Breathlessness

The following information is for patients, carers and health care professionals to understand more about how the lungs function and that there can be many causes of breathlessness. If you suffer breathlessness your treatment team will assess and treat you dependant on what they know of your condition(s) and what might be causing your breathlessness.

Understanding the lungs and breathlessness

To make it easier to understand breathlessness it may help to understand the way lungs work.

People have two lungs; one on each side of the chest. When we breathe in, air passes from our nose or mouth through the windpipe (trachea), which divides into two tubes (airways), one going to each lung. These are known as the right and left bronchus. They divide to form smaller tubes called bronchioles, which carry air through the lungs.

At the end of the bronchioles are millions of tiny air sacs called alveoli. In the alveoli, oxygen is absorbed from the air we breathe in and passes into the bloodstream to be circulated around the body.

Carbon dioxide is a waste gas that needs to be removed from the body. It passes from the bloodstream into the alveoli and is then breathed out by the lungs.

When you breathe in the muscles of respiration move the lungs down and outwards to expand the lungs and when you breathe in the lungs go back by moving up and inwards. Normally in good health the lungs sit within the rib cage and fit snugly. The lung and the inside of the rib cage are both covered by a thin membrane or film called the pleura. The space between the two layers of pleura is called the pleural cavity or pleural space. Usually the pleural space contains about two teaspoons of fluid, this helps to lubricate the lung, so that it can slide easily within the rib cage.

Just below your lungs is a sheet of muscle called the diaphragm. The diaphragm and the muscles of the lower chest are the main breathing muscles used when you are relaxed.

During heavy exercise, the muscles in your shoulders and upper chest can also help with breathing. These muscles are not designed to work for long periods of time and tire easily.

Figures 1 & 2. The lungs and surrounding structures

The causes and management of breathlessness

This section of the website will discuss the causes (why do you feel breathless) and how breathlessness can be managed/ improved. There are likely to be a number of health care professionals involved in your care and involved in helping to manage your breathlessness, particularly as breathlessness can have more than one cause in any one individual. Breathlessness, or feeling short of breath, is also known as dyspnoea and can have many causes when someone has lung cancer.  As there are so many potential causes, and any one individual may have more than one cause for their breathlessness it is necessary to take a full history of the breathlessness experience, for example when it occurs, what makes it better or worse and using a scale to indicate level of breathlessness. A thorough evaluation is important to ensure that correctable causes are addressed and that the appropriate drug therapies are optimised.

The following are the commonest reasons for breathlessness, however, this list is not exhaustive, please click on the section(s) you would like to read more about:

ANXIETY AND PANIC

Anxiety and panic are common causes of feeling breathless. Some patients with breathlessness experience respiratory panic attacks. There are a number of ways to help control the sensation of breathlessness and panic using both pharmacological management (medications) and non-pharmacological management (training on coping strategies on how to manage your breathlessness). It is also essential that any reversible causes of breathlessness are managed, many of these points are discussed later in this section, but these include such things as treating infection, treating anaemia, drainage of pleural effusions, treatment of pulmonary emboli and treatment of underlying conditions that may be impacting on breathlessness, for example, COPD/ asthma/ cardiac failure, etc. Further information regarding pharmacological management and non-pharmacological management of breathlessness to improve anxiety and panic will now be discussed:-

PHARMACOLOGICAL MANAGEMENT(i.e. using medicines)  - Optimising drug therapies (i.e. getting you on the right medicines, at the right doses) for non-lung cancer conditions, for example COPD and heart failure, this means ensuring that these conditions are being appropriately treated to minimise their impact on breathlessness. Drug therapies that can be used specifically for breathlessness in lung cancer include - oramorph, lorazepam, steroids, oxygen therapy, and nebulised therapies. Any or all of these drug therapies can be tried to assess if they ease breathlessness, which can lessen anxiety and help to prevent respiratory panic attacks. Your doctor or specialist team will discuss whether these drugs are suitable for you to try. Here is some information about each drug:-

Oramorph - this is a liquid morphine preparation that can be very effective in easing the sensation of breathlessness. If you are currently on morphine your GP, or specialist team, may be able to advise you of dose changes that can help. If you are not currently on morphine then this can be commenced for a trial period and reassessed.

