Does spirometry predict dyspnoea in advanced cancer?

Fan Therapy Is Effective in Relieving Dyspnea in Patients With Terminally Ill Cancer: A Parallel-Arm, Randomized Controlled Trial

CONTEXT

Dyspnea is a common distressing symptom among patients with advanced cancer.

OBJECTIVE

The objective of this study was to determine the effect of fan therapy on dyspnea in patients with terminally ill cancer.

METHODS

This parallel-arm, randomized controlled trial included 40 patients with advanced cancer from a palliative care unit at the National Cancer Center Hospital in Japan. All patients experienced dyspnea at rest with a score of at least three points on a subjective 0- to 10-point Numerical Rating Scale (NRS), showed peripheral oxygen saturation levels of ≥90%, had an Eastern Cooperative Oncology Group grade of 3 or 4, and were aged 20 years or more. In one group, a fan was directed to blow air on the patient's face for five minutes. This group was compared to a control group wherein air was blown to the patient's legs. Patients were randomly assigned to each group. The main outcome measure was the difference in dyspnea NRS scores between fan-to-face and fan-to-legs groups.

RESULTS

No significant differences were seen in baseline dyspnea NRS between groups (mean score, 5.3 vs. 5.1, P = 0.665). Mean dyspnea changed by -1.35 points (95% CI, -1.86 to -0.84) in patients assigned to receive fan-to-face and by -0.1 points (-0.53 to 0.33) in patients assigned to receive fan-to-legs (P < 0.001). The proportion of patients with a one-point reduction in dyspnea NRS was significantly higher in the fan-to-face arm than in the fan-to-legs arm (80% [n = 16] vs. 25% [n = 5], P = 0.001).

CONCLUSION

Fan-to-face is effective in alleviating dyspnea in patients with terminally ill cancer.

Observing dyspnoea in others elicits dyspnoea, negative affect and brain responses

Dyspnoea is usually caused by diagnosable cardiorespiratory mechanisms. However, frequently dyspnoea relates only weakly or not at all to cardiorespiratory functioning, suggesting that additional neuropsychosocial processes contribute to its experience. We tested whether the mere observation of dyspnoea in others constitutes such a process and would elicit dyspnoea, negative affect and increased brain responses in the observer.

In three studies, series of pictures and videos were presented, which either depicted persons suffering from dyspnoea or nondyspnoeic control stimuli. Self-reports of dyspnoea and affective state were obtained in all studies. Additionally, respiratory variables and brain responses during picture viewing (late positive potentials in electroencephalograms) were measured in one study.

In all studies, dyspnoea-related pictures and videos elicited mild-to-moderate dyspnoea and increased negative affect compared to control stimuli. This was paralleled by increased late positive potentials for dyspnoea-related pictures while respiratory variables did not change. Moreover, increased dyspnoea correlated modestly with higher levels of empathy in observers.

The present results demonstrate that observing dyspnoea in others elicits mild-to-moderate dyspnoea, negative affect, and increased brain responses in the absence of respiratory changes. This vicarious dyspnoea has clinical relevance, as it might increase suffering in the family and medical caregivers of dyspnoeic patients.

Characteristics and correlates of dyspnea in patients with advanced cancer

BACKGROUND

Dyspnea is a very distressing symptom present in the vast majority of patients with advanced cancer. There are limited data on the characteristics and correlates of dyspnea in this population. The purpose of this study was to characterize dyspnea, explore the differences between breakthrough and continuous presentations, and to determine factors associated with its intensity.

METHODS

Prospective observational study among 70 patients with dyspnea referred to a palliative care service. Dyspnea was assessed using the Edmonton Symptom Assessment System (ESAS, 0-10) and the Oxygen Cost Diagram (OCD). Oximetry, pulmonary function tests, Hospital Anxiety and Depression Scale (HADS), and a detailed systematic evaluation of daily characteristics of dyspnea were performed. Other symptoms were recorded using the ESAS.

RESULTS

Of 30 patients, 70 (43%) were female, median age was 58 (range, 28-87), and the most frequent cancer diagnosis were lung (31/70; 44%) and urologic (15/70; 21%). Constant dyspnea occurred in 27 of 70 (39%) patients, with 14 of 70 (20%) presenting breakthrough episodes. Breakthrough-only dyspnea occurred in 43 of 70 (61%). The majority of patients with breakthrough episodes (39/57; 68%) presented fewer than 5 episodes daily, most frequently lasting for less than 10 minutes (50/57; 88%). In univariate analyses ESAS dyspnea was associated with fatigue (p < 0.0001), sleep (p = 0.002), anxiety (p = 0.006), depression (p = 0.01), sensation of well-being (p = 0.03), and with OCD (p = 0.001). In multivariate analysis, ESAS dyspnea was associated with fatigue (p = 0.001), forced expiratory volume (p = 0.004), pain (p = 0.01), and depression (p = 0.03). Dyspnea intensity significantly interfered with activities (general activity, p = 0.01, mood, p = 0.02, walking ability, p = 0.04, normal work p = 0.04, and enjoyment of life, p = 0.01).

