How your doctor can help

Before your doctors can manage your breathing problems they will need to ask you a lot of questions about the history of your illness and breathing difficulties. This may seem like too much to deal with if you are very breathless or tired at the time. You probably just want your doctor to give you something to improve your breathing at once. But it is very important that your doctor and nurses take the time to understand all about your breathing problems. Then they can give you the right treatment for your breathlessness. If you really don't feel that you can answer all the questions, your family and friends may be able to help.

Your doctor will examine you and may do some other tests. Your doctor or specialist nurse may ask you

• Are you short of breath all the time or only when you move around?
• Does anything help lessen the breathlessness - for example, sitting in a certain position?
• Do you feel as if you are gasping for breath or just breathing more quickly?
• When did it begin?
• Do you have a wheeze?
• Do you have a cough?
• Are you coughing up any phlegm?
• Did it get worse after you had any type of treatment such as chemotherapy or radiotherapy?
• Were you short of breath before you were diagnosed with cancer?
• Do you have any other medical conditions?

After you have answered these questions your doctor will examine you. They may

• Examine your chest and abdomen
• Get you to blow into a tube called a ‘peak flow meter‘ which can measure how much air you can breathe in and blow out
• Take your blood pressure and pulse

Your doctor may suggest a chest X-ray, CT scan, lung function tests or blood tests to get more information about your breathlessness and what is causing it.

Your treatment depends on what is causing your breathlessness. You may have

• Blood transfusions or iron tablets
• Erythropoietin
• Antibiotics
• Fluid drained from your chest or abdomen
• Laser treatment
• Oxygen
• Nebulisers and drugs to open your airways
• Steroids
• Other drugs
• Complementary therapies
• Referral to a breathlessness clinic

In this section of CancerHelp UK there is a page on ‘how you can help yourself’ when you are breathless.

Blood transfusions or iron tablets

If you have mild anaemia, you may just need a course of iron tablets. But if you have more severe anaemia, you may need to have a blood transfusion to bring your red blood cell count up again. A blood transfusion is when you have someone else’s blood given to you. You can have a transfusion as an outpatient or stay overnight in hospital. It usually takes between 6 and 9 hours, depending on how many units of blood you need.

Some people worry about blood transfusions. It is blood donated by someone else. But these days the blood is screened for different infections before it is used. It is very safe and many people feel much better afterwards.

Erythropoietin

Another treatment for anaemia is a drug called erythropoietin (EPO). EPO encourages your bone marrow to make more red blood cells. So your haemoglobin levels go up and so does the amount of oxygen your blood can carry. EPO may help if you have myeloma and your anaemia is due to kidney failure, or if you have ovarian cancer and have had chemotherapy with platinum blased drugs, such as carboplatin or cisplatin.

Antibiotics

If you have a chest infection, you will probably need a course of antibiotics. You may have these as tablets or as injections into a vein in your arm. Once your infection is cleared your breathing will improve.

Fluid drained from your chest or abdomen

Fluid on the lungs is called a pleural effusion. The fluid collects between the two sheets of tissue that cover the outside of the lungs - the pleura. The fluid takes up space where your lungs should be. It stops your lungs expanding fully. So you have to take shallower breaths and need to make more effort to breathe.

It is possible to have the fluid drained off. But it will almost certainly build up again. How long this takes will vary from person to person. You can have the fluid drained again and again. But each time, there is a risk that you will get an infection in the area where the needle goes in. And you will have the discomfort of the fluid building up each time and affecting your breathing.

Pleurodesis is a medical procedure that stops the fluid building up. After draining the fluid, the doctor injects talc or an antibiotic into the space between the pleura. The talc or antibiotic irritate the pleura, which makes them stick together. Now there is no space for the fluid to collect, so it doesn’t build up any more. This doesn't always work completely the first time, but you may be able to have it done again. 

Researchers are running trials looking at pleurodesis treatment. One trial called the TIME3 trial is looking at using a drug called urokinase to help drain fluid from around the lung to make breathing easier. Sometimes there is more than 1 pocket of fluid between the lung and chest wall. This makes it difficult to drain all the fluid away. Urokinase may help to break down the pockets. The aim of the trial is to see if urokinase can help control and improve shortness of breath caused by pleural effusion and improve the success rate of pleurodesis. Another trial called the Meso VATS trial  is recruiting people with a type of lung cancer called mesothelioma. This trial is looking at 2 procedures called pleurodesis and pleurectomy to see which works best to prevent a build up of fluid around the lung.

