Previous changes

April 2025 — minor update. QOF indicators removed in line with NHS England's 2025 Quality and Outcomes Framework.

February 2024 — minor update. Adverse effects of morphine have been added in line with an update to the manufacturer’s Summary of Product Characteristics (SPC).

December 2023 — minor update. Recommendations relating to COVID-19 infection have been removed from this topic.

July 2022 — minor update. Added new NICE guideline reference in the advice relating to COVID-19.

March 2021 — reviewed. Literature searches were conducted in February 2021 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic.

November 2020 — minor update. Sleep apnoea syndrome added as an adverse effect of opioids.

April 2020 — minor update. New management scenario created to provide information regarding COVID-19. 

July 2015 to October 2016 — reviewed. Literature searches were conducted in September 2016 to identify evidence-based guidelines, UK policy, systematic reviews, and key randomized controlled trials published since the last revision of this topic. There have been structural changes to the topic and changes to the recommendations have been updated in line with NICE guidance Care of dying adults in the last days of life [NICE, 2015]. 

July 2015 — topic title changed to reflect broader topic coverage than specifically cancer care.

April 2015 — minor update. Update to the text to reflect a new law on drugs and impaired driving.

June 2013 — minor update. The 2013 QOF options for local implementation have been added to this topic.

February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic.

November 2012 — reviewed. A literature search was conducted in August 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. Changes have been made to the section on when to offer a benzodiazepine. The section on prescribing oral opioids has been updated. A new prescribing information section on the use of subcutaneous opioids has been added.

October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic.

March 2012 — minor update. The 2012/2013 QOF indicators have been added to this topic. Issued in April 2012.

May 2011 — minor update. The 2011/2012 QOF indicators have been added to this topic. Issued in June 2011.

February 2011 — topic structure revised to ensure consistency across CKS topics. No changes to clinical recommendations have been made.

April to August 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence. Changes have been made to the sections discussing the use of corticosteroids to treat dyspnoea (including emergency treatment). In the section on symptomatic treatment, more details on oxygen treatment and information about bronchodilators have been added. The topic has been restructured to include assessment of a person with dyspnoea in a palliative care situation, symptomatic treatment of dyspnoea in a palliative care situation, and treatment of dyspnoea of known cause in a palliative care situation.

January 2006 — minor update. Prescriptions for diamorphine updated to reflect the change in handwriting requirements for controlled drug prescriptions. Issued in February 2006.

October 2005 — minor technical update. Issued in November 2005.

August 2003 — written. Validated in December 2003, and issued in February 2004.

New evidence

Evidence-based guidelines

No new evidence-based guidelines since 1 July 2026.

HTAs (Health Technology Assessments)

No new HTAs since 1 July 2026.

Economic appraisals

No new economic appraisals relevant to England since 1 July 2026.

Systematic reviews and meta-analyses

No new systematic reviews or meta-analysis which reach the CKS threshold for inclusion since 1 July 2026.

Primary evidence

No new primary evidence which reaches the CKS threshold for inclusion published since 1 July 2026.

New policies

No new national policies or guidelines since 1 July 2026.

New safety alerts

No new safety alerts since 1 July 2026.

Changes in product availability

No changes in product availability since 1 July 2026.

Clinical features on history-taking

Table 1. Typical symptoms associated with breathlessness and possible diagnoses. Note: atypical presentations are common.

Clinical features on examination

Table 2. Typical examination findings associated with breathlessness and possible diagnoses.

Basis for recommendation

These recommendations are based on the European Society for Medical Oncology (ESMO) clinical practice guidelines Management of breathlessness in patients with cancer [Hui, 2020], the NHS Scotland publication Scottish palliative care guidelines [HIS, 2025], expert opinion in a review article on breathlessness in advanced disease [Pascoe, 2025], and expert opinion in palliative care textbooks [Regnard, 2010; Chan, 2015; Twycross, 2021]. They are also pragmatic, based on what CKS considers to be good clinical practice.

