Dyspnea: Assessment and treatment

Dyspnea, or breathlessness, is a very distressing and prevalent symptom for patients with terminal cancer. Assessment for this symptom is generally poorly conducted, and it is therefore frequently underdiagnosed and inadequately treated. This paper outlines several tools found in the literature that may be beneficial to us in assessing this symptom. There will also be a full report on the application of these scales as used in a hospital audit of all in-patients at the Queensway- Carleton Hospital in Nepean, Ontario, during the month of June 1995. Results of this hospital audit revealed that 33% of all patients in hospital complained of some degree of breathlessness on both the Linear Analogue Scale Assessment and the Borg Scale. However, when the Modified Medical Research Council Dyspnea Scale and the Oxygen Cost Diagram Scale were used 75.6% and 78.5% respectively now complained of significant shortness of breath interfering with their quality of life. We also found that patients experiencing dyspnea were 39% more likely to complain of other symptoms than patients with no shortness of breath and were 55% more likely to report other symptoms as being severe. A short section will also outline the medical and nursing management of dyspnea and will include a discussion of possibly correcting the cause of breathlessness, environmental issues, and pharmacological management of dyspnea. It is advocated that during the terminal stages of a patient's illness, when assessment tools are no longer feasible or possible, that a breathing comfortably approach be adopted for patient and family comfort.Presented as an invited lecture at the 8th International Symposium: Supportive Care in Cancer, Toronto, Canada, 19–22 June 1996     

Dyspnea

When evaluating a dyspneic patient in the office, a quick initial assessment of the airway, breathing, and circulation, while gathering a brief history and focused physical examination are necessary. Most often, an acute cardiopulmonary disorder, such as CHF, cardiac ischemia, pneumonia, asthma, or COPD exacerbation, can be identified and treated. Stable patients who improve can be sent home, but those in acute distress with unstable or impending unstable conditions need to be transferred emergently to definitive care. Because of the difficult logistics involved in attempting to work up an outpatient for new onset of SOB, some patients will need to be transferred to the nearest ED for a definitive diagnosis.     

Dyspnea during thalidomide treatment for advanced ovarian cancer

OBJECTIVE: To detail the dyspnea encountered in women receiving thalidomide as therapy for advanced ovarian cancer. CASE SUMMARIES: Eight of 18 (44%) patients with recurrent ovarian cancer developed dyspnea while receiving thalidomide 200 mg daily as part of a prospective Phase II study. Dyspnea was evaluated with pulse oximetry, chest X-ray and, if indicated, spiral computed tomography scan. Four patients had abnormal chest X-ray findings (1 pleural effusion, 1 pneumonia, 2 mild congestive heart failure), and one of these patients also had a pulmonary embolus. The other 4 patients had no objective test findings to explain their dyspnea. Five patients had resolution of symptoms when thalidomide was discontinued and, when the drug was resumed at a 50% dose reduction, experienced no further shortness of breath. DISCUSSION: While dyspnea in association with thalidomide has not previously been reported as a common adverse event, it was a frequent complaint of patients receiving this drug as part of a Phase II study. Comorbid conditions causing dyspnea were evaluated since they are common in this patient population; however, half of our patients had no objective evidence of such conditions. The Naranjo probability scale indicated a probable relationship between dyspnea and thalidomide therapy in the patients with no objective evidence of comorbidity. We advocate discontinuation of thalidomide until symptoms have resolved, at which time reintroduction of thalidomide at a reduced dose may be considered. CONCLUSIONS: Patients receiving thalidomide may develop dyspnea as an adverse effect of the drug. In selected patients, thalidomide may be safely reintroduced once symptoms resolve.     

Dyspnea

Patients experiencing a dyspnea exacerbation will often report feeling smothered or suffocated. This highly distressing, prevalent, multidimensional symptom is the chief complaint signifying pulmonary dysregulation. Increasing dyspnea intensity heralds the onset of respiratory failure, leading to hospitalization and/or admission to the intensive care unit (ICU). Dyspnea can only be known from the patient's report about the personal experience. However, many ICU patients experience temporary or permanent cognitive impairment precluding a symptom report; thus, a behavioral assessment is indicated. Comprehensive dyspnea assessment informs subsequent treatment. Conventional treatment of dyspnea includes reducing or eliminating the underlying cause, mechanical ventilation, supplemental oxygen, balancing rest with activity, and positioning. Opioids and benzodiazepines reduce dyspnea and the associated fear or anxiety and are most often used to maintain ventilator-patient synchrony, in terminal illness or during the withdrawal of mechanical ventilation. Inhaled furosemide is under investigation as an alternative to opioids. The focus of this article is to provide an evidence-based approach to nursing assessment and management of dyspnea.     

Dyspnea

A multidimensional model of dyspnea that includes sensation, perception, distress, response, and reporting components is presented. Assessment tools currently available are evaluated as are recent research findings for pharmacologic, oxygen, physical, and psychologic treatments. This article concludes by suggesting a role for the nurse in dyspnea amelioration.     

Dyspnea in cancer patients

'Dyspnea' is a subjective symptom defined as "an uncomfortable sensation of breathing". It should be distinguished from 'respiratory failure' defined as hypoxia. It is important to know that dyspnea is also related to psychological distress such as anxiety. The important points of management of dyspnea are described here; (1)Treat the underlying causes (e.g. antibiotics for pneumonia, blood transfusion for anemia), (2) pharmacological interventions such as morphine and anxiolytics, (3) non-pharmacological interventions such as oxygen, respiratory rehabilitation and relaxation. Since dyspnea in cancer patients has multidimensional aspects, interdisciplinary team approach for the symptom management is important.     

Dyspnea review for the palliative care professional: treatment goals and therapeutic options

Although dyspnea is frequently encountered in the palliative care setting, its optimal management remains uncertain. Clinical approaches begin with accurate assessment, as delineated in part one of this two-part series. Comprehensive dyspnea assessment, which encompasses the physical, emotional, social, and spiritual aspects of this complex symptom, guide the clinician in choosing therapeutic approaches herein presented as part two. Global management of dyspnea is appropriate both as complementary to disease-targeted treatments that target the underlying etiology, and as the sole focus when the symptom has become intractable, disease is maximally treated, and goals of care shift to comfort and quality of life. In this setting, current evidence supports the use of oral or parenteral opioids as the mainstay of dyspnea management, and of inhaled furosemide and anxiolytics as adjuncts. Nonpharmacologic interventions such as acupuncture and pulmonary rehabilitation have potential effectiveness, although further research is needed, and use of a simple fan warrants consideration given its potential benefit and minimal burden and cost.