Ascites (a-site-eez) is the medical name for fluid on the abdomen. Ascites pushes up onto the diaphragm which gives it less room to move and causes breathlessness.

If you have ascites, your doctor can put a needle into the abdomen and drain off the fluid (this is called paracentesis).

But the fluid will collect again in time. How long this takes varies from person to person. You can keep having the fluid drained, but each time you do there is a risk that you could get an infection (peritonitis). It may not be possible to do this if the fluid has built up in different pockets in the abdomen. Drugs to make you pass more urine (diuretics) can help to reduce the fluids, but it is important that you have frequent blood tests if you are taking these regularly.

Another type of treatment is to insert a 'shunt'. This is a tube with a valve, which allows the ascites to drain from your abdomen into a major vein. This is more useful in some types of cancer (such as breast or ovarian cancer) than in others. It does not work so well if the ascites is caused by stomach or bowel cancer. This procedure can lead to serious complications, for instance blood clots, in about 1 in 20 (5%) people. It is unlikely to work well if the ascites is in separate pockets in your peritoneum. There are also permanent tubes (catheters) that connect to the surface of the skin of your tummy. Then when the fluid builds up again you connect it to a container to drain it off.  They can stay in as long as you need it. The main problem with these types of catheters is infection and blockage.

Treatments for your cancer may also help to reduce the build up of fluid.

Laser treatment

Laser treatment is really a type of surgery. Doctors mostly use laser surgery to treat advanced lung cancer. They can use it to cut away any tumour that is blocking a main airway and making breathing difficult. You have this done through a tube down the throat (bronchoscopy). You have an anaesthetic or strong sedation first so you won't remember much, if anything, about it. Lasers seal off bleeding as they go. So you don't have to stay in hospital for long after the treatment. You may even be able to go home the same day.

Just about any hospital that treats lung cancer could carry out laser surgery. The operation usually works very well at relieving breathing difficulties. But it is not a cure. It does not treat cancer that has spread anywhere else in the body. The tumour in the airway may grow back. If necessary, it may be possible for the laser surgery to be done more than once.

In the lung cancer section of CancerHelp UK, there is detailed information about laser treatment in advanced lung cancer.

Oxygen

Some people may get relief from using oxygen. But it does not help everyone who is short of breath. A fan to cause movement in the air around you may help more. It is certainly worth trying.

Your doctor will prescribe oxygen for you if they think that it will help. Your GP can organise oxygen at home for you if you need it. In Scotland and Northern Ireland, this is arranged through your pharmacist. But since early 2006 there has been a different arrangement in England and Wales. There are 4 companies which supply oxygen to peoples' homes. They will supply cylinders or an oxygen concentrator. This extracts the required oxygen from room air and runs on electricity. You should also have an oxygen cylinder as a backup. There is more information about having oxygen at home in the lung cancer questions section.

Some people need to use oxygen all the time but others just need it before or after any exercise - for example, taking a shower or going out for a walk.

If you are using oxygen a lot, your doctor will give you a set of tubes called 'nasal cannulae'. This plastic tubing fits into your nose and connects to the oxygen cylinder. Once you get used to it, it is more comfortable than a mask and means you can talk, eat and drink while using the oxygen. There are even small portable oxygen cylinders you can take out with you if you need them.

Using oxygen can sometimes make your mouth and nostrils very dry. If left, a dry mouth can become very uncomfortable and lead to bad breath, infections and sore cracked lips. Care for your mouth regularly by keeping your teeth clean and putting lip balm or Vaseline on your lips. Most importantly, drink as often as you can. This way, you can prevent problems before they start.

Nebulisers and drugs to open your airways

If the tubes that carry air into your lungs have narrowed, making breathing difficult, you can take drugs to open them up again. These drugs are called bronchodilators. You may have them as tablets, inhalers, or through a mask called a nebuliser. A nebuliser is a machine that makes a mist of tiny drops (an aerosol) out of a liquid drug, which you then breathe in. In hospital, your nebuliser will be attached to the piped air in the ward.

There are home nebuliser kits available to borrow or buy. You may need to have nebulisers as often as every 4 hours, depending on how breathless you are.

Sterile saline (salt water) in a nebuliser may help you if you have a chesty cough. It will loosen phlegm and make it easier for you to bring it up. For an irritating cough, your doctor may suggest a very small amount of a local anaesthetic called bupivacaine to help suppress it.