Clinical features on history-taking

• The ESMO clinical practice guidelines note that as breathlessness is a subjective experience, assessment should be based on self-reported symptoms, where possible [Hui, 2020].
• The recommendation to ask about onset of symptoms is based on the fact that acute (minutes) onset breathlessness may suggest a new and potentially reversible condition such as pneumonia or pleural effusion. Subacute (hours to days) onset may represent an exacerbation of an underlying chronic condition, and chronic symptoms (weeks to months) may suggest a longterm condition [Twycross, 2021].
  • The recommendation to consider use of a visual analogue scale is based on the ESMO clinical practice guidelines [Hui, 2020] and expert opinion in palliative care textbooks [Chan, 2015; Twycross, 2021].
• The recommendation to ask about psychological symptoms such as fear and panic is based on the fact these may be associated with past and anticipated future episodes of breathlessness, and can perpetuate and exacerbate the symptom [Pascoe, 2025]. It is also based on the NHS Scotland guidelines [HIS, 2025]. The information about clinical features which may suggest hyperventilation due to anxiety or panic is based on expert opinion in a palliative care textbook [Twycross, 2021].
• The recommendation to ask about comorbidities is based on the fact that breathlessness is often multifactorial, and more than one condition often contributes to symptom [Pascoe, 2025]. In addition, the severity of breathlessness is associated with comorbidities such as chronic obstructive pulmonary disease (COPD), anxiety, depression, pain, poor performance status, and living alone. In particular, anxiety is the only cormobidity to consistently correlate with the finding of breathlessness in advanced disease [Twycross, 2021].
• The recommendation to ask about medications is extrapolated from the ESMO clinical practice guidelines [Hui, 2020] and expert opinion in a palliative care textbook [Twycross, 2021].
• The recommendation to ask about smoking and occupational history is extrapolated from expert opinion in a review article [Pascoe, 2025] and expert opinion in a palliative care textbook [Twycross, 2021].
• The recommendations to assess the person's social situation and impact of breathlessness is based on the ESMO clinical practice guidelines [Hui, 2020], expert opinion in palliative care textbooks [Chan, 2015; Twycross, 2021], and the NHS Scotland guidelines, which highlight that 'the impact of, and distress caused by, breathlessness are often underestimated' [HIS, 2025].
• The recommendation to ask about coping strategies is based on the fact that physical deconditioning, self-isolation, and reduced activity levels to avoid episodes of breathlessness can perpetuate and exacerbate the symptom over time [Pascoe, 2025].
  • Expert opinion in a review article highlights the potential value of the modified Medical Research Council (MRC) dyspnoea scale to assess a person's experience of breathlessness and to monitor its progression over time [Pascoe, 2025]. This approach is supported by the ESMO clinical practice guidelines [Hui, 2020], the NHS Scotland guidelines [HIS, 2025], and expert opinion in a palliative care textbook [Chan, 2015].  

Clinical features on examination

• The ESMO clinical practice guidelines note that breathlessness can be missed or overlooked if relying only on observation of the person at rest for example sitting or in bed, where they may appear comfortable. They highlight that vital signs are useful to indicate respiratory distress and possible underlying causes for breathlessness, but physiological assessment should not 'replace' self-reported breathlessness symptoms [Hui, 2020].
• Expert opinion in a palliative care textbook notes that people with severe breathlessness may appear exhausted and not be able to provide much history, where examination findings will guide initial management [Chan, 2015].
• The recommendation to assess vital signs including oxygen saturation level, temperature, and hydration status is based on the ESMO clinical practice guidelines [Hui, 2020], the NHS Scotland guidelines [HIS, 2025], and expert opinion in palliative care textbooks [Regnard, 2010; Chan, 2015].
• The recommendation to perform a general examination is based on the ESMO clinical practice guidelines [Hui, 2020] and expert opinion in a palliative care textbook [Chan, 2015]. Expert opinion in an additional palliative care textbook notes that cyanosis may not be present in people with severe anaemia despite hypoxaemia, so it is not always a reliable sign on examination [Twycross, 2021].
• The recommendation to perform respiratory and cardiovascular examinations is based on the ESMO clinical practice guidelines [Hui, 2020] and expert opinion in palliative care textbooks [Chan, 2015; Twycross, 2021].
• The recommendation to observe a person walking or carrying out a set task is based on expert opinion in a palliative care textbook [Twycross, 2021].

