| Article Access Statistics|
| Viewed||5113 |
| Printed||255 |
| Emailed||1 |
| PDF Downloaded||208 |
| Comments ||[Add] |
| Cited by others ||2 |
Click on image for details.
|Year : 2011 | Volume
| Issue : 4 | Page : 29-32
Recent advances in the management of breathlessness
Flinders University, Adelaide, Australia
|Date of Web Publication||28-Jan-2011|
Flinders University, Adelaide
Source of Support: None, Conflict of Interest: None
Breathlessness is a frightening symptom to both witness and experience. It is common in many conditions, especially in the palliative setting, profoundly affecting the quality of the person's life. The purpose of this article is to provide an overview of the recent advances in the management of breathlessness in the areas of, knowledge of disease trajectories, assessment, pharmacological and non-pharmacological interventions and the use of oxygen.
Keywords: Refractory breathlessness, Supportive care, Palliative care
|How to cite this article:|
Breaden K. Recent advances in the management of breathlessness. Indian J Palliat Care 2011;17, Suppl S1:29-32
| » Introduction|| |
Breathlessness is a complex experience of the mind and the body.
Expanding on the above quote, the sensation of breathlessness involves not just the body and mind, but the spirit as well. It is a frightening symptom to both witness and experience and is common in many conditions, especially in the palliative setting, profoundly affecting the quality of the person's life. Every activity, from showering to eating is an enormous struggle, leading to a contracted world for the sufferer and his or her family. Anxiety and fear are constant companions. 
Breathlessness has been variably defined as an unpleasant awareness of breathing, or an uncomfortable sensation.  There are many causes of breathlessness, too numerous to mention here, but they all fall into one of two categories; cancer related or noncancer related. The incidence of breathlessness ranges from 21% to 90% in cancer patients, depending on the severity and type of cancer involved.  In those people who suffer from heart failure or lung disease, the incidence is approximately 65% and 90%, respectively.  Breathlessness occurs nearly universally as death approaches. 
The purpose of this paper is to provide an overview of the recent advances in the management of breathlessness. Before outlining these interventions, it is helpful to examine aspects of the breathlessness trajectory as it relates to the type of disease involved.
| » Different Trajectories|| |
There is a difference in the trajectories of breathlessness in terms of prevalence and severity depending on the type of diagnosis. People with chronic obstructive pulmonary disease (COPD) often have slowly developing breathlessness over a number of years made worse by exertion until it is present even at rest. The slow decline is interspersed with exacerbations of severe breathlessness which may require admission to hospital; death may occur unpredictably.  In the final stages of this disease, breathlessness is the most frequently reported symptom.  One large Australian study (n = 5862) exploring the perception of breathlessness in the last three months of life found that this symptom was more severe in people with a non-cancer diagnosis (mainly COPD) and the level of severity was constant over the three-month period prior to death despite treatment. In contrast, people with cancer had initially lower levels of breathlessness than the non cancer group, but this level increased during the last 10 days of life.  In addition, in the cancer setting, the presence of breathlessness indicated a shorter prognosis and often developed rapidly  This information has implication for resource allocation and service planning-if a palliative service only admits those patients with cancer, then it is missing out on seeing many people with distressing levels of breathlessness. People with nonmalignant or malignant associated breathlessness have similar level of need.
| » Assessment|| |
During the assessment of breathlessness, it is important to ask why-why this symptom at this time? The Flinders University teaching team has named this clinical decision and assessment framework, the "Why Framework" giving priority to the possibility of potentially reversible symptoms. Within this framework, there are two important guiding questions:
- Is this an expected or unexpected problem? and,
- Can (and should) we do something about it? This decision making requires an understanding and knowledge of the disease trajectory, differential diagnoses and reversible and nonreversible causes. 
Physiological indicators such as arterial blood gases, oxygen saturation, spirometry or respiratory rate do not necessarily correlate with the degree of breathlessness; they are not direct measures. , Therefore, other assessment methods are required. As it is a subjective experience, patient self-report is vital in assessment-not simply staff report. A visual analog scale is well suited for measuring the intensity of the symptom  as is the Borg scale.  Alternatively, a quality of life measurement might be more appropriate for an holistic assessment, including the impact that the breathlessness has on a person's physical, emotional, and social functioning. 
