Respiratory Symptoms in Palliative Care

Introduction

Respiratory symptoms are among the most frightening and distressing experiences for palliative care patients. Unlike pain, which a patient can often hide, breathlessness is visible and terrifying — for the patient, the family, and the nurse.

💡 Key Message: Your calm presence, skilled positioning, and timely interventions can transform a panic-stricken, suffocating patient into someone who feels safe and supported — even if the underlying disease cannot be cured.

Breathlessness (Dyspnoea)

What Is Breathlessness?

Breathlessness is a subjective, frightening sensation of difficult or uncomfortable breathing. It is not the same as low oxygen levels — a patient can have normal oxygen saturation but still feel they are suffocating.

The patient's words: "I felt like I was suffocating," "I couldn't get enough air," "It felt like I was about to die."

Physiological Expansion (The "Air Hunger" Mechanism): Dyspnoea occurs when there is a mismatch between the brain's motor command to breathe (respiratory drive from the medulla) and the mechanical response of the respiratory system. When chemoreceptors (sensing CO2/O2) or mechanoreceptors (in the lungs/chest wall) send signals that the breathing effort is insufficient, the brain registers this as life-threatening "air hunger," triggering massive sympathetic nervous system panic.

Causes of Breathlessness

System	Causes
Respiratory	Primary or secondary lung cancers, pleural effusion, pulmonary embolism, tracheal tumours, airway collapse, infections (pneumonia, TB), lymphangitis carcinomatosa (cancer spread to lymphatic vessels), COPD, weak respiratory muscles.
Cardiac	Superior vena cava obstruction (SVCO), anaemia, cardiac failure, cardiomyopathy, pericardial effusion.
Other	Ascites (pressure on diaphragm), radiotherapy/chemotherapy side effects, pneumonectomy, anxiety.

🧠 Mnemonic for Causes of Breathlessness: "R-E-S-P-I-R-E"

R - Respiratory (cancer, effusion, embolism, infection, COPD)
E - Effusion (pleural, pericardial)
S - SVCO (Superior Vena Cava Obstruction)
P - Pulmonary embolism
I - Infection (pneumonia, TB)
R - Radiotherapy / treatment effects
E - Emotional (anxiety, panic)

Assessment of Breathlessness

Question to Ask	Why It Matters
"When did it start? Sudden or gradual?"	Sudden = embolism, pneumothorax, acute infection.
"Is it worse lying down?" (Orthopnoea)	Suggests cardiac failure, pleural effusion, SVCO.
"Is it worse on exertion?"	Suggests cardiac or respiratory limitation.
"Any chest pain?"	Pleuritic pain = infection, embolism, tumour.
"Any blood in sputum?"	Haemoptysis — see Section 5.
"What makes it better or worse?"	Guides positioning and intervention.
"How does it make you feel emotionally?"	Identifies anxiety and panic as contributors.

Non-Pharmacological Management

Intervention	Details	Rationale
Positioning	Usually sitting upright with pillows for support.	Gravity pulls abdominal organs down, allowing maximum diaphragmatic excursion.
Pleural effusion positioning	Lie on affected side with good lung upwards.	Maximises ventilation and perfusion matching (V/Q) of the healthy lung.
Ventilation	Open windows, use a fan, or fan with newspaper.	Cool air stimulates trigeminal nerve → reduces sensation of breathlessness.
Breathing techniques	Slow, deep breathing; pursed-lip breathing.	Increases positive end-expiratory pressure (PEEP), keeping airways open and reducing panic.
Activity pacing	Rest between activities; avoid overexertion.	Conserves cellular energy and reduces oxygen demand.
Suction secretions	Gently suction excessive secretions if present.	Clears mechanical airway obstruction.
Reassurance and presence	Stay with the patient; hold their hand; speak calmly.	Reduces sympathetic nervous system panic, which worsens breathlessness.

💡 Why a Fan Works (Neuroanatomy Application): Cool air across the face stimulates the sensory branches of the Trigeminal Nerve (CN V1 & V2). These nerves send inhibitory signals directly to the brain's respiratory center in the medulla, overriding and dampening the sensation of "air hunger." It is free, safe, and highly effective — never forget this simple nursing tool.