Arranging investigations in primary care

• Expert opinion in a palliative care textbook notes that selective investigations may help to assess for an underlying cause(s) of breathlessness, and help to guide management at different stages of a person's illness. It highlights that the severity of breathlessness does not reliably correlate with the degree of hypoxaemia and lung function test results [Chan, 2015].
• The recommendations to consider arranging blood tests and chest X-ray are based on expert opinion in palliative care textbooks [Chan, 2015; Twycross, 2021]. 
• Expert opinion in a further palliative care textbook similarly notes that lung function tests such as spirometry may not reflect the impact of breathlessness on the person [Regnard, 2010]. Expert opinion in an additional palliative care textbook notes that in a palliative care setting, if airway obstruction is suspected, a trial of treatment (such as bronchodilator therapy) may be a more pragmatic approach than arranging objective tests of ventilatory function [Twycross, 2021].
• The recommendation to consider arranging an electrocardiogram (ECG) is based on expert opinion in a palliative care textbook [Twycross, 2021]. 

What non-drug measures may relieve breathlessness?

If a person has breathlessness in a palliative care setting, advise on the use of non-drug measures for symptom relief.

• Advise keeping the room cool and improving air circulation with a fan or open window.
• Encourage relaxation, re-positioning, and breathing techniques.
  • Advise about relaxation and distraction techniques and how to self-manage anxiety and fatigue. The Marie Curie website (www.mariecurie.org.uk) has patient information on Anxiety and Fatigue in terminal illness. See the CKS topic on Generalized anxiety disorder for more information.
  • Optimal positioning includes:
    • Relaxed sitting (with hands or elbows rested on thighs) or standing (using a wall as support) may help reduce muscle tension associated with anxiety.
    • A 'forward lean' position with arms/elbows resting on the knees or bracing the arms may improve ventilatory capacity.
    • 'High side lying' (lying on the side with the normal lung down if there is unilateral lung disease), supporting head and chest may also help.
  • Breathing techniques and retraining aim to help the person regain a sense of control and improve respiratory muscle strength, to relieve the perception of breathlessness during exercise or whenever breathlessness is triggered. Offer referral to a chest physiotherapist or clinical nurse specialist to teach techniques, depending on local availability and referral pathways, if needed. The Marie Curie website (www.mariecurie.org.uk) has patient information on Help with breathlessness which covers different breathing positions, breathing control techniques, relaxation and anxiety management.
    • Pursed-lip breathing involves inhaling through the nose for several seconds with the mouth closed, then exhaling slowly through pursed lips for 4–6 seconds.
    • Diaphragmatic breathing, reduced use of accessory muscles, and timed breathing may also help.
• Advise about and support smoking cessation, if clinically appropriate. See the CKS topic on Smoking cessation for more information.
• Explore the person's fears and concerns about breathlessness, and provide reassurance and an explanation for its underlying causes, where possible.
  • Reassure that breathlessness in itself is not dangerous or life-threatening.
• Encourage regular mobility, physical activity, and pacing of activities, depending on the person's motivation and capabilities.
  • Explain that exertion to the point of breathlessness can increase exercise tolerance and maintain fitness. The level of physical activity that is realistically achievable will vary from person to person.
  • Advise about pacing of activities (balancing rest and activity), for example by doing the same activities or tasks at a slower rate. Offer referral to a physiotherapist for consideration of pulmonary rehabilitation, depending on local availability and referral pathways.
  • Offer support to improve the person's mobility, and offer referral to a physiotherapist and/or occupational therapist for consideration of mobility aids, if appropriate.
  • The Marie Curie website (www.mariecurie.org.uk) has patient information on Mobility issues when living with a terminal illness, how to help someone walk, sit and stand up, help with breathlessness, which includes advice on physical activity, and Fatigue in terminal illness.
• Advise on local sources of information and support.
  • Local peer groups, day care facilities, social support, and respite care may be helpful, depending on the needs and wishes of the person and/or family members/carers. See the CKS topic on Palliative care - general issues for more information.
• Assess for and manage any other physical, psychological, social, cultural, religious, and spiritual needs of the person, family members and/or carers. See the CKS topic on Palliative care - general issues for more information.

