Easing Breathlessness in Patients With Advanced Cancer

The one intervention that seemed to be the most effective among all the methods analyzed was use of a fan. Holding a small handheld or electric fan up to a patient’s face for approximately 5 minutes can help alleviate some of the sensation of breathlessness and the anxiety it often produces.

This particular intervention makes sense to Dorothy Dulko, PhD, APRN-C, AOCNP, WHNP-BC, OB/GYN-NP, CCRP, a faculty member in the Master of Science in Nursing (MSN) program at Walden University. As an advanced oncology nurse practitioner, Dr Dulko has opened windows for patients and taken them to open-air terraces on hospital campuses. The cooler air and the sensation of air moving around them often reduces their anxiety levels and helps them breathe a little easier.

“The anxiety only makes the shortness of breath worse,” explains Dr Dulko.

Dr Gupta notes that the fan intervention was only deemed effective for 5-minute periods, as that’s the time length that’s been studied. Fan therapy may work for longer periods of time, but as of yet, there’s no research to confirm that.

The other inpatient intervention, bilevel ventilation, was found to be beneficial for dyspnea compared with using regular oxygen. However, Dr Gupta points out that it can be resource- and personnel-intensive, as it may require frequent monitoring to achieve.

That’s also a concern with some of the outpatient interventions. As the researchers noted, “Integrative medicine delivery requires trained staff and may not be covered by all payers.”

Julie Rasmussen, BSN, RN, an oncology nurse with Indiana University Health, likes the idea of having some interventions available that don’t involve medication. She would like to see more research that examines the potential effect of interventions such as meditation, yoga, and mindfulness, which may help patients cope with breathlessness, rather that requiring sedating medications that might put them to sleep.

“We want them to try to live as fulfilling a life as they can,” she says.

Blending Approaches to Tailor Interventions

Nurses have been able to turn to evidence-based guidelines from the Oncology Nursing Society⁴ to help guide them in making the best choices for treating breathlessness. Nurses have also been able to refer to current guidelines, such as those from the National Comprehensive Cancer Network,⁵ which recommend the use of both pharmacologic and nonpharmacologic interventions, including fans and bilevel ventilation.

Pharmacologic interventions may be appropriate for addressing dyspnea in patients with cancer in certain situations. For example, according to the ONS guidelines, immediate-release morphine has been shown to be helpful in reducing the sensation of dyspnea.⁴

Dr Dulko acknowledges that there is still a role for medication in the treatment of breathlessness in cancer patients. “It is not an all or nothing,” she says. “It is a multimodality approach.”

However, in this review, the research team concluded that the nonpharmacologic interventions may be the best place to start. “Given the limited success and potential harms associated with pharmacologic interventions, nonpharmacologic interventions should be considered as first-line treatment options for managing breathlessness,” they concluded. Ultimately, it may come down to the individual patient’s needs and wishes.

“As always, patient (and caregiver) preferences and tolerability must be recognized when evaluating the specific intervention to recommend,” the researchers wrote.

References

1. Dy SM, Lorenz KA, Naeim A, Sanati H, Walling A, Asch SM. Evidence-based recommendations for cancer fatigue, anorexia, depression, and dyspnea. J Clin Oncol. 2018;26(23):3886-3895. doi:10.1200/JCO.2007.15.9525
2. Gupta A, Sedhom R, Sharma R, et al. Nonpharmacological interventions for managing breathlessness in patients with advanced cancer: a systematic review. JAMA Oncol. 2021;7(2):290-298. doi:10.1001/jamaoncol.2020.5184
3. Dy SM, Gupta A, Waldfogel JM, et al; Johns Hopkins University Evidence-based Practice Center. Systematic Review: Interventions for Breathlessness in Patients with Advanced Cancer. Comparative Effectiveness Review No. 232. Rockville, MD: Agency for Healthcare Research and Quality; 2020. AHRQ Publication No. 21-EHC024; PCORI Publication No. 2020-SR-01. Accessed March 19, 2021. https://effectivehealthcare.ahrq.gov/sites/default/files/pdf/dyspnea-advanced-cancer-report.pdf
4. DiSalvo WM, Joyce MM, Tyson LB, Culkin AE, Mackay K. Putting Evidence Into Practice®: evidence-based interventions for cancer-related dyspnea. Clin J Oncol. 2008;12(2):341-352.  doi:10.1188/08.CJON.341-352
5. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®). Palliative Care Version 2.2021 — February 12, 2021. Accessed March 19, 2021. https://www.nccn.org/professionals/physician_gls/pdf/palliative.pdf