Consider reversible causes and treat as appropriate:

• Anaemia
• Anxiety
• Ascites
• Cerebral tumours
• Congenital heart disease
• Cystic fibrosis
• Increased respiratory secretions
• Pain
• Pericardial effusion
• Pleural effusion
• Pneumonia
• Pneumothorax
• Primary or secondary lung tumours
• Pulmonary embolism
• Raised intracranial pressure
• Respiratory muscle weakness
• Superior vena cava obstruction
• Uraemia

Management

General measures

• Breathlessness needs careful assessment: it is sometimes a necessary physiological response (for example in keto-acidoisis) and it is not always a problem for the child. However, if it is a problem, the breathlessness is very likely also to cause anxiety and both need addressing together for a good result
• Since anxiety is likely to be a feature associated with breathlessness, exploring meaning, explanations and reassurance where appropriate, is helpful
• Moving air is known to be helpful, and a cool draught from a fan/window can be tried
• Positioning the child as upright as possible or leaning over a table or pillow may help
• Breathing exercises: giving control back to the child in this situation is useful. Older children can be shown how to control their breathing & often the physiotherapist or occupational therapist will be able to support this training
• Poor respiratory effort or excess secretions may respond to gentle physiotherapy ± suction
• The role of distraction is important. Consider play therapy/age appropriate distraction

Medication

Oxygen

Studies have shown this is unlikely to help unless the breathlessness is related to relatively acute desaturation, but it may be worth a trial. Consider nasal specula if mask raises anxiety.

Consider humidifying oxygen, which will dry mouth less.

Oximetry, except in the acute situation, is of limited value; use clinical judgment.

Ipratropium

May be helpful if bronchospasm is present

Form

Nebulised solution: 250µg in 1mL, 500µg in 2mL

Dose (nebulised)

Child less than 1 year: 62.5µg 3 to 4 times daily,
Child 1-5 years: 125-250µg 3 to 4 times daily,
Child 5-12 years: 250-500µg 3 to 4 times daily,
Child over 12 years: 500µg 3 to 4 times daily.

Salbutamol

May be helpful if bronchospasm is present.

Aerosol Inhalation:

Child 1 month-18 years: 100-200µg (1-2 puffs) for persistent symptoms up to four times a day.

Nebulised solution: (2.5mg in 2.5mL, 5mg in 2.5mL, 5mg in 1mL)
Neonate: 1.25-2.5mg up to four times daily,
Child 1 month-18 years: 2.5-5mg up to four times daily.

N.B. Salbutamol may make agitation worse, and cause a tremor if over- used.

Morphine

Reduces anxiety, pain, and pulmonary artery pressure.

Begin with half the analgesic dose, and titrate to effect (see section on pain).

Midazolam

Form

Injection: 10mg in 2mL; 10mg in 5mL.

Injection may be diluted if required, in sodium chloride 0.9% or glucose 5%. Injection can be used for buccal, intranasal, oral or rectal administration.

Oral solution (2.5mg/mL unlicensed), buccal liquid (5 mg/mL Buccolam®) and injection 1mg/mL, 2mg/mL, 5mg/mL (Epistatus® 10mg/mL) are also available from ‘specials’ manufacturers or specialist importing companies (unlicensed). NOTE The buccal and oral formulations available may differ in strength – take care with prescribing.

Dose: Intravenous/subcutaneous

>1month -18yr: 100µg/kg

Dose: Buccal:

Any age: 100µg/kg as a single dose (maximum initial dose 5 mg).

Tastes bitter when given orally but can be mixed with juice or chocolate sauce.

Dose: Continuous intravenous/subcutaneous infusion over 24 hours

Dosages of 30-50% of terminal seizure control dose can be used to control anxiety and terminal breathlessness.

Contraindications and warnings: caution with pulmonary disease, hepatic and renal dysfunction (reduce dose), severe fluid electrolyte imbalance and congestive cardiac failure. Avoid rapid withdrawal after prolonged treatment.

Licence: licensed for sedation in intensive care and for induction of anaesthesia in children > 7 yr. Other routes and indications not licensed.

Lorazepam

Form

Tablets: 1mg (scored), 2.5mg.

Oral suspension only available as ’special’ Injection: 4mg in 1ml, 1ml ampoule

Dose

By mouth:

Child < 2 years: 25µg/kg 2–3 times daily,
Child 2–5 years: 500µg 2–3 times daily,
Child 6–10 years: 750µg 3 times daily,
Child 11–14 years: 1mg 3 times daily,
Child 15–18 years: 1–2mg 3 times daily.

Sublingual:

Children of all ages: 25µg/kg as a single dose. Increase to 50µg/kg (maximum 1 mg/dose) if necessary.

Usual adult dose: 500µg – 1mg as a single dose, repeat as required

Well absorbed sublingually (good for panic attacks) and child has control. Injection can also be given sublingually.

Contraindications and warnings: severe pulmonary disease, sleep apnoea, coma, CNS depression. Caution in hepatic and renal failure.

Licence: tablets licensed in children >5yr as premedication. Injection not licensed in children <12yr except for treatment of status epilepticus.

Dexamethasone

May be helpful in some very rare circumstances such as bronchial obstruction, lymphangitis carcinomatosis, superior vena cava obstruction (SVCO). Should be prescribed with guidance from the specialist palliative medicine team.)