Pharmacological Management

Drug	Dose	Indication	Notes / Mechanism
Morphine	2.5–5 mg PO every 4 hours	Reduces the sensation of breathlessness	If already on morphine for pain, increase by 2.5 mg. Mechanism: Binds to Mu-receptors in the medulla, altering the brain's response to high CO2, making the brain "ignore" the air hunger. Does NOT dangerously suppress respiration at these low doses.
Diazepam	2–5 mg at night	Anxiety and panic associated with breathlessness	Also helps sleep. Enhances GABA (inhibitory neurotransmitter).
Dexamethasone	8–12 mg daily	SVCO, lymphangitis carcinomatosa, airway compression	Potent corticosteroid. Reduces peritumoral oedema and inflammation, mechanically opening the airway.
Bronchodilators	Salbutamol, ipratropium	Reversible airway obstruction (COPD, asthma)	Nebulised or inhaler. Relaxes bronchial smooth muscle.
Diuretics	Frusemide 40 mg IV	Cardiac failure, pleural effusion, ascites	Reduces fluid overload and pulmonary congestion.
Oxygen	2–4 L/min via nasal cannula	If hypoxic (SpO2 < 90%) and available	May not help the sensation of dyspnoea if SpO2 is already normal.

❓ Nursing Exam Tip: Morphine Myth-Busting: Morphine relieves breathlessness by reducing the brain's perception of the symptom — not by sedating the patient into unconsciousness. At 2.5–5 mg, it is exceptionally safe and effective. Never withhold low-dose morphine from a suffocating palliative patient out of fear of causing respiratory arrest.

Cough

Epidemiology

Population	Incidence of Cough
All cancer patients	~30%
Lung / bronchus cancer patients	~80%
HIV/AIDS patients with cough	Any duration of cough = high suspicion of TB

Uganda : In any patient living with HIV/AIDS, cough should always raise suspicion of tuberculosis. Refer for GeneXpert (MTB/RIF) testing immediately.

Causes of Cough

Anatomy of the Cough Reflex: Receptors in the airway detect irritation → Vagus nerve (afferent) sends signal to Medulla → Medulla sends efferent signal via Phrenic and Spinal nerves → Diaphragm and intercostal muscles contract forcefully against a closed glottis, which then snaps open to expel air.

Cause	Explanation
Bronchial obstruction	Primary tumour or enlarged mediastinal lymph nodes — most common cause in cancer.
Infection	TB, pneumonia — especially in immunosuppressed patients.
Left ventricular failure	Dyspnoea and cough that wakes the patient at night (paroxysmal nocturnal dyspnoea) due to fluid backing up into the lungs.
Vocal cord paralysis	Due to hilar tumour or lymphadenopathy compressing the Recurrent Laryngeal Nerve, making the vocal cords unable to close properly for an effective cough.
Unrelated causes	Smoking, common cold, asthma, congestive heart failure.

Assessment of Cough

Feature to Assess	What to Look For
Type of cough	Productive (with phlegm) or dry?
Ability to cough effectively	Weak cough = severe risk of aspiration and retained secretions leading to pneumonia.
Sputum characteristics	Colour (yellow/green = infection; blood = haemoptysis); amount; consistency.
Precipitating factors	Worse at night? After eating? On exertion? In certain positions?
Associated symptoms	Fever (infection), weight loss (TB, cancer), chest pain, dyspnoea.
Physical examination	Mouth, throat, lungs (auscultation), heart.

Management of Cough

Productive Cough (Do NOT heavily suppress!)

Intervention	Details
Postural drainage	Position patient to allow gravity to drain secretions from affected lung segments.
Steam inhalation	Helps liquefy thick sputum; add menthol or eucalyptus if available.
Antibiotics	For confirmed or suspected infection (e.g., TB, pneumonia).
Bronchodilators	Salbutamol in cough mixture if bronchospasm present.
Hydration	Adequate fluids thin secretions (if not contraindicated by heart failure).

Non-Productive (Dry) Cough

Drug	Dose	Notes
Codeine linctus	10 ml every 4 hours (1 mg/ml)	Suppresses the medullary cough reflex; highly useful at night to allow sleep.
Morphine	2.5 mg, increase usual dose by 2.5 mg every 4 hours	More potent medullary cough suppressant; also helps if pain coexists.

💡 Nursing Tip: A productive cough should not be heavily suppressed — the body needs to clear secretions. Suppressing a productive cough traps bacteria in the lungs, guaranteeing severe pneumonia. Suppress only if the cough is distressing, completely non-productive, or preventing sleep.