When should I consider prescribing opioids for breathlessness?

If a person presents with symptomatic breathlessness which is not fully responding to  non-drug measures in a palliative care setting:

• Consider prescribing a strong opioid for symptom relief and monitor response to treatment regularly.
  • Prescribe opioids for intermittent use when needed, if breathlessness is not constant, and titrate the dose depending on symptom response and adverse effects. Consider switching to a modified-release preparation with immediate-release morphine available for 'breakthrough' breathlessness, if needed.
    • Prescribe immediate-release low-dose oral morphine first-line if the person is opiate-naive.
    • Ensure laxative and antiemetic medication is also prescribed when a person is using opioid medication. See the CKS topics on Palliative care - constipation and Palliative care - nausea and vomiting for more information.
  • If the person cannot take or tolerate oral medication, consider prescribing a subcutaneous bolus of morphine to be used when needed. Consider using a syringe driver to administer subcutaneous delivery of morphine for continuous symptom control, if more than two or three doses of 'as required' medication have been given within 24 hours.
  • See the section on Opioids in Prescribing information for more information on choice of opioids, dose regimens, and potential adverse effects. See the section on Management in the terminal phase for more information on prescribing opioids in the terminal phase of illness.
• Advise the person to continue using non-drug strategies when initiating opioid medication. See the section on Non-drug measures for more information.

When should I consider prescribing benzodiazepines for breathlessness?

If a person presents with symptomatic breathlessness which is not fully responding to non-drug measures and opioids in a palliative care setting:

• Consider prescribing benzodiazepine medication short-term:
  • If breathlessness is associated with severe anxiety or panic (which may contribute to, or result from, breathlessness). The Marie Curie website (www.mariecurie.org.uk) has patient information on Anxiety.
  • In the terminal phase of illness. See the section on Management in the terminal phase for more information.
• The choice of benzodiazepine depends on the person's stage of illness, the severity of any anxiety, and the desired onset of action.
  • Be aware that the combination of opioid and benzodiazepine medication may be beneficial for symptom relief of breathlessness, but the person must be monitored regularly for over-sedation, falls, delirium, and other adverse effects. See the section on Benzodiazepines in Prescribing information for more information on choice of benzodiazepines and potential adverse effects.

When should I consider prescribing corticosteroids for breathlessness?

If a person presents with symptomatic breathlessness in a palliative care setting:

• Consider immediate use of high-dose corticosteroids if there is an emergency situation involving severe airway obstruction. See the section on Scenario: Known cause of breathlessness for more information about emergency management.
• Consider the use of corticosteroids for symptom relief of refractory breathlessness which has not responded to other non-drug and drug treatments.
  • Corticosteroids should ideally be initiated only by, or on the advice of, a palliative care or respiratory specialist.
  • If specialist advice is not available when needed, the decision to prescribe should be based on the underlying likely cause of breathlessness, and the relative benefits and potential risks including adverse effects. Follow local prescribing guidelines, ensure the person is closely monitored, and obtain specialist advice and/or review as soon as possible, depending on clinical judgement. See the CKS topic on Corticosteroids - oral for more information.

When should I consider prescribing bronchodilators for breathlessness?