Lorazepam - can help to reduce anxiety associated with breathlessness. Lorazepam is relatively short acting, as compared with diazepam which can reduce anxiety but is in the system for a longer period of time. Lorazepam is commonly used in helping to manage breathlessness at a dose of 500 micrograms as required.

Steroids (also known as corticosteroids) - can help to reduce inflammation in the airways of the lungs which can help to reduce breathlessness, the most commonly used steroid tablets are dexamethasone and prednisolone. Steroids are not suitable for everyone as they can cause a number of side-effects, your GP or specialist team will assess if a trial of steroids is appropriate for you.

Oxygen therapy - People with breathlessness commonly believe that oxygen therapy will help, this is not always the case. Using a fan or sitting by an open window with cool air blowing on to your face may give the same benefit.

A trial of oxygen, via mask or nasal prongs, may be the only way to determine if you will benefit from this therapy. It should only be used if you are breathless at rest or perhaps for a short period (e.g. 10 minutes) before or after physical activity that causes breathlessness. Your GP can prescribe oxygen cylinders for use at home and your local pharmacy will arrange delivery, not all pharmacies deal with oxygen therapy delivery and installation, your GP's surgery will guide you regarding this.

Saline nebules - Sterile salt water can be given through a nebuliser to loosen sticky phlegm, thus allowing your airways to be more easily cleared.

Ventolin nebules - Ventolin is a bronchodilator drug which widens the air passages and increase air flow and can be given as an inhaler or through a nebuliser.

NON-PHARMACOLOGICAL MANAGEMENT (not using medicines) - There are a number of ways of trying to help improve breathlessness without the use of medications, however, some individuals will require medications and the following strategies to get the maximum benefit with their breathing. Others may only require the following strategies. Which include: - exploring the individual's understanding of breathlessness; breathing retraining and control; coping strategies, including relaxation and anxiety management. Simple breathing exercises can be taught and practised regularly to help you to learn to breathe efficiently and in a controlled way. Also pacing yourself, prioritising activities and planning what you do each day can help to reduce the distress of breathlessness and make your breathing easier. There are a number of websites giving very helpful information regarding managing breathlessness, however, a simple breathing technique will now be identified, and there are links later in this chapter to other useful sites.

Breathing techniques

Get into a comfortable position

When you feel breathless, it can help to get in a comfortable position that allows your shoulders and upper chest to relax and lets your diaphragm and tummy expand. This could be:

• sitting and leaning slightly forward with your forearms resting on your thighs
• sitting and leaning forward with your head resting on several pillows stacked on a table, and resting your arms on the table on either side of the pillows
• standing and leaning against a wall
• standing and leaning forward on to a secure surface.

Breathe gently

Once you're in a comfortable position, try breathing in through your nose and out gently through your mouth. Some people find it helpful to breathe out through pursed lips - as if blowing out a candle.

Focus on your breathing and count your breath in for three counts and out for four. If you find breathing in through your nose difficult, you can breathe through your mouth instead.

Controlled breathing

Breathlessness can cause you to breathe with the upper chest and shoulder muscles in a fast and shallow way. This can use up a lot of energy and tire you out.

An important part of managing breathlessness is learning a technique called controlled breathing, which uses your diaphragm and lower chest muscles. Controlled breathing can help you to relax and breathe more gently and effectively using lower chest breathing.

Practise these exercises when you're not feeling too short of breath. You'll then become familiar with them and can use them when you're more breathless.

1. Sit comfortably with your neck, shoulders and back well supported - an upright chair with armrests is ideal.
2. Relax your shoulders.
3. Place your hands on your tummy, just below your ribcage.
4. Give a little cough; the muscle you feel under your hand is your diaphragm.
5. As you breathe in, you'll feel your hands rising and being pushed out by your diaphragm and tummy muscles.
6. As you breathe out, your hands will sink down and in. Try to get a sense of breathing from around the waist rather than from your upper chest, and feel your lungs expand as more air is able to get in.

It may help to sit sideways to a mirror so you can see that your lower chest is moving.

Relax your shoulders and upper chest muscles

When you breathe out, feel your shoulders and upper chest relax. As you breathe in gently, keep your shoulders relaxed. If this is hard to do, ask someone to press down gently on your shoulders to help relieve some of the tension.

Breathe in slowly and out gently, feeling your upper chest muscles relax more and more with each breath out.

It can take a bit of time to get used to these exercises. Try not to force the exercises or expect instant results. Aim for a gradual change from breathlessness to controlled breathing.