Nursing Management of Cough

Positioning: Propped up with 2–3 pillows in the most comfortable position.
Pleural effusion: Lie on side of effusion in semi-recumbent position.
Humidification: Steam inhalation or humidified oxygen.
Encourage expectoration: Provide tissues, emesis basin; assist weak patients.
Monitor for haemoptysis: See Section 5.
Infection control: If TB suspected, wear a mask; isolate if confirmed.

Death Rattles (Terminal Secretions)

What Are Death Rattles?

Death rattles — also called terminal secretions or noisy breathing — occur when a dying patient loses the ability to cough or swallow, and saliva and bronchial secretions accumulate in the back of the throat and upper airways. This creates a gurgling, rattling sound with each breath.

💡 Key Point: Family Distress: Death rattles are a sign that death is imminent (usually hours to days). They are not distressing to the patient (who is usually unconscious or semi-conscious due to hypoxia and brainstem failure), but they are extremely distressing to family members who may interpret the terrifying sound as choking or suffering.

Why Do Death Rattles Occur? (Pathophysiology)

Mechanism	Explanation
Loss of swallowing reflex	The brainstem (Glossopharyngeal IX and Vagus X nerves) functions that control swallowing fail.
Loss of cough reflex	Secretions cannot be cleared from the airway due to severe muscle weakness and neurological decline.
Pooling of secretions	Saliva and bronchial secretions accumulate in the oropharynx and trachea. Air bubbling through this fluid creates the sound.
Relaxation of muscles	The jaw and airway muscles relax, allowing secretions to pool further.

Assessment

Level of consciousness: Usually reduced or unconscious.
Airway sounds: Gurgling, rattling, bubbling — usually louder on inspiration.
Secretions in mouth: Pooling of saliva; may dribble from the mouth.
Respiratory pattern: Often irregular (Cheyne-Stokes breathing or agonal gasps).

Non-Pharmacological Management

Intervention	How to Do It / Rationale
Repositioning	Turn patient onto their side (lateral position). Allows gravity to drain secretions from the mouth rather than pooling in the throat.
Oral suctioning	Gentle suction of mouth and oropharynx ONLY. Clears visible secretions. Do NOT deep suction (causes severe distress, bleeding, and trauma).
Mouth care	Swab mouth with moistened gauze or sponge. Keeps mouth comfortable; removes excess thick saliva.
Elevate head of bed	30–45° if possible. Assists postural drainage.
Reassure family	Explain that this sound is normal, not distressing to the patient, and a sign that death is near. This is your most important intervention!

Pharmacological Management (Anticholinergics)

Anticholinergic drugs block the parasympathetic nervous system, drastically reducing salivary and bronchial secretions ("drying them up"), thereby reducing the rattling sound.

Drug	Dose / Route	Notes & Blood-Brain Barrier (BBB) Effect
Hyoscine butylbromide (Buscopan)	20 mg SC or IV every 4–6 hours	Reduces secretions; also heavily smooth muscle relaxant (helps with colic).
Hyoscine hydrobromide	0.4 mg SC every 4 hours or via syringe driver	CROSSES the blood-brain barrier. This causes central sedation. Highly effective for secretions. Preferred if the patient is agitated or unconscious.
Glycopyrronium bromide	0.2–0.4 mg SC every 4 hours or via syringe driver	DOES NOT cross the blood-brain barrier. Causes zero central sedation. Preferred if the patient is still somewhat conscious and wants to interact with family.
Atropine	1% eye drops — 2 drops sublingually Q4H	Sublingual route is an excellent alternative if injections are unavailable.

Communicating with Family About Death Rattles

Your explanation and reassurance are often more therapeutic than any drug. Families remember how you made them feel during this time.

"Is he choking?" ➔ "No, he is not choking. The sound is from saliva pooling in the throat because he is too weak to swallow. He is not in distress."
"Is she suffering?" ➔ "She is unconscious and not aware of the sound. We are keeping her comfortable and her mouth moist."
"Can't you do something to stop it?" ➔ "We are giving medicine to reduce the secretions and turning her to help drainage. The sound may lessen but may not stop completely. This is a natural part of the dying process."
"How long does this last?" ➔ "It usually means death is hours to a few days away. We will stay with you and keep her comfortable."

Haemoptysis (Coughing Up Blood)

What Is Haemoptysis?

Haemoptysis is the coughing up of blood from the respiratory tract — ranging from blood-streaked sputum to massive, life-threatening bleeding.

Mild: Blood-streaked sputum; small amounts.
Moderate: Frank blood in sputum; several tablespoons.
Massive: >100–600 ml in 24 hours. Can be fatal rapidly due to asphyxiation.

