King's College London

To deliver a step-change in the evidence-based management of breathlessness in palliative and end of life care.

The BETTER-B investigators conducted a randomized, double-blind, clinical trial in order to test the efficacy and cost-effectiveness of mirtazapine compared to a dummy drug in patients located in the UK, several European countries, Australia and New Zealand. The project also included an online survey, the production of a Europe-wide guide on the management of breathlessness in palliative and end-of-life care, and interviews with trial participants to understand their experiences.

From the BETTER-B online survey, we found wide variations in how breathlessness is managed. People received different levels of care based on where they were treated and the disease that they had. Some people may be seen by respiratory physicians, while others may be treated by palliative care physicians. Of those that responded, a sizeable number of respiratory and palliative care physicians often or always recommended antidepressants for patients with advanced respiratory diseases, even where there was no evidence of depression. This finding demonstrated the need for proper assessment of medicines.

Trial results

We enrolled 225 patients and 75 caregivers across the UK, Europe, Australia and New Zealand into the trial. The project engaged with patient-led groups and clinicians across the countries.

Key finding: the antidepressant mirtazapine does not alleviate severe breathlessness. Our findings raise questions about using medicines in a manner different from its licence.

There was no difference in severe breathlessness between those people taking mirtazapine and those taking placebo during the main period of the trial, of 56 days.

Similar results were found for other measures. This included a person’s quality of life, broader symptoms, anxiety and depression, and frequency of breathlessness episodes. There were no differences found up to six months after the start of the trial.

Read more about the trial results.

BETTER-B provides a wide-reaching impact by translating the trial and research results to produce recommendations, educational materials and clinical improvements for clinicians and policymakers in palliative, supportive, respiratory, primary and end-of-life care.

• Patient and Carer Brief (including translated versions on the European Lung Foundation website)
• Policy Brief (including translated versions on the European Lung Foundation website)
• Clinician Brief
• Practice Review: 'Pharmacological management of severe chronic breathlessness in adults with advanced life-limiting diseases'. The review provides practice recommendations on the safe use of pharmacological therapies for severe chronic breathlessness.

Some resources developed by our King's team that you may find helpful in breathlessness management are listed below:

Breathlessness Support Service Toolkit

• Patient education and advice about breathlessness
• Managing breathlessness
• Hand-held fan
• Positional techniques
• Distraction techniques
• Sleep hygiene
• Breathlessness poem

Free e-resources for professionals 

• E-BREATHE
• NHS England module on managing chronic breathlessness

For further information on managing breathlessness in advanced illness, please read the feature article 'Managing breathlessness in advanced illness'.