If a person presents with symptomatic breathlessness in a palliative care setting:

• If there is an emergency situation involving severe airway obstruction, see the section on Scenario: Known cause of dyspnoea for more information about emergency management.
• If there is associated wheeze thought to be due to partial airway obstruction (from a tumour, for example):
  • Offer specialist oncology referral for possible management of an underlying cancer and its complications (such as radiotherapy or stenting to a tumour), depending on the person's wishes, stage of illness, and estimated prognosis.
  • Consider prescribing a trial of bronchodilator inhaled therapy while the person is waiting for specialist assessment, if specialist referral is not clinically appropriate, or if there are comorbidities such as asthma or chronic obstructive pulmonary disease (COPD). See the CKS topics on Asthma and Chronic obstructive pulmonary disease for more information.

When should I consider prescribing oxygen therapy for breathlessness?

If a person presents with symptomatic breathlessness in a palliative care setting:

• Consider immediate administration of oxygen therapy if there is an emergency situation involving severe airway obstruction. See the section on Scenario: Known cause of breathlessness for more information about emergency management.
• Consider arranging referral for oxygen therapy if there is known or suspected symptomatic hypoxaemia (oxygen saturation levels less than or equal to 92%).
  • Advise continuing non-drug measures and other drug treatments, as clinically indicated.
  • Long-term oxygen therapy (LTOT, used for 15 hours or more a day) ideally should be initiated by a respiratory or palliative care specialist for people with severe disabling breathlessness due to cancer or other progressive, life-shortening conditions. Target oxygen saturation levels are usually 94–98% unless there is associated hypcapnia, when lower targets of 88–92% may be appropriate, depending on specialist advice.
  • See the section on Oxygen therapy in the section on Prescribing information for more information on practical prescribing issues and potential risks of oxygen therapy.
• Consider a trial of ambulatory oxygen (ideally after seeking advice from a respiratory or palliative care specialist) if considered clinically appropriate; for example, it may help pre-planned daily activity that triggers breathlessness, such as washing or dressing.
  • Short-burst oxygen therapy should be initiated at 2 L/min with an initial duration of between 15–30 minutes (or until the person feels benefit). If there is any uncertainty about prescribing short-burst oxygen therapy, seek urgent specialist advice.
• Do not routinely start palliative oxygen therapy if the person is in the terminal phase of illness and last days of life, in the absence of respiratory distress.
  • Advise on the use of non-drug measures to manage breathlessness.
  • See the section on Management in the terminal phase for more information on drug treatments to manage breathlessness in the terminal phase of illness.

How should I manage specific causes of breathlessness?

If a person has breathlessness in a palliative care setting:

• Arrange immediate emergency management or hospital admission if there is acute severe airway obstruction, for example due to tumour compression or superior vena cava obstruction, depending on clinical judgement, the person's stage of illness, estimated prognosis, and their wishes.
  • Sit the person upright.
  • Ensure a flow of cool air to the face.
  • Check the oxygen saturation level if a pulse oximeter is available. Start 24% oxygen if the oxygen saturation level is 90% or less.
  • If the person develops stridor, consider initiating high-dose corticosteroids immediately, ideally following urgent discussion with a palliative care specialist.
    
    • Give a single oral dose of dexamethasone 16 mg if the person can swallow. If they are unable to take oral medication, administer via the intramuscular, subcutaneous (off-label), or intravenous (IV) route (IV administration may be less practical in primary care, and should be given as a slow injection over 2 minutes), or,
    • Give a single dose of oral prednisolone 60 mg if dexamethasone is not available.
  • Arrange immediate hospital admission if clinically appropriate or discuss ongoing management with an appropriate specialist, depending on clinical judgement.
• If immediate emergency management or hospital admission is not needed for breathlessness due to a specific cancer-related or non-cancer cause:
  • Advise on the use of non-drug measures to help provide symptom relief.
  • Consider use of additional drug treatments and/or oxygen therapy, if clinically appropriate. See the section on Scenario: Symptomatic treatment for more information.
  • Consider additional management strategies, depending on the underlying cause of breathlessness, the person's stage of illness, estimated prognosis, and their wishes. Seek specialist advice if there is any uncertainty as to treatment options for a specific underlying cause for breathlessness.
    