Complementary therapies that help you relax may help you manage your breathlessness.

There are a number of different resources available to help including a "living with breathlessness" booklet http://be.macmillan.org.uk/Downloads/MAC11132Livingwithbreathlessness.pdf and a "Relax & Breathe" CD. These are available free of charge from Macmillan Cancer Backup, alternatively your lung cancer nurse, district nurse or palliative care nurse can access these for you. Your lung cancer nurse or palliative care nurse may be able to offer a programme on "living with breathlessness" please discuss with your specialists locally.  This link will take you to the Macmillan Cancerbackup site for further information, or to order the "Relax & Breathe CD". http://www.macmillan.org.uk/Cancerinformation/Livingwithandaftercancer/Symptomssideeffects/Breathlessness/Managingbreathlessness.aspx

The Roy Castle Foundation also have helpful information on learning to control your breathing and breathing exercises including helpful pictures on useful positions for breathing exercises:http://www.roycastle.org/content/LeftNavigation/LungCancer/LivingWithLungCancer/Copingwithbreathlessness/Breathingexercises.aspx

Pulmonary rehabilitation can be helpful for some patients living with, or who have had curative treatment for their, lung cancer. Information regarding this is available from the British Lung Foundation or by speaking to specialists locally.

PLEURAL EFFUSION

This is an accumulation of fluid produced by the lung cancer or mesothelioma tumour in the space between the two layers of the pleural membrane. In healthy individuals there is normally a very small amount of pleural fluid, about two teaspoons of fluid. Lung cancers and mesotheliomas can cause problems with the production and re-absorption of fluid, and thereby fluid can build up within the pleural space. Breathlessness is caused by fluid pressing on the lung preventing it from expanding fully, so that you are unable to take a deep breath.

A pleural effusion is confirmed by chest x-ray. The treatment of a pleural effusion has two main aims: the first is to remove as much of the fluid as possible to enable the lung to re-expand; the second is to try to prevent the fluid from coming back. Removing pleural fluid is usually done by passing a thin tube between the ribs under local anaesthetic. This tube is called a chest drain, this chest drain is connected to a bottle to collect the fluid. It may take one or two days for the fluid to drain out. Unfortunately pleural effusions often recur and can become increasingly difficult to drain because the fluid tends to form in pockets (i.e. becomes ‘loculated') or becomes very sticky.

In order to prevent recurrent effusions the procedure of pleurodesis is performed. Pleurodesis is a method of making the two layers of the pleural membrane stick together which obliterates the space between them thus preventing the formation of further effusions. The procedure involves introducing an irritant material, usually a mixture of sterile talc and a solution of saline via a tube (either a chest drain or thoracoscope) into the space between the pleural layers (any fluid has to be drained first). This is sometimes aided by video-camera viewing of the inside of the chest - a VATS (video-assisted thoracoscopy) procedure. You may feel flu like symptoms for a few days after the talc has been put in, this is quite normal.

If pleural effusions continue to re-accumulate certain patients may be suitable for a permanent drain to be inserted, this is called a tunnelled indwelling pleural catheter.

Tunnelled Indwelling Pleural Catheter?

A tunnelled indwelling pleural catheter is a specially designed small tube to drain fluid from around your lungs easily and painlessly whenever it is needed. It avoids the need for repeated painful injections and chest tubes every time the fluid needs to be drained. The drainage can be performed either by you, your carer or by a district nurse, whichever is easier for you. The catheter is a soft flexible tube that is thinner than a pencil, which remains inside the chest and passes out through the skin. There is a valve on the outer end of the catheter to prevent fluid leaking out of the catheter.

Why Do I Need a Tunnelled Indwelling Pleural Catheter?

The pleural space consists of two thin membranes - one lining the lung and the other lining the chest wall. Between these layers there is usually a very small space which is almost dry. In your case fluid has collected in this space so that the lung cannot expand properly making you short of breath.

What Can Be Done to Help Me When This Happens?

Draining away the fluid helps relieve breathlessness for a time, but the fluid then often recollects making you short of breath again. Whilst it is possible to have repeated drainage of fluid in this way, it can be uncomfortable and means many trips to hospital. The indwelling catheter is a way of allowing fluid to be drained repeatedly without you having to come to the hospital to have repeated uncomfortable procedures.

How Is the Catheter Put in My Chest?