💡 Physiological Expansion: Why is Haemoptysis so dangerous? The lungs have a dual blood supply: the low-pressure pulmonary arteries, and the high-pressure bronchial arteries (which branch directly off the aorta). Most massive haemoptysis comes from eroded bronchial arteries. Because they are under high systemic blood pressure, they bleed furiously. The patient rarely bleeds to death (exsanguination) — instead, they die of asphyxiation because the blood rapidly floods the alveoli, completely blocking gas exchange.

Causes of Haemoptysis in Palliative Care

Cause	Explanation
Lung cancer	Tumour erosion directly into blood vessels; most common cause in oncology.
Tuberculosis (TB)	Cavitary TB erodes into pulmonary arteries, sometimes forming a fragile aneurysm (Rasmussen's aneurysm) that bursts.
Pulmonary embolism	Infarction causes necrosis and bleeding into alveoli.
Infection / Bronchiectasis	Severe pneumonia, lung abscess, or dilated damaged airways with fragile neovascularized vessels.
Coagulopathy	Low platelets, anticoagulant medications, liver failure.
Aspergilloma	Fungus ball growing inside a pre-existing lung cavity (very common in healed TB).

Uganda Context: In HIV-positive patients, TB and fungal infections (aspergilloma) are incredibly important causes of haemoptysis. Always consider TB!

Assessment: Haemoptysis vs. Haematemesis

It is vital to distinguish coughing up blood (lungs) from vomiting blood (stomach).

Feature	Haemoptysis (Lungs)	Haematemesis (Stomach)
Colour	Bright red, frothy (mixed with air)	Dark red or coffee-ground (digested by stomach acid)
pH	Alkaline	Acidic
Associated with	Cough, dyspnoea, chest symptoms	Nausea, vomiting, abdominal pain
History	Lung disease, TB, cancer, smoking	Peptic ulcer, liver disease, NSAID use

Management of Haemoptysis

Mild Haemoptysis (Blood-Streaked)

Reassurance: Explain that small amounts are common and not immediately dangerous.
Treat underlying cause: Antibiotics for infection, anti-TB if confirmed.
Cough suppression: Codeine or morphine to reduce coughing (vigorous coughing can dislodge clots and worsen bleeding).
Monitor: Watch for increase in amount or frequency.

Moderate to Massive Haemoptysis (MEDICAL EMERGENCY)

Call for help immediately: This is life-threatening.
Position patient: Lie the patient on the side of the BLEEDING lung (if known) or semi-prone. Rationale: Gravity keeps the blood in the diseased lung, preventing it from spilling over and drowning the healthy "good" lung.
Keep calm and reassure: Panic spikes heart rate and blood pressure, which forcefully increases the bleeding.
Suction & Oxygen: Keep airway clear of blood; provide high-flow O2.
IV access: Large-bore cannula; fluids for shock.
Medications: Tranexamic acid (1 g IV — antifibrinolytic), Vitamin K / FFP for coagulopathy, Morphine for severe distress and cough suppression.
Definitive treatment: Bronchial artery embolisation if available.

⚠️ CRITICAL WARNING: In massive haemoptysis, the patient usually dies from asphyxiation (drowning in their own blood), not from blood loss. Airway protection via correct positioning is your absolute highest priority.

Nursing Care & Palliative Planning in Haemoptysis

Stay with the patient: Reduces panic; allows instant monitoring for deterioration.
Dark-coloured towels/bowls: Blood is highly visible and terrifying on white sheets. Using dark green/blue towels hides the visual impact of the blood, significantly reducing panic for the patient and family. Prepare these in advance for at-risk patients!
Monitor vital signs: Tachycardia and hypotension indicate hypovolemic shock. Document estimated blood loss.
Advance Care Planning: In advanced incurable disease where massive bleeding is expected, clarify DNR (Do Not Resuscitate) wishes. Have a terminal sedation protocol ready (e.g., Midazolam 5–10 mg SC/IV) to rapidly relieve terror if a terminal bleed occurs. Allow family to be present if they wish, or leave if it is too traumatic.