    • Offer management of any potentially reversible cause(s), such as anaemia, acute exacerbation of asthma or chronic obstructive pulmonary disease (COPD), pulmonary oedema, pneumonia, or arrhythmia. See the CKS topics on Anaemia - iron deficiency, Asthma, Breathlessness, Chest infections - adult, and Chronic obstructive pulmonary disease for more information.
    • Offer management of associated anxiety, panic, fear, and/or depression. See the section on Non-drug measures for more information.
    • Offer specialist oncology referral for possible management of an underlying cancer and its complications (such as radiotherapy or stenting of a tumour, drainage of a pleural effusion).
    • Offer specialist respiratory, cardiology, or other referral or seek specialist advice if the cause of breathlessness is not directly related to an underlying cancer, but may benefit from other specialist management (for example severe end-stage COPD or heart failure, or uncontrolled symptomatic atrial fibrillation). See the CKS topics on Atrial fibrillation, Chronic obstructive pulmonary disease and Heart failure - chronic for more information.
    • Offer referral to a palliative care specialist, dietician, and/or physiotherapist if there is cachexia contributing to breathlessness and/or if breathlessness is affecting the person's ability to eat and drink, leading to a risk of malnutrition. See the CKS topic on Adult malnutrition for more information.

How should I manage breathlessness in the terminal phase of illness?

If a person has breathlessness in the terminal phase of illness:

• Discuss with the person their disease status, progression, estimated prognosis, and what to expect in the terminal phase of illness, if they wish. See the CKS topic on Palliative care - general issues for more information.
  • The Marie Curie website (www.mariecurie.org.uk) has information about End of life breathing changes which may be helpful.
• Offer an opportunity to discuss and document advance care planning with the person. See the CKS topic on Palliative care - general issues for detailed information about advance care planning discussions.
• Identify and treat any potentially reversible causes of breathlessness, such as infection, pulmonary oedema, or pleural effusion, depending on clinical judgement and the person's wishes. See the section on Management of specific causes for more information.
• Do not routinely start oxygen therapy if the person is in the terminal phase of illness and last days of life. See the section on Oxygen therapy for more information.
• Advise on the use of non-drug strategies to manage breathlessness. See the section on Non-drug measures for more information.
  • The Marie Curie website (www.mariecurie.org.uk) has patient information on Help with breathlessness.
  • Explain that for some people with breathlessness on exertion, if they become chair- or bed-bound, symptoms may be less distressing.
• If dry mouth or airway secretions are causing distress, offer appropriate management. See the CKS topics on Palliative care - oral and Palliative care - secretions for more information.
• Consider prescribing one or more of the following drug treatments for breathlessness, depending on the person's wishes and clinical judgement, and titrate 'as-needed' and regular doses to obtain satisfactory symptom relief:
  • An opioid, or
  • A benzodiazepine, or
  • A combination of an opioid and benzodiazepine (off-label indications). See the sections on Opioids and Benzodiazepines in Prescribing information for more information.

What are the adverse effects of home oxygen therapy?

Oxygen therapy has potential psychosocial and other adverse effects that can influence acceptability, tolerability, and compliance.

• Adverse effects of oxygen therapy include [Hardinge, 2015; Hui, 2020; Pascoe, 2025]:
  
  • Psychological dependence. Being deprived of oxygen for even a short period may provoke acute anxiety and further breathlessness.
  • Social restriction. Oxygen equipment severely limits mobility inside and outside the house, and some people feel a social stigma and embarrassment.
  • Need for regular monitoring. Symptoms of hypercapnia and oxygen saturations on oxygen are needed to check that the oxygen provided remains therapeutic.
  • Drying of airways. Oxygen therapy contains less water vapour than air, which can lead to discomfort owing to its drying effect, particularly on the nasal mucosa when using nasal cannulae.
  • Combustibility. There are risks of fire, burns, and smoke inhalation from flammable sources such as smoking when using oxygen therapy. Home oxygen assessment services may decide not to prescribe home oxygen to smokers if the risks are in their judgement too high. Patients should be made aware that they should not use e-cigarettes and chargers within the vicinity of their home oxygen. In addition, oil-based emollients and petroleum jelly can support combustion in the presence of oxygen. Patients should be made aware that only water-based products should be used on the hands and face or inside the nose while using oxygen.
  • Falls risk. Patients and carers should be aware that tubing should be checked on a regular basis and repositioned as necessary to ensure safety by preventing trips and falls. 