Steroids

If side effects from radiotherapy are making you breathless, your doctor may suggest steroid tablets. The most common are called dexamethasone and prednisolone. You will probably need to take them for a few weeks after your radiotherapy finishes. Once your breathing improves, your doctor will gradually decrease the dose of the steroids before stopping them altogether. There are side effects to taking these drugs. Although these side effects can sound alarming, most are unlikely unless you’ve been on steroids for a long time. And they are temporary. They will go away when you stop taking the tablets.

The main side effects of steroids include

• Having a bigger appetite
• Having more energy
• Difficulty sleeping
• Indigestion
• Muscle weakness

When you have been taking steroids for some time you may notice some swelling in your hands, feet or eyelids. You may also put on weight. Steroids can cause water retention and this is what causes the swelling and weight gain.

Your doctor will be looking out for other side effects of your steroids. These are

• Raised blood pressure
• Increased risk of picking up infections
• Raised blood sugar and sugar in your urine

You may be asked to test your urine for sugar or to take samples to the hospital or GP's for testing.

Steroids can lower your resistance to infection and it is best to avoid people with colds and flu while you are taking them.

It is important that any doctor treating you for any reason should know you are taking steroids. So in case of emergencies, your doctor will give you a card that says you are taking steroids. You will need to carry the card with you at all times.

Remember - never stop taking steroids without checking with your doctor. Suddenly stopping or lowering your dose can be dangerous.

Other drugs

Other drugs that may be used to help control your breathing problems include

• Cough medicines
• Muscle relaxing drugs, such as diazepam
• Certain pain medicines, such as morphine
• Drugs to reduce secretions, such as glycopyrronium

A lot of cough medicines you can buy don’t really do much. Some people find codeine linctus helpful. Remember that codeine can make you constipated. Some people find the over the counter cough medicines for chesty coughs helpful but it really depends on what is causing your cough.

Muscle relaxants like diazepam or lorazepam can help you to breathe more fully by relaxing your chest and abdominal muscles. You can get lorazepam in a tablet you dissolve under your tongue, which means it works fast and may be easier for you than swallowing a tablet. These drugs can also help with anxiety. Not surprisingly, breathing difficulties can make people very anxious.  A Cochrane systematic review in January 2010 found that these types of drugs didn't significantly help and recommended that they should be considered only if other treatments weren't working.  They also said that we need more research.   

As well as relieving pain, morphine can help with breathing problems. It slows down your breathing rate (your respiration rate). If you are very short of breath, especially when you do any exercise, your doctor may prescribe small morphine doses to help you.

If your lungs are producing a lot of secretions, you might find it difficult to breath. Your doctor can give you drugs to help dry up these secretions and ease your breathing. For example, glycopyrrolate or hyoscine hydrobromide. Hyoscine can also make you quite drowsy. You usually have these drugs through a syringe driver. They might be mixed with painkillers. Other drugs, for example carbocisteine, break down the thickness of your sputum and make it easier to cough up. This can help your breathing. These drugs come as capsules or a syrup.

Complementary therapies

These days, some GP’s surgeries, hospital clinics and hospices work with people offering different kinds of treatment. Don’t be surprised if your doctor or nurse suggests relaxation classes, massage or acupuncture to help your breathlessness. Many hospitals now run breathlessness clinics and these treatments may be available there. Acupuncture and relaxation, particularly, may help with breathlessness.

If you are interested in trying a particular complementary therapy, talk to your nurse. If it is not available at your hospital or clinic, there may be a local cancer support group that offers this type of service or at least can put you in touch with local practitioners. Look at our complementary therapy section for more about how to find a practitioner.

Referral to a breathlessness clinic

Your doctor may suggest you go to a breathlessness clinic. A lot of hospitals have set these up because we know they can help breathless patients. It won’t just be people with cancer who go to these clinics. There will be people with chronic lung disease there too.

The clinics are usually staffed by specialist nurses, occupational therapists and physiotherapists who can help you learn techniques to manage your breathlessness better. You may be helped to learn better breathing techniques, relaxation and how to pace yourself. You usually go to the clinic for 4 to 8 weeks. The people most likely to benefit are those who are breathless when they are active, but not too bad when sitting at rest. There is information on breathing and relaxation techniques on the next page of this section.