Red flags
- Stridor - impending airway obstruction, needs urgent senior input +/- dexamethasone/nebulised adrenaline
- Sudden severe dyspnoea + pleuritic chest pain - PE, still needs consideration/treatment discussion even in palliative patients if it changes management
- Massive haemoptysis with dyspnoea
- SVC obstruction - facial/neck swelling, distended neck veins, worse lying flat
- Rapidly accumulating pleural effusion/pericardial effusion with haemodynamic compromise (tamponade)
Differential by mechanism
By reversibility - always ask first whether there is a treatable driver
- Potentially reversible: pleural effusion, pericardial effusion, anaemia, bronchospasm/COPD exacerbation, infection, PE, SVC obstruction, ascites splinting the diaphragm, heart failure
- Disease progression (less reversible): diffuse tumour infiltration, lymphangitis carcinomatosa, cachexia/respiratory muscle weakness, extensive fibrosis
- Anxiety-driven or anxiety-amplified - a real contributor, not a diagnosis of exclusion to dismiss the symptom
Focused history
- Onset (sudden vs gradual), positional variation, exertional vs at rest
- Associated chest pain, haemoptysis, fever, cough, leg swelling
- Functional impact - dyspnoea is what the patient says it is; a normal respiratory rate/SpO2 does not mean the symptom is not real
- Anxiety, panic component, prior coping strategies
- Goals of care - what investigation/treatment intensity is wanted
Focused examination
- Respiratory rate, work of breathing, accessory muscle use, SpO2 (interpret alongside symptoms, not in isolation)
- Reduced breath sounds/stony dullness (effusion), wheeze, crepitations, tracheal deviation
- Raised JVP, peripheral oedema (heart failure), facial swelling (SVC obstruction)
- Pallor (anaemia)
Investigation strategy
- Only if the result will change management given goals of care - a core palliative principle
- CXR - effusion, infection, lymphangitis, mass
- FBE (anaemia - transfusion may meaningfully help), consider D-dimer/CTPA if PE suspected and treatment would follow
- Bedside ultrasound for effusion if drainage being considered
Management
Treat reversible causes first
- Drain a symptomatic pleural effusion (consider indwelling pleural catheter if recurrent)
- Transfuse if symptomatic anaemia and consistent with goals of care
- Bronchodilators/steroids for bronchospasm, antibiotics for infection if consistent with the patient's goals
- Dexamethasone for lymphangitis carcinomatosa or SVC obstruction (+ radiotherapy/stenting for SVC obstruction)
Symptomatic management once reversible causes addressed/not present
- Opioids (low-dose) are first-line pharmacological therapy for refractory dyspnoea - reduce the ventilatory response to hypoxia/hypercapnia and the sensation of breathlessness, not primarily via sedation or respiratory depression at correctly titrated doses
- Opioid-naive: low starting dose (e.g. morphine 2.5 mg PO or equivalent), titrate
- Benzodiazepines - added for a significant anxiety/panic component, not as monotherapy for dyspnoea itself
- Oxygen - reserve for hypoxic patients (SpO2 <90-92%); no benefit over room air/fan in non-hypoxic dyspnoea despite being reflexively applied
- Handheld fan directed at the face - genuinely evidence-supported, low-cost, no side effects (trigeminal nerve stimulation reduces breathlessness perception)
- Non-pharmacological - positioning (upright, leaning forward), breathing techniques, pacing, fan, calm environment, treat concurrent anxiety psychologically
Traps
- Reflexively applying oxygen to a non-hypoxic breathless patient - no evidence of benefit, and it can create dependence and limit mobility
- Withholding opioids for dyspnoea from fear of hastening death - correctly titrated low-dose opioid is standard of care and evidence does not support this fear
- Treating dyspnoea as "just anxiety" without examining/investigating for a reversible cause
- Ignoring the fan - a simple, high-value intervention that is often skipped
- Over-investigating a patient with a clearly comfort-focused goal of care
Talk track
1. Always ask: is there something reversible here
- "Effusion, anaemia, bronchospasm, infection - I look for these before calling it disease progression."
2. Believe the symptom, not just the number
- "A normal saturation doesn't mean the breathlessness isn't real - I treat what they're experiencing."
3. Opioids are first-line for refractory dyspnoea
- "Low-dose, titrated - this isn't about sedation, it's standard symptom control."
4. Oxygen only if hypoxic
- "A fan on the face has better evidence than oxygen in a non-hypoxic patient."
5. Match investigation intensity to goals of care
- "I only order what will actually change the plan."
8 of 8 sections written · drafted 2026-09-13