Practical prescribing issues

Oxygen therapy will usually be initiated by a respiratory or palliative care specialist with ongoing monitoring by the specialist team.

• A mask or nasal cannulae are options for oxygen delivery. Nasal cannulae may be preferred to a mask because they do not impair speech or eating and drinking, however nasal cannulae can cause dryness and soreness of the nasal mucosa [Hardinge, 2015; Twycross, 2021].
• Oxygen should be prescribed at the lowest flow rate possible to produce benefit because of potential adverse effects. Clinical assessment may involve measuring breathlessness scores at different flow rates of oxygen. A trial flow rate of 1–2 L/min may be used initially to see if this provides symptom relief  [HIS, 2025].
• People starting oxygen therapy should be provided with education and written instructions that include advice about the dangers of smoking or naked flames near oxygen therapy [Hardinge, 2015].
• People should be reassessed regularly after commencing therapy, to determine the continuing benefit of oxygen therapy over time [Hardinge, 2015].

Choice of opioid

• Immediate-release oral morphine is the usual initial opioid of choice for people who are opioid-naive [HIS, 2025].
• If the person cannot take or tolerate oral medication, morphine may be given as a subcutaneous bolus when required, or as a subcutaneous continuous infusion delivered through a syringe driver. In some people, continuous subcutaneous delivery of morphine is better tolerated and provides greater symptom relief than oral doses, by avoiding dose peaks causing adverse effects and troughs causing loss of effect [Twycross, 2021].

Oral morphine dose regimen

Follow local palliative prescribing guidelines when prescribing oral morphine preparations, if available. Tailor any opioid dose regimen to the person's individual needs and clinical context. Seek specialist advice if there is any uncertainty when prescribing opioids.

• The initial starting opioid dose will depend on the person's previous exposure to opioids, their age, symptoms, degree of frailty, and comorbidities including lung disease, kidney, and liver function. In people with breathlessness, morphine should be increased more cautiously than when used for palliative care pain relief.
• In an opioid-naive person
  • Start with oral immediate-release morphine 1–2 mg as needed up to one-hourly; maximum total oral dose 12 mg in 24 hours.
  • Some people with breathlessness may not need regular doses initially, and if needed for breathlessness on exertion, advise to take oral morphine about 30 minutes before any activity or exertion.
• In a person taking a weak opioid (such as codeine)
  • Consider switching to oral morphine equivalent dosing. Only continue the weak opioid if clinically appropriate.
• In a person already receiving regular morphine for pain relief
  • Divide the 24 hour dose by 6 and start with 'as-needed' doses equivalent to 25% of the calculated 4-hourly dose. This dose may be sufficient for people with mild-to-moderate breathlessness at rest. If needed, increase to 50% of the calculated 4-hourly dose.
• In a person taking oral morphine who needs to uptitrate the dose
  • If the person has no adverse effects and morphine is providing symptom benefit, reassess the morphine dose and increase if necessary. For example, if the person is taking 3 or more doses of 'as needed' 2 mg immediate-release morphine in 24 hours, advise to take 2 mg regularly 4–6 times a day.
  • If the person is needing 3 or more doses of 'as needed' 2 mg immediate-release morphine in 24 hours in addition to the regular dose, increase by 30–50% increments of 'as needed' doses in the preceding 24 hours.
  • Convert to a modified-release morphine preparation for regular dosing if a dose of 10 mg or more is needed in 24 hours. Most people have benefit from oral modified-release morphine 10 mg over 24 hours.
  • Once a stable dose has been reached, the new 4–6 hourly and 'as-needed' dose is one-tenth to one-sixth of the new total daily dose.