In spite of our best efforts to manage the reversible causes, for many people breathlessness remains to exist. Breathless is then considered to have become intractable, i.e., It has become refractory.
Recent advances in the management of refractory breathlessness
The treatment of breathlessness is complex. It depends on the underlying causes and the potential to reverse the reversible. Management requires, if possible, a multidisciplinary team involvement and needs to focus on the following: 
- Address and relieve discomfort and distress of patient and their carers; and
- Reverse or treat the disease process if possible, and appropriate.
In order to accomplish these aims, current evidence highlights the following pharmacological and nonpharmacological strategies in the management of refractory breathlessness.
- Opioids-either oral or parenteral-are now considered to be the gold standard in reducing ventilatory demand.  A slow release preparation of morphine has been found to be beneficial.  The opioid dose will depend on whether the patient is opioid-naive or not. The patient subpopulation that will benefit most from this intervention is still being investigated.  There is little or no evidence for the use of nebulized opioids in the management of breathlessness.  However, inhaled frusemide has shown promise in some preliminary studies. 
- Anxiolytics may assist in the anxiety component of breathlessness. However, these may be poorly tolerated in some patients, especially in those with liver failure.  Benzodiazepines such as oxazepam have a shorter half-life and, therefore, less sedating effects than some other preparations.  However, newer evidence from a recent Cochrane review has found that benzodiazepines did not improve breathlessness in people with COPD or advanced cancer, yet they may have a role to play when other means have failed.  The use of sedatives in the management of breathlessness requires careful consideration and more research is needed in this area.  Phenothiazines may also be useful in treating anxiety associated with breathlessness. 
- Long acting beta agonists may be beneficial in breathlessness due to COPD in reducing the work of breathing. , Bronchodilators help in relaxing muscles and improving muscle tone in the airways. The correct technique and the use of a spacer are vital to ensure that the full dose reaches the airways. 
The use of oxygen
The use of oxygen has been shown to be no better than room air administered through nasal cannulae at 2 l/min in patients (especially in people with cancer) who are mildly or non-hypoxic, i.e., paO 2 >55 mgHg. ,
A trial of 3-4 days should be sufficient to show whether there will be a benefit or not in its application.
The nonpharmacological methods outlined below will not suit every patient. The key is to tailor interventions to the individual so that they are congruent with their values and beliefs concerning health and illness. Many of the following strategies can be nurse-led.
- Listen to the patients' experience and avoid telling them to just ''calm down''. 
- Fans/open windows/cold washers on the face are often helpful in reducing the sensation of breathlessness. The effect is thought to be due to the stimulation of the second and third branches of the trigeminal nerve. 
- There does seem to be a relationship between anxiety and breathlessness, however, which one comes first is difficult to tell. Strategies such as relaxation training and distraction do seem to help as do cognitive behavioral therapies. However, such strategies need to be introduced early in the disease trajectory as their introduction in the last days of life is seldom appropriate when significant fatigue may also be present. 
- The effectiveness of physical conditioning has been shown to be useful in COPD patients, and in those with cancer.  We also know that taking to one's bed results in a worsening of breathlessness.
- Acupuncture may be beneficial in people with COPD. There has been some preliminary research into this therapy. Lung function and exercise tolerance does seem to improve after acupuncture. , The reduction in breathlessness is thought to be due to the release of endogenous opioids.  More research is needed in this area.
- Advanced planning in the event of an acute exacerbation is vital and conversations regarding where the person wants to be cared for in such an event needs to be documented. 
- Controlled breathing exercises and techniques such as an upright leaning forward position and pursed lip breathing are also beneficial. 
- Chest wall vibration, neuroelectrical muscle stimulation, walking aides, and breathing training were found to be effective in reducing breathlessness in a recently conducted systematic review. 
