Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [112], C).
2. 2.Show
   Explore the meaning of breathlessness to the patient, their family and carers.
   To ascertain fears and anxieties (Chin and Booth [25], E).
3. 3.Show
   Involve the multidisciplinary team.
   To ensure clinicians, the physiotherapist and the occupational therapist help to optimize symptom control (Chan et al. [23], E).
4. 4.Show
   Help the patient into a high side‐lying position (using pillows or the electric bed head) and forward lean onto pillows.
   To support the patient's position in bed, optimizing air entry (Booth et al. [16], R).
5. 5.Show
   Offer a lubricant (such as lip balm) for lips if they become dry due to mouth breathing. If the patient is having oxygen therapy, avoid products containing petroleum jelly or oil‐based emollients. Use water‐based products (such as vitamin E or Surgilube) instead.
   To prevent dry, cracked lips (Cancer Research UK [20], C).

   Petroleum jelly and oil‐based products are fire hazards. E

Procedure

1. 6.Show
   Reassure the patient and try to ensure someone stays with them during the dyspnoea episode, especially if this is a new or acute episode.
   To help with fear and anxiety (Lacey [77], C).
2. 7.Show
   Ensue the call bell is within reach.
   To ensure the patient can call for help if their symptoms worsen or if they feel particularly anxious. P
3. 8.Show
   Offer a fan (if appropriate to the clinical area).
   To reduce subjective sensation of dyspnoea (Chin and Booth [25], E; Dudgeon [42], E; Ekstrom et al. [43], E)
4. 9.Show
   Optimize positioning: help the patient to sit upright, well supported with pillows.
   Specific positions can help with breathing exercises to optimize air entry and are often taken up instinctively by patients (Booth et al. [16], E).
5. 10.Show
   Offer guidance on breathing techniques, such as breathing through pursed lips, diaphragmatic breathing and pacing techniques. Note: some of these techniques may not be appropriate as the patient approaches the last days to hours of life.
   Specific breathing techniques (including the recovery breathing method, breathing control and pacing techniques) can help patients to regain (and maintain) some control over their breathing (Booth et al. [15], R; Chan et al. [23], R).
6. 11.Show
   Encourage relaxation, using techniques suitable to the individual patient (such as breathing techniques, music or mindfulness).
   Relaxation can help the patient to feel less anxious and more in control of their breathing. They can also apply these techniques when needed to reduce anxiety (Booth et al. [15], R).
7. 12.Show
   Consider acupuncture (delivered by an appropriately trained practitioner).
   To help with the sensation of breathlessness (Minchom et al. [94], R).
8. 13.Show
   Consider and implement required pharmacological interventions, such as:

   • antibiotics
   • inhaled or nebulized bronchodilators
   • steroids
   • cough suppressants
   To help optimize symptom control (Chan et al. [23], R; Ekstrom et al. [43], E; Jennings et al. [70], R):

   • Use antibiotics if dyspnoea is caused by infection.
   • Use bronchodilators to reduce any bronchoconstriction or wheeze.
   • Use steroids to reduce any inflammation.
   • systemic opioids
   • oxygen therapy (if patient is hypoxic)
   • heliox
   • benzodiazepines.
   • Use cough suppressants to ease a persistent cough.
   • Use opioids to relieve the sensation of dyspnoea (Barnes et al. [8], R; Jennings et al. [70], R).
   • Use oxygen to treat hypoxia.
   • Use heliox because helium has a low density and the potential to reduce the work of breathing.
   • Use benzodiazepines to relax the patient and help address issues of panic and anxiety (Chan et al. [23], R).
9. 14.Show
   Assess and intervene if chest secretions are audible. Suctioning may be appropriate in some patients; however, this is an invasive procedure that causes discomfort and sometimes distress, and therefore it requires careful consideration as to its suitability in this setting. Consider an anticholinergic medication.
   Suctioning should only be used where clinically appropriate to enhance patient comfort (Lacey [77], C).

   Anticholinergic medication helps to dry out secretions (Twycross et al. [156], C).
10. 15.Show
    Review current artificial hydration; assess the need for it and ascertain whether it could be contributing to chest secretions and therefore increasing dyspnoea.
    To ensure additional fluid is not adding to additional chest secretions (Lanz et al. [79], C).
11. 16.Show
    Consider diuretic medications to offload some fluid from the chest and lungs.
    To optimize symptoms and reduce breathlessness (Dudgeon [42], E).
12. 17.Show
    Request the input of physiotherapy.
    To help the patient get into a supportive position that is comfortable and optimized for breathing, and to request advice on chest physiotherapy if suitable (Chan et al. [23], R).

Post‐procedure

1. 18.Show
   Evaluate the effectiveness or ineffectiveness of any interventions and document them accordingly.
   To ensure the interventions are reviewed and communicated to the multidisciplinary team. This will also help to avoid the repeated implementation of any interventions that were ineffective. E