Update on Managing Dyspnea

TON - November 2013 Vol 6 No 10 — November 24, 2013

Dyspnea is the most prevalent symptom in patients with cancer, occurring in 22% to 55% of all affected individuals, and up to 79% at the end of life. Most patients with advanced lung cancer will have dyspnea. It is challenging to manage, and the only evidence-based intervention is opioids once dyspnea becomes disabling.

“Dyspnea is one of the most frightening symptoms in patients with cancer. There is no road map for treating dyspnea. Opioids are the only recommended therapy, and many physicians as well as nurses are reticent to use these drugs. This is probably based on fear of failure,” stated Awni Awad Daibes, Master, Institute Jules Bordet, Brussels, Belgium, at the European Cancer Congress (ESMO/ECCO/ESTRO), held September 27-October 1, 2013, in Amsterdam, the Netherlands.

The causes of dyspnea are multifactorial, and optimal measurement is unclear, he continued. Dyspnea is a subjective feeling of not being able to breathe, often associated in a symptom cluster with fatigue, anxiety, and depression.

Dyspnea can be caused by medical problems that should be treated promptly. These include plural effusion, pneumothorax, pulmonary edema or embolism, chronic obstructive pulmonary disease, congestive heart failure, cardiac tamponade, lung obstruction, and pulmonary hypertension.

Refractory dyspnea occurs mainly in advanced lung cancer and is defined as difficulty breathing. Sensations vary in intensity and it is frequently debilitating, he said.

Daibes noted that many cancer patients with dyspnea are referred too late to the palliative setting. Patients with advanced lung cancer should be referred for palliation at the outset of dyspnea, so the symptom can be controlled.

Although the visual analog scale is the simplest way to measure dyspnea, there is no validated agreed-upon standard measure. Measures of respiration include oxygen saturation and pulmonary function tests, but the results of these measures are unlikely to affect management, he said.

The goal of treatment is to improve the sensation of breathing and empower the patient to control the symptom. In advanced lung cancer, it is not possible to target the underlying etiology.

“Nurses are not always aware of the latest evidence. There is a huge amount of published materials, and some of it can be difficult to interpret. Putting evidence-based medicine into practice is a must,” Daibes stated.

To this end, the European Oncology Nursing Society and the Oncology Nursing Society in the United States have initiated a joint project called Putting Evidence Into Practice (PEP). Nurses will be able to go online to the PEP website and get evidence-based guidance on how to manage cancer-related symptoms, including dyspnea. PEP uses traffic-light colors for its recommendations: green = go (strong evidence from rigorously designed studies); yellow = caution (effectiveness not established); red = stop (don’t use; can cause harm).

The only green-light recommendation for dyspnea is immediate-release oral and parenteral opioids. Yellow-light recommendations include extended-release morphine, anxiolytics, transmucosal fentanyl, and nebulized furosemide; nonpharmacologic interventions include a fan, acupuncture, and psychoeducation. Palliative oxygen is a red-light recommendation (can cause harm).

“The management of dyspnea is not writ in stone. Evidence-based practice is alive, and it is an ongoing process. Interventions we currently use may be deemed ineffective, and new effective ones may be identified. You must use sound judgment in your daily practice,” he told listeners.

Reference
Daibes A. Dyspnoea—an oncological challenge. Presented at: 2013 European Cancer Congress; September 27-October 1, 2013; Amsterdam, the Netherlands. Abstract 361.

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