Many of the above strategies are not necessarily new, yet research evidenced is building in several of these areas to underpin what has been used for decades in the management of refractory breathlessness. It does seem, however, that psychological support, breathing exercises and the development of coping strategies can assist patients in the management of refractory breathlessness. 
| » Conclusion|| |
Breathlessness is a common symptom in palliative care and its causes are multiple. It is a complex symptom to manage and needs the input from a multidisciplinary team. There is growing evidence for the use of both pharmacological and nonpharmacological interventions; however, further research is needed to firmly establish the best way forward in treating refractory breathlessness.
| » Acknowledgments|| |
I would like to thank Professor Currow and Dr. Meera Agar for reviewing a draft of this paper.
| » References|| |
|1.||Booth S, Moosavi SH, Higginson I. The etiology and management of intractable breathlessness in patients with advanced cancer: A systematic review of pharmacological therapy. Nat Clin Pract Oncol 2008;5:90-100. |
|2.||Corner J, Plant H, A'Hern R, Bailey C. Non-pharmacological intervention for breathlessness in lung cancer. Palliat Med 1996;10:299-305. |
|3.||Chan KS, Tse D, Sham M, Thorsen AB. Palliative medicine in malignant respiratory diseases, in Oxford Textbook of Palliative Medicine. In: Hanks G, Cherny, N., Christakis, NA., Fallon M., Kaasa S & Portenoy R. Oxford, New York: Oxford University Press; 2010; p. 1108. |
|4.||Muers M, Round.C. Palliation of symptoms in non-small cell lung cancer: A study by Yorkshire Regional Cancer Organisation Thoracic group. Thorax 1993;48:339-43. |
|5.||Lynn J, Teno JM, Phillips RS, Wu AW, Desbiens N, Harrold J, et al. Perceptions by family members of the dying experience of older and seriously ill patients. Ann Intern Med 1997;126:97-106. |
|6.||Ripamonti C. Management of dyspnea in advanced cancer patients. Support Care Cancer 1999;7:233-43. |
|7.||Leach RM. Palliative care in non-malignant, end-stage respiratory disease, in Oxford Textbook of Palliative Medicine. In: Hanks G, Cherny, N., Christakis, NA., Fallon M., Kaasa S & Portenoy R. Oxford, New York: Oxford University Press; 2010. p. 1231-56. |
|8.||The SUPPORT principle investigators. A controlled trial to improve care for seriously ill hospitalised patients. The study to understand prognosis and preference for outcomes and risks of treatment (SUPPORT). J Am Med Assoc 1995;274: 1591-8. |
|9.||Currow DC, Smith J, Davidson PM, Newton PJ, Agar MR, Abernethy AP. Do the trajectories of dyspnoea differ in prevalence and intensity by diagnosis at the end of life? A consecutive cohort study. J Pain Symptom Manage 2010;39:680-90. |
|10.||Improving research methodology in breathlessness: a meeting convened by the MRC clinical trials unit and the Cicely Saunders Foundation. Palliat Med 2006;20:219-20. |
|11.||Currow D, Clarke K. Emergencies in palliative and supportive care. Oxford: Oxford University Press; 2006. |
|12.||Thomas J, Gunten CV. Clinical management of dyspnea. Lancet Oncol 2002;3:223-8. |
|13.||Gift A, Narsavage G. Validity of the numeric rating scale as a measure of dyspnoea. Am J Crit Care 1998;7:200-4. |
|14.||Borg G. Psychophysical bases of perceived exertion. Med Sci Sports Exerc 1982;14:377-81. |
|15.|| Abernethy AP, Currow DC, Frith P, Fazekas BS, McHugh A, Bui C. Randomised, double blind, placebo controlled crossover trial of sustained release morphine for the management of refractory dyspnoea. BMJ 2003;327:523-8. |