CONCLUSION

Dyspnea in patients with advanced cancer more frequently had breakthrough characteristics, was of very short duration, and interfered with daily activities.

Measurement of dyspnoea in the clinical rather than the research setting

PURPOSE OF REVIEW

Refractory dyspnoea is a common and difficult to treat symptom in advanced disease. Accurate assessment helps to guide treatment and prognosis.

RECENT FINDINGS

The absence of commonly agreed assessment tools has been a significant barrier to improving care through inhibition of clinical research and limitation of clinicians' ability to assess the effectiveness of their interventions. Two recently published systematic reviews on measurement tools for breathlessness identified a variety of tools but none could be recommended as gold standard. Validation of these tools in palliative care seems more appropriate than development of new tools. For clinical purposes, the combination of a unidimensional tool to assess dyspnoea severity and a multidimensional tool to evaluate the impact on a person's quality of life seem most appropriate. This review discusses the present evidence and puts forward a strategy for assessment and measurement of the symptom in clinical practice.

SUMMARY

Despite a variety of measurement tools none can be recommended as gold standard for the assessment of dyspnoea. A combination of unidimensional and multidimensional tools seems to be the best for clinical assessment. Measurement of dyspnoea has to be seen in context with the person's history, physical examination and diagnostic tests.

A randomized, double-blind, crossover trial of the effect of oxygen on dyspnea in patients with advanced cancer

Dyspnea is a common symptom in palliative care. Despite this, there is uncertainty regarding the role of oxygen to treat the symptom in patients with advanced illness. This randomized, double-blind, crossover trial examined the effect of oxygen versus air on the relief of dyspnea in patients with advanced cancer. Following the blinded administration of air and oxygen via nasal prongs, 51 patients rated dyspnea and indicated preferences for the blinded treatments. On average, patients improved symptomatically with both air and oxygen, and there were no significant differences between the treatments. The subgroup of 17 hypoxic patients overall did not demonstrate a significant difference between air and oxygen, despite having improved oxygen saturations when administered oxygen. Hypoxia was corrected in 13 of 17 patients using the treatment dose of 4 L/min of oxygen. The experience of dyspnea is a complex, multifactorial phenomenon, with oxygen tension not correlating with the subjective experience. The administration of either air or oxygen via nasal prongs on average confers improvement of the symptom.

Patient reporting and doctor recognition of dyspnoea in a comprehensive cancer centre

The aim of this study was to examine different aspects of dyspnoea in an Australian acute cancer care population, specifically prevalence, recognition, reporting, symptom control methods and prognostic significance. Patients and treating hospital medical officer were concurrently asked to evaluate the experience of dyspnoea. The prevalence of dyspnoea was 33%, with discrepancies observed between patient and doctor reporting of the presence of dyspnoea (P = 0.021), as well as its intensity and distress. Symptomatic methods for the relief of cancer-related dyspnoea are underused, particularly opioids. The medical underestimation of dyspnoea is consistent with previous studies and potentially detracts from effective management of this symptom.

Dyspnea and its correlates in taiwanese patients with terminal cancer

This study prospectively assessed dyspnea and related bio-psycho-social-spiritual factors--including severity, cause, psychological distress, and fear of death--that were possibly related to dyspnea in 125 terminal cancer patients at admission and two days before their death. At admission, 74 patients had dyspnea, which improved but later worsened. Causes included cachexia, anemia, pleural effusion, and lymphangitis. Quality of life, anxiety, depression, and fear of death improved after admission; anxiety was correlated with dyspnea before death (r = 0.211, P < 0.05, univariate analysis). Lung infection (odds ratio = 2.29, 95% confidence interval = 0.68-3.90; multiple regression), airway obstruction (2.27, 1.41-3.13), acidemia (1.82, 0.72-2.98), and pericardial effusion (1.38, 0.44-2.32) were independent correlates of dyspnea severity at admission (42.8% of explained variance). Before death, airway obstruction, esophageal cancer, pericardial effusion, lung infection, and mediastinal mass were independent correlates of severity (42.7% of explained variance). Comprehensive care, including improved psychospiritual status, can help in controlling dyspnea and enhancing patients' quality of life.

Managing dyspnea and cough

Dyspnea, like pain, is a subjective experience that incorporates physical elements and affective components. Management of breathlessness in patients with cancer requires expertise that includes an understanding and assessment of the multidimensional components of the symptom, knowledge of the pathophysiologic mechanisms and clinical syndromes that are common in cancer, and familiarity with the indications and limitations of the available therapeutic approaches. Relief of breathlessness should be the goal of treatment at all stages of cancer. Good control of dyspnea will improve the patient's quality of life.