The tube will be put into your chest in a special procedure room. You will be asked to lie in a comfortable position by your doctor. Some sedative medication may be given through the needle in your arm to make you sleepy. This is not an anaesthetic and it is common for you to remember some of the procedure despite this sedative injection. Some people choose to have the procedure without a sedative injection.

Once you are resting comfortably, the skin will be cleaned with an antiseptic fluid. This often feels cold. A local anaesthetic is then injected into the skin to numb the area where the catheter will go. This can feel mildly uncomfortable but this pain passes off quickly. Your doctor will then make two small cuts in the numb area of skin and create a path for the catheter. This should not be painful although you may feel some pressure or tugging. One cut is for the catheter to pass through the skin, and the second is for it to be passed into the chest. The indwelling catheter is then gently positioned into the chest.

Will It Be Painful?

The local anaesthetic is used so that you do not feel the drain going in. Painkilling

medications are given to control any discomfort. At the end of the procedure the chest may feel bruised or sore for about a week. The medical staff will provide you with painkilling tablets to relieve this discomfort.

How Long Do I Have to Stay in Hospital?

The procedure may require a short stay in hospital or can sometimes be done as a day

case. If you have had a sedative for the procedure, someone will need to drive you home because it would be unsafe for you to drive for 24 hours. Similarly, you should not operate any dangerous machinery or enter into any legally binding agreements within 24 hours of having a sedative.

How Does the Drain Stay in Position?

Indwelling catheters are designed to be a permanent solution to the problem of pleural

fluid (although they can be removed if they are no longer needed). There is a soft band around the catheter under the skin, around which the skin heals and so keeps it securely in position and prevents it from falling out.

Two stitches will be put in when your catheter is inserted. One of these will be removed after 7 days. The other can stay in place indefinitely.

Who Will Drain the Fluid From My Tube Once it is in Place?

Drainage of the fluid is a straightforward procedure. There are a number of ways that this can be undertaken.

A trained member of staff will be able to teach you, a relative or friend, how to drain the fluid so that it can be done in the comfort of your own home. If however, you or your relative/friend are unable to drain the fluid, then arrangements will be made for a member of the hospital team or a district nurse to do this for you. If this is not possible arrangements can be made to have the fluid drained at the hospital.

All these arrangements will be made for you, so you will not need to organise any of this for yourself.

How Often Can I Drain Fluid and How Often Do I Need to Do This?

When your catheter is inserted most of the fluid from your chest will be removed at the same time. The rate the fluid comes back varies between people and some patients need daily drainage while others may require only weekly drainage or less.

You can drain fluid as often or as infrequently as needed. You will be advised how often this may need to be done.

Are There Any Risks With Indwelling Catheter Insertion?

In most cases the insertion of a chest catheter is a routine and safe procedure.

However, like all medical procedures, chest drains can cause some problems. All of these can be treated by your doctors and nurses;

• Most people get some discomfort from their indwelling catheter in the first week. You will be provided with painkilling medication to control this.
• Sometimes indwelling catheters can become infected but this is uncommon (affecting about one in 50 patients). Antibiotics are given at the time of insertion to prevent this. Your doctor will thoroughly clean the area before putting in the chest drain and you will be taught how to keep your catheter clean. You will be given telephone numbers of who to contact should you have any problems, for example, fever, increasing pain or redness around the catheter.
• Very rarely, during the insertion, the catheter may accidentally damage a blood vessel and cause bleeding. This probably only affects about one in 500 patients. Unfortunately, if it does happen it can be a serious problem which may require an operation to stop it. Very, very, rarely such bleeding can be fatal. Your doctors and nurses will do everything they can to avoid this problem.

Are There Any Risks Associated with Long Term Indwelling Catheter Use?

Generally indwelling catheters are well tolerated in the long term.

• The main risk is infection entering the chest down the tube. This risk is minimised by good catheter care and hygiene. You will be taught how to look after your catheter.
• Sometimes the cancer can affect the area around the indwelling catheter. Sometimes radiotherapy is used to help prevent this. Please let your doctors know if you develop a lump, or any pain, around your catheter. If this problem does develop your doctor will advise you on appropriate treatment.

Can I Wash and Shower Normally?

Initially after insertion there will be a dressing placed on the catheter and you will be asked to keep this dry until the stitch is removed seven days later. Providing the site is then clean and dry you will be able to bath and shower normally. After a month it is even possible to go swimming.

