstruction
  • Pulmonary emboli
  • Lymphangitis carcinomatosis
  • Pericardial effusion
  • Anaemia
  • Depression
  • Anxiety and panic.

Other symptoms Anxiety

  • Leads to dyspnoea, which in turn worsens anxiety
  • Benzodiazepines (such as short-acting lorazepam 0.5–1 mg sublingually 8–12 hourly) are effective for respiratory panic
  • Acute panic may be helped by midazolam 2.5 mg IV, increased in steps of 1 mg, given in a controlled environment with oxygen
  • Relaxation exercises and diaphragmatic breathing training may help some patients.


  • Try simple or codeine linctus
  • Methadone linctus 2–4 mg nocte or bd may be of benefit
  • Nebulized saline may help expectoration
  • Nebulized local anaesthetic often helps, e.g. 5 ml 2% lidocaine maximum tds (avoid in asthmatics, as it causes bronchospasm). Pharyngeal numbness is likely to occur, so avoid fluids for 1 hour after.

Pleural effusion

  • Drain if symptomatic and pleurodese early if recurrent, although not if prognosis is poor (less than a few months)
  • Consider an in-dwelling tunnelled catheter (such as Pleurx) to drain fluid if effusion is symptomatic and pleurodesis has failed due to trapped lung.

Poor appetite

  • Common symptom and may be primary due to cachexia–anorexia syndrome, or secondary, due to mouth problems such as candidiasis, nausea, hypercalcaemia, drugs, or depression
  • May be improved in the short term (about 6 weeks) by a course of oral steroids, such as prednisolone 20 mg daily
  • Cachexia leads to decreased respiratory muscle strength and increased shortness of breath
  • Consider nutritional supplements.

Brain metastases

  • Steroids relieve the cerebral oedema associated with brain metastases, e.g. dexamethasone 4 mg bd–qds initially and then decrease
  • Avoid steroid dosing in the evening, as sleep is affected
  • Radiotherapy may be considered if there is a good response to steroids.

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