|16.||Watson M, Lucas C, Hoy A & Wells J. Oxford Handbook of Palliative Care. 2nd ed. Oxford, New York: Oxford University Press; 2009. |
|17.|| Jennings AL, Davies AN, Higgins JP, Gibbs JS, Broadley KE. A systematic review of the use of opioids in the management of dyspnoea. Thorax 2002;57:939-44. |
|18.||Currow DC, Plummer J, Frith P, Abernethy AP. Can we predict which patients with refractory dyspnea will respond to opioids. J Palliat Med 2007;10:1031-6. |
|19.||Currow DC, Abernethy AP. Pharmacological management of dyspnoea. Curr Opin Support Palliat Care 2007;1:96-101. |
|20.|| Newton PJ, Davidson PM, Macdonald P, Ollerton R, Krum H. Nebulised furosemide for the management of dyspnea: Does the evidence support its use? J Pain and Symptom Manage 2008;36:424-41. |
|21.||Chan KS, Tse D, Sham M, Thorsen AB. Palliative medicine in malignant respiratory diseases, in Oxford Textbook of Palliative Medicine. In: Hanks G, Cherny, N., Christakis, NA., Fallon M., Kaasa S & Portenoy R. Oxford, New York: Oxford University Press; 2010; p. 1107-44. |
|22.|| Simon ST, Higginson IJ, Booth S, Harding R, Bausewein C. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev 2010;1: CD007354. |
|23.||Davidson P, Currow D. Management of refractory dyspnoea: evidence-based interventions. Cancer Forum 2010;34:1-5. |
|24.||Abernathy A, Wheeler J, Currow D. Common approaches to dyspnoea management in advanced life-limiting illness. Curr Opin Support Palliat Care 2010;4: 53-5. |
|25.|| Uronis HE, Currow DC, McCrory DC, Samsa GP, Abernethy AP. Oxygen for relief of dyspnoea in mildly- or non-hypoxaemic patients with cancer: A systematic review and meta-analysis. Br J Cancer 2008;98:294-349. |
|26.||Qaseem A, Snow V, Shekelle P, Casey DE Jr, Cross JT Jr, Owens DK; et al. Evidence-based interventions to improve the palliative care of pain, dyspnea, and depression at the end of life: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2008;148:141-6. |
|27.||Jobst K, Chen JH, McPherson K, Arrowsmith J, Brown V, Efthimiou J, et al. Controlled trial of acupuncture for disabling breathlessness. Lancet 1986;2:1416-9. |
|28.|| Neumeister W, Kuhlemann H, Bauer T, Krause S, Schultze-Werninghaus G, Rasche K. Effect of acupuncture on quality of life, mouth occlusion pressures and lung function in COPD. Med Klin 1999;94:106-9. |
|29.||Filshie J, Thompson JW. Acupuncture, in Oxford Textbook of Palliative Medicine. In: Hanks G, Hanks G, Cherny, N., Christakis, NA., Fallon M., Kaasa S & Portenoy R. Oxford, New York: Oxford University Press; 2010. p. 768-84. |
|30.|| Trappenburg JC, Koevoets L, de Weert-van Oene GH, Monninkhof EM, Bourbeau J, Troosters T, et al. Action plan to enhance self-management and early detection of exacerbations in COPD patients: A multicentre RCT. BMC Pulm Med 2009;29:9-52. |
|31.||Bausewein C, Booth S, Gysels M, Higginson I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev 2008;16:CD005623. |
|32.||Bredin M, Corner J, Krishnasamy M, Plant H, Bailey C, A'Hern R. Multicentre randomised controlled trial of nursing intervention for breathlessness in patients with lung cancer. BMJ 1999;318: 901-4. |
|This article has been cited by|
||Dyspnea Management in Early-Stage Lung Cancer
| ||Anna Cathy Williams,Marcia Grant,Brian Tiep,Jae Y. Kim,Jennifer Hayter |
| ||Journal of Hospice & Palliative Nursing. 2012; 14(5): 332 |
|[Pubmed] | [DOI]|
||Dyspnea management in early-stage lung cancer: A palliative perspective
| ||Williams, A.C. and Grant, M. and Tiep, B. and Kim, J.Y. and Hayter, J. |
| ||Journal of Hospice and Palliative Nursing. 2012; 14(5): 332-340 |