  

When Is the Indwelling Catheter Taken Out?

Indwelling catheters are designed to remain in position permanently. However, sometimes the fluid in the chest dries up and the catheter is no longer needed. In this situation the catheter can be removed as a day-case procedure.

INFECTION/PNEUMONIA

When you have a chest infection or pneumonia you feel breathless because the lungs can become inflamed and fluid can accumulate in the air filled spaces of the alveoli, which lessens the surface area for gas exchange.

When you have a lung cancer or mesothelioma, depending on the area of lung affected you may be more prone to infections. People tend to think that chest symptoms are always caused by their cancer, this is often not the case. If you notice a change in your phlegm and is dirty green in colour; if you start to bring up small amounts of blood; if you develop a temperature or pain when you breathe, then you should seek GP advice and assessment, as an antibiotic may be required to treat a chest infection or a pneumonia. A chest x-ray may be required, but is not always necessary, and hospital admission is not always necessary, as your GP may be able to treat you and monitor you.

LOSS OF CHEST WALL MOBILITY, LOSS OF VOLUME, PLEURAL THICKENING AND WEAKENED MUSCLES

Loss of chest wall mobility frequently occurs in mesothelioma, when the mesothelioma attaches itself to chest wall structures which makes them less flexible, this reduces the chest movements required in breathing. Similarly, extensive thickening and rigidity of the pleura may cause the lung to become ‘fixed'. Although there are no ways of resolving these problems with medication or surgery, patients may be helped by learning to control and pace their breathing.

Cancers in the lung can cause you to lose lung volume, as can treatments, such as surgery (where part of the lung, or a whole lung, has been removed) and radiotherapy (which can sometimes cause radiation-induced fibrosis - a stiffening of the lung). For some patients with lung cancer the muscles that help breathing can become weak making breathing more difficult.

PERICARDIAL EFFUSION

Involvement of the pericardium by tumour can lead to the development of a pericardial effusion. The pericardium is the sac surrounding the heart, extra fluid within this sac can causes pressure which compresses the heart, which can lead to abnormal heart functioning and subsequent breathlessness, tiredness, with possible chest tightness and dizziness. If this is a problem you are having your hospital specialist will assess if drainage of pericardial fluid is safe and appropriate.

INTRINSIC AND EXTRINSIC COMPRESSION WITHIN THE LUNGS AIRWAYS

Airway compression can cause you to feel breathless as the breathing tubes are narrowed. There are two main types of compression, intrinsic and extrinsic. Extrinsic compression means the cancer is externally compressing an airway from the outside of the airway pushing in, and intrinsic compression means there is cancer within the airway itself, which causes narrowing of the airway. There are a range of treatments to prevent or treat airway obstruction including conventional external beam radiotherapy, endobronchial surgical debulking of the cancer, stenting and endoscopic endobronchial treatments, e.g. stenting, photodynamic therapy, laser, electrocautery, brachytherapy and cryotherapy. Endobronchial therapies available are either a) used to debulk the cancer (brachytherapy, electrocautery, thermal laser ablation, and PDT) or b) used to maintain or re-establish airway patency (endobronchial stenting). Your respiratory physician will discuss endobronchial therapy options in more detail with you, if appropriate.

Table 1. Description of endobronchial treatments

Treatment	Description
Brachytherapy	A catheter is placed is placed bronchoscopically and this is used to deliver a radioactive source within or near an endobronchial cancer. This delivers high dose local irradiation
Electrocautery (diathermy)	High frequency electrical current is used which produces heat from tissue electrical resistance to destroy cancer cells.
Cryotherapy	Extreme cold is used to cause delayed local destruction of cancer tissue. It is applied in cycles of freezing and thawing, causing tissue necrosis
Thermal laser ablation	In laser therapy, the heat energy from laser light is used to coagulate and vaporise endobronchial cancer tissue.
PDT	In PDT a systemic photosensitiser which is selectively retained and concentrated in cancer cells is administered. Subsequent exposure to light of a particular wavelength induces cancer cell death
Airway stents	A number of airway stents are available for the palliation of dyspnoea. Tracheal and bronchial stents are commonly used in patients with endoluminal obstruction and extrinsic compression to maintain airway patency and integrity

