In 2017 a report published by the British Lung Foundation (BLF) highlighted the staggering impact of lung disease in the UK (BLF, 2017); an impact which leads to 115 000 people dying from lung disease every year (Public Health England, 2019). With the impact of diagnosis posing a significant burden on the health of those who, for example, have a diagnosis of chronic obstructive pulmonary disease (COPD) – a burden which includes, breathlessness, cough, sputum production, wheezing, chest tightness and congestion (Miravitlls and Ribera, 2017) – and with associated costs to the NHS exceeding £11 billion annually (BLF, 2017), it is not surprising that The NHS Long Term Plan identifies the management of respiratory disease as a clinical priority (NHS, 2019a).
Furthermore, these figures are undeniably of grave concern when considering the ageing UK population, the need to reduce avoidable hospital admissions and the ever-increasing associated healthcare costs (NHS, 2019a).
Breathlessness
The experience of breathlessness is complex and influenced by a number of factors including emotional, environmental, cultural and social and requires a holistic approach to optimise its management (Bajwah et al, 2020).
Breathlessness or, to use its medical term, dyspnoea, is defined as:
‘The distressing sensation of a deficit between the body's demand for breathing and the ability of the respiratory system to satisfy that demand’
Breathlessness affects many people living with chronic and life-limiting illnesses, ranging from COPD, lung cancer and heart disease to renal failure and AIDS. With many being reluctant to seek the help they need, this can considerably impact on the lives of both the patient and their family (Hutchinson et al, 2018).
With research indicating relationships between a cluster of symptoms associated with COPD in particular – breathlessness, pain, sleep disturbance, anxiety, depression and fatigue (Borge et al, 2010) – it is evident that an effective holistic assessment of patient need is required (Booth and Johnson, 2019).
Assessment tools
The use of assessment tools in palliative care for example can be of considerable value in the identification of unmet need and the evaluation of care interventions, and support the planning of safe and effective patient care (Long et al, 2021). An example of which is The Medical Research Council (MRC) Dyspnoea/Breathlessness Scale (National Institute for Health and Clinical Excellence (NICE), 2022).
Despite a plethora of assessment tools being available – including spirometry and the use of simple questioning tools such as the Medical Research Council Breathlessness Scale (Medical Research Council, 2021) – breathlessness, according to Ahmadi et al (2018), often remains inadequately assessed and under-treated in society. Furthermore, in a study undertaken by Sung et al (2020) the authors highlighted that there is a need to improve the measurement of breathlessness in order to ensure prompt identification and create suitable planned interventions.
‘The treatment of breathlessness is not simply restricted to the use of pharmacological interventions; non-pharmacological interventions can also prove of value, although disappointingly these are frequently underused, not least because they necessitate a high level of motivation from the patient to be able to make and sustain such changes.’
Pharmacological interventions
Currently, a wide array of treatment modalities exist to support the alleviation of breathlessness including pharmacological interventions such as opioids, anxiolytics, inhalers and diuretics. Although the effect of morphine on breathlessness isn't fully understood, ‘opioids reduce the sensation ‘urge to breathe’ through cortical mechanisms' (Johnson and Currow, 2020). Bronchodilator inhalers are suggested treatments by the Greater Manchester and Eastern Cheshire Strategic Clinical Networks (GMECSCN, 2019). They work by relaxing the muscles in the lungs and widening the airways (NHS, 2019c). Benzodiazepines can be used as part of a treatment plan for breathlessness although they do not treat breathlessness itself, rather the relating symptoms that often feature alongside breathlessness, such as anxiety (GMECSCN, 2019).
However, the prescribing of medication is not without significant risk (WHO, 2017), with many prescribers needing to prescribe multiple medications in order to promote optimal health – a practice known as polypharmacy; a process common in the older population with multi-morbidity (Masnoon et al, 2017).
Duerden et al (2013) assert that polypharmacy is generally understood as referring to the concurrent use of multiple medication items by one individual. And while polypharmacy can be both appropriate and problematic (Duerden et al, 2013), prescribing multiple medications can increase the possibility of side effects and interactions between medications and can make the taking of medication increasingly challenging for the patient (WHO, 2017).
A wide range of definitions exist that seek to define polypharmacy (Eriksen et al, 2020). For example, the WHO (2017) define polypharmacy as:
‘The routine use of four or more over-the-counter, prescription and/or traditional medications at the same time by a patient.’
