Pippa Hall, MD, CCFP, MEd, FCFP, Assistant Professor, Department of Family Medicine, Program Director, Palliative Medicine Residency Program, University of Ottawa, SCO Health Service, Ottawa, ON.

Dyspnea is experienced by patients with advanced lung and heart disease and cancer. When conventional therapy has been optimized, dyspnea can be managed in a systematic, evidence-based approach, involving an inter-professional team. The patient and family contribute to optimal care plan development. Non-pharmacological approaches are important. Compressed air, oxygen and steroids may be helpful. Strong evidence supports the use of opioids, while some evidence supports the use of neuroleptics and anxiolytics. Escalating distress in the last hours of life may necessitate interventions that improve dyspnea control at the price of deeper sedation. If upper airway congestion develops, anticholinergics are recommended.
Key words: dyspnea, terminal care, refractory symptom, palliation.

Introduction
Dyspnea, defined as a subjective sense of shortness of breath or uncomfortable breathing, is a common symptom in patients with advanced lung and heart disease, as well as in patients with cancer.^1,2 Dyspnea has been reported to be as distressing a symptom as pain, with patients often feeling they are about to die from suffocation or choking.