Comparison Table: All Respiratory Symptoms

Symptom	Key Feature	Most Common Cause	First-Line Management	Nursing Priority	Red Flag
Breathlessness	Frightening sensation of suffocation	Lung cancer, effusion, COPD, anxiety	Morphine 2.5–5 mg; fan; upright positioning	Stay with patient; reassurance	Stridor = airway emergency
Cough (productive)	Cough with phlegm	Bronchial obstruction, infection, TB	Postural drainage, antibiotics, bronchodilators	Positioning; infection control	Haemoptysis
Cough (dry)	Harsh, non-productive cough	Tumour irritation, post-nasal drip	Codeine linctus 10 ml Q4H; morphine	Night-time sedation; comfort	Increasing frequency
Death Rattles	Gurgling, rattling sound in dying patient	Loss of swallow/cough reflex	Hyoscine or glycopyrronium; repositioning	Reassure family	Family distress — manage this actively
Haemoptysis (massive)	Large-volume fresh blood	Eroded vessel, aspergilloma, TB	Position on bleeding side down; suction; O2	Airway protection; calm presence	Asphyxiation risk — emergency

Mnemonics and Exam Tips

🧠 Mnemonic for Breathlessness: "F-A-N-S"

F - Fan (Cool air across the face / Trigeminal nerve)
A - Anxiolytics (Diazepam for panic)
N - Narcotic (Morphine reduces sensation of breathlessness)
S - Steroids (Dexamethasone for SVCO, lymphangitis)

🧠 Mnemonic for Death Rattles: "R-A-T-T-L-E"

R - Reposition (side-lying allows drainage)
A - Anticholinergics (Hyoscine, glycopyrronium)
T - Tell the family (Explain this is normal)
T - Turn regularly (Prevents pooling)
L - Listen and reassure (Your presence matters)
E - Explain (Education reduces fear)

🧠 Mnemonic for Haemoptysis Emergency: "B-L-E-E-D"

B - Bleeding side down (Protect the good lung)
L - Large-bore IV (For fluids/drugs)
E - Emergency call (Get help immediately)
E - Endotracheal suction (Keep airway clear)
D - Dark towels (Reduce visual panic)

📝 Exam-Style Questions

Q1: A patient with lung cancer becomes increasingly breathless. Oxygen saturation is 94% on room air. What is your first nursing intervention?
Answer: Position upright and use a fan. Oxygen may not help the sensation if SpO2 is adequate. The fan stimulates the trigeminal nerve and reduces the perception of breathlessness. Reassure the patient and stay with them.

Q2: A dying patient has loud, gurgling breathing. The family is distressed and asks if the patient is drowning. How do you respond?
Answer: Explain that this is terminal secretions — a normal part of the dying process. The patient is unconscious and not in distress. Turn the patient onto their side, give anticholinergics, and provide continuous reassurance to the family. Never deep suction.

Q3: An HIV-positive patient has had a cough for 3 weeks with night sweats and weight loss. What is your priority action?
Answer: Refer for TB investigation (GeneXpert). In Uganda, any cough in an HIV-positive patient must raise high suspicion of TB. Isolate if TB is confirmed.

Q4: A patient with lung cancer suddenly coughs up 200 ml of bright red blood. What is your immediate action?
Answer: This is massive haemoptysis (medical emergency). Position on the bleeding side down, call for help, suction airway gently, give oxygen, stay calm, and monitor for shock.

Summary: Key Nursing Points

Breathlessness is frightening — your calm presence is as important as any drug.
A fan is free, safe, and effective for breathlessness — never forget it.
Morphine relieves the sensation of breathlessness at low doses — it does not kill the patient.
In HIV-positive patients, cough = think TB — refer for GeneXpert.
Productive cough should not be heavily suppressed — the body needs to clear secretions.
Death rattles are distressing to families, not the patient — your explanation is therapeutic.
Never deep suction a dying patient — gentle oral suction and repositioning are sufficient.
Glycopyrronium is preferred over hyoscine if the patient is still somewhat alert (less sedation).
Massive haemoptysis is an airway emergency — position on the bleeding side down and protect the airway.
Dark towels reduce panic during haemoptysis — prepare them in advance for at-risk patients.

Final Clinical Pearl: Respiratory symptoms in palliative care often come together — a patient with lung cancer may have breathlessness, cough, and eventually death rattles. Your nursing care must adapt to the stage of illness: from active management (fan, morphine, positioning) in earlier stages, to compassionate presence and family support in the final hours. In every stage, how you make the patient and family feel is your legacy as a nurse.

References

World Health Organization (WHO) Guidelines for the Pharmacological and Radiotherapeutic Management of Cancer Pain in Adults and Adolescents.
Oxford Textbook of Palliative Nursing.
National Guidelines for Palliative Care in Uganda.
American Academy of Hospice and Palliative Medicine (AAHPM) Guidelines on Symptom Management.

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