In a systematic review of definitions undertaken by Masnoon et al (2017) they determined that although the main basis for a definition of polypharmacy was the use of numerical data; the most commonly used term being 5 or more medications:
‘The clinical basis for using a numerical data to define polypharmacy and the potential of this to rationalise medication use and optimise health outcomes was not elucidated to in most of the studies' they reviewed.’
Commonly used within healthcare, polypharmacy can lead to an increased risk of adverse events and an increased tablet burden. Therefore, it is essential that any associated benefit of symptom relief is considered carefully when prescribing polypharmacy. And while according to Chin and Booth (2016), opioids have the largest evidence base for the management of breathlessness of various causes, Senderovich and Yenamuri (2019) purport that other types of medication such as anxiolytics can also be used; while a combination of inhalers and opioids can produce significant reductions in the impact of dyspnoea.
The treatment of breathlessness is not simply restricted to the use of pharmacological interventions; non-pharmacological interventions can also prove of value, although disappointingly these are frequently underused, not least because they necessitate a high level of motivation from the patient to be able to make and sustain such changes (Marshall, 2020). Therefore, providing support to both the patient and their carer(s) is essential, if patients are to sustain long-term behavioural change and effectively manage their symptoms.
Non-pharmacological interventions
Non-pharmacological interventions including, for example, the use of an easily accessible small handheld fan may be of use in the relieving of breathlessness (Chin and Booth, 2016). This is supported by Booth and Johnson (2019), who purport that fans can help reduce breathlessness recovery time, while a range of exercises, known as airway clearance techniques, can aid breathing by helping to clear mucus from the lungs of someone with bronchiectasis (NHS, 2021).
Oxygen therapy, while useful in treating hypoxaemia:
‘has not been proven to have any consistent effect on the sensation of breathlessness in non-hypoxaemic patients’
And with NHS Scotland (2021) asserting that oxygen therapy should only be prescribed after careful consideration, contending that it is important to reduce the risks associated with psychological dependence, it is essential that an individual assessment of patient need is undertaken to determine whether oxygen therapy would indeed benefit the patient and should be discontinued if none is seen.
Cognitive behavioural therapy (CBT) is a talking therapy based on the premise that personal thoughts, feelings, physical sensations and behaviours are interrelated and although not a cure for physical symptoms, it can help someone manage their problems more effectively by breaking them down into smaller parts (NHS, 2019b). CBT, psychoeducation-based interventions and touch (Bove et al, 2017) may all help to precipitate a reduction in breathlessness symptoms, by helping to reduce the anxiety often associated with breathlessness.
In research undertaken by Bove et al (2017), evidence indicates that some people undertaking CBT felt that this also gave them an opportunity to talk about other issues relating to end-of-life care planning. Furthermore, the empathy provided by the nursing team and the regular support provided enables nurses to address patients' breathlessness in terms of assessment and symptom management, and they often share relationships with patients that span months or even years (Booth and Johnson, 2019).
Conclusion
The management of breathlessness is complex, the aim of which is to reduce its impact on the patient and their quality of life (Booth and Johnson, 2019). With each individual patient being unique, the need for a holistic assessment is an essential element in the provision of optimal care in those patients with breathlessness (Booth and Johnson, 2019).
Treating any potential reversible causes linked to breathlessness as appropriate, optimising current therapeutic interventions – both non-pharmacological and pharmacological – while acknowledging any patient fears and anxieties experienced (NHS, Scotland, 2021) is essential if patients are to be effectively supported. Furthermore, the development of an emergency healthcare plan (NHS England, 2021) can potentially help to reduce the need for hospital stays and out of hours input (Booth and Johnson, 2019). This may enable patients to stay in their own home, should they prefer, as well as reducing the impact on an increasingly burdened NHS.
KEY POINTS:
- The experience of breathlessness is complex and influenced by a number of factors including emotional, environmental, cultural and social and requires a holistic approach to optimise its management
- Breathlessness often remains inadequately assessed and under treated in society
- A wide array of treatment modalities exist to support the alleviation of breathlessness including pharmacological interventions such as opioids, anxiolytics, inhalers and diuretics, but nurses should be aware of the risks of inappropriate polypharmacy
- Non-pharmacological interventions – such as airway clearance techniques and cognitive behavioural therapy – can also prove of value in breathlessness, although these are frequently underused
CPD reflective practice:
- How can breathlessness impact the quality of life of your patients?
- Do you feel that your breathless patients are adequately assessed at present? How could this be improved?
- What are the challenges with pharmacological and non-pharmacological treatment of breathlessness?