Radiotherapy - external beam radiotherapy can be effective in the management of endobronchial obstruction, it is less invasive than other endobronchial treatments and effective in around two-thirds of patients. Radiotherapy is the use of high energy x-rays, the application of ionising radiation is given with the intent of causing damage to the DNA of cancer cells, causing cancer cell death. It is normally given in a series of short daily treatments in the radiotherapy department using equipment similar to a large x-ray machine. Palliative or a course of curative treatment can be given to the lung with the aim of helping breathlessness or preventing or slowing its onset. A word of caution, radiotherapy given in high doses can worsen breathlessness either temporarily or permanently. Your clinical or radiation oncologist will take in to account a number of factors (including your: fitness, lung function, symptoms, size and location of the lung cancer) before suggesting radiotherapy as a treatment option.

RADIATION PNEUMONITIS

Radiotherapy to the chest can cause inflammation of the lung (pneumonitis) which can lead to breathlessness. This tends to be a short term side-effects and can usually be improved by starting corticosteroid therapy, as a trial, and if this helps then this can be continued for some weeks if necessary. However, some people who have intensive radiotherapy to the chest can develop hardening and thickening (fibrosis - tissues which have been irradiated tend to become less elastic over time due to a diffuse scarring process) which can cause long term breathlessness.

PULMONARY LYMPHANGITIC CARCINOMATOSIS

This is diffuse tumour infiltration of the pulmonary lymphatics channels by tumour, various cancers can cause lymphangitic carcinomatosis. Lymphangitic carcinomatosis can result in breathlessness, changes can be seen on chest x-ray or CT scan. If your doctor has diagnosed this or suspects this they may start you on corticosteroids which can be helpful to improve breathlessness.

ANAEMIA

This means low levels of red blood cells in the blood and can be due to cancer, or it's treatment, including chemotherapy and radiotherapy, it may also be due to a non-cancer cause. If the level of red blood cells in the blood is low you may become very tired and breathless. Your doctor may recommend that you have a blood transfusion. There are a number of different types of anaemia and not all require treatment with a blood transfusion, your GP or specialist can discuss this further with you.

PULMONARY EMBOLISM

This can cause sudden breathlessness and pain when you breathe; if you have these symptoms contact your doctor immediately.

Pulmonary embolism (PE) develops when a blood-borne substance lodges in a branch of the pulmonary artery and obstructs the flow. Having cancer can increase your risk of PE. The symptoms of a PE may be sudden onset of breathlessness and sudden onset of acute chest pain, also, an increase in respiratory rate, for example rapid shallow breaths, or there may be a cough with blood streaked sputum. If a PE is suspected you will undergo further tests, and if the problem is thought to be serious or life threatening then the medical staff treating you may use clot busting drugs to dissolve the clot, there are risks involved with these therapies and are not suitable for everyone. Other treatment is to thin your blood, if this is safe to do so. The aim is to prevent further clots developing by way of anticoagulation, using either low molecular weight heparin which is administered by sub-cutaneous injection, or warfarin, (an oral anticoagulation drug). Your medical team will decide which of these anticoagulation treatments is the best for you, and for how long treatment should last, taking into consideration your PE diagnosis and your lung cancer and other relevant health issues.

LUNG COLLAPSE OR PARTIAL COLLAPSE

Cancers within the airways can cause a lung, lobe or part of a lobe of the lung to collapse. The right lung has 3 lobes and the left lung has 2 lobes, if these areas are closed off by a cancer, or other obstruction, the lung collapses. This causes a loss of surface area for gas exchange to take place and consequently individuals can suffer breathlessness. Treating the underlying cancer problem can help to allow the lung to re-inflate, however, when the lung has been collapsed for longer than a few weeks it can be difficult for the lung to re-inflate even if the blockage is removed or shrinks.

We have already discussed some of the treatments that can be used to help treat obstructions within the airway in the section - Extrinsic and Intrinsic compression

SMOKING

Smoking makes breathlessness worse and contributes to many actual and/or potential health problems. There are a number of medications that can be used to help with smoking cessation and there may also be specialist smoking cessation clinics in your local area to help quit smoking. Your GP’s surgery can advise you of these services. You may also wish to discuss smoking cessation with your lung specialist nurse.

OPTIMISE COPD TREATMENT, ETC.

It is not within the scope of this site to detail treatment for other illnesses that may be contributing to your breathlessness, your GP or specialist team will consider these causes and advise you appropriately.