 [Twycross, 2021; HIS, 2025]

Subcutaneous opioid dose regimen

Follow local palliative prescribing guidelines when prescribing subcutaneous opioid preparations, if available. Tailor any opioid dose regimen to the person's individual needs and clinical context. Seek specialist advice if there is any uncertainty when prescribing opioids.

• The initial starting opioid dose will depend on the person's previous exposure to opioids, their age, symptoms, degree of frailty, and comorbidities including lung disease, kidney, and liver function. In people with breathlessness, morphine should be increased more cautiously than when used for palliative care pain relief.
• In an opioid-naive person
  • Start with a subcutaneous morphine dose of 1–2 mg as-needed, maximum total dose 6 mg in 24 hours.
  • If taking 3 or more doses in 24 hours with symptom benefit, prescribe morphine 5 mg in 24 hours by continuous subcutaneous infusion by syringe driver.
  • If the person is needing 3 or more doses of 'as needed' rescue morphine doses in 24 hours in addition to the continuous dose, increase by 30–50% increments of 'as needed' doses in the preceding 24 hours.
• If converting from oral morphine to subcutaneous morphine:
  • The oral to subcutaneous potency ratio of morphine is between 1:2 and 1:3 (that is, the subcutaneous dose is one-third to one-half of the oral dose). In practice, most centres divide the oral dose by two and re-titrate as necessary. See Table 3.

[Twycross, 2021; HIS, 2025]

Table 3. Equivalent doses of oral morphine sulphate to the subcutaneous route in milligrams (mg).

Adverse effects

Potential adverse effects of opioids include the following. If there are persistent adverse effects, consider switching to an alternative opioid. Seek specialist advice if needed.

• Arrhythmias; confusion; constipation; dizziness; drowsiness; dry mouth; euphoric mood; flushing; hallucination; headache; hyperhidrosis; hypotension (with high doses); miosis; nausea (more common on initiation); palpitations; respiratory depression (with high doses); skin reactions including itch; urinary retention; vertigo; visual impairment; vomiting (more common on initiation); withdrawal syndrome.

[BNF, 2026]

Choice of benzodiazepine

• Lorazepam, diazepam, and midazolam are benzodiazepines that may be used to help manage distressing breathlessness associated with anxiety [Regnard, 2010; Twycross, 2021; HIS, 2025].
  • The initial dose of a benzodiazepine depends on the person's age, symptoms, degree of frailty, comorbidities, previous benzodiazepine use, and urgency of symptom relief.
  • Lorazepam is a short-acting benzodiazepine (half-life of 12–15 hours) which has a fast onset of action and works within 10 minutes when administered sublingually. A starting dose of 500 micrograms sublingually may be given 4–6 hourly as needed.
  • Diazepam is a medium- to long-acting benzodiazepine with a half-life of 20–100 hours. A starting dose of 2–5 mg at bedtime may be given if there is continuous distressing anxiety.
  • Midazolam has a half-life of 2–5 hours which may be prolonged in people over 60 years of age. A starting dose of midazolam 2 mg subcutaneously given 4–6 hourly as needed may be useful for intractable breathlessness, if the oral or sublingual routes are not appropriate or tolerated.

Adverse effects

Potential adverse effects of benzodiazepines include the following. If there are persistent adverse effects, consider switching to an alternative benzodiazepine. Seek specialist advice if needed.

• Alertness decreased; anxiety; ataxia (more common in elderly); confusion (more common in elderly); depression; dizziness; drowsiness; dysarthria; fatigue; headache; hypotension; mood altered; muscle weakness; nausea; respiratory depression (particularly with high dose and intravenous use); sleep disorders; tremor; vision disorders; withdrawal syndrome.
• May cause drowsiness, impair judgement and increase reaction time, and so affect ability to drive or perform skilled tasks; effects of alcohol increased. The hangover effects of a night-time dose may impair performance on the following day. The Department for Transport (2014) publication Drug driving: guidance for healthcare professionals may be helpful.

[BNF, 2026]