A 56-year-old male diagnosed with end-stage small-cell lung cancer presented to the emergency department with increased shortness of breath (SOB). Following assessment, it was found that his disease had progressed and that the dyspnea was caused due to bulky disease. How would you manage this patient's shortness of breath?
Dyspnea is defined as an unpleasant, subjective awareness of difficulty in breathing. However, it should not be confused with objective signs of tachypnea and hyperventilation. The intensity of the perception of dyspnea is modulated in the right posterior cingulate gyrus of the brain where other neural inputs come into play. As breathing is under behavioral control by cortical and subcortical brain centers, any emotional state can worsen dyspnea, which may seem out of proportion to the magnitude of the actual physiological impairment. For example, higher levels of anxiety have been associated with more intense SOB. Dyspnea is ranked in the top 10 of advanced cancer symptoms, and the incidence is 70% in the last six weeks of life. Dyspnea is an independent indicator of prognosis secondary to performance status.
When assessing a patient with dyspnea, it is important to note time and nature of onset; exacerbating factors of the SOB; and if it is associated with pain, cough, sputum, wheezing, and hemoptysis. It is also helpful to explore what the SOB means to the patient, his coping strategies, past illnesses, and clinical monitoring of the severity of breathlessness using the ESAS tool, for example. It is also important to check the patient's posture and physical symptoms.
Investigations should be kept to a minimum in the palliative care setting -- restricted to those what might alter management. For example, I may order a full blood count, chest X-ray, and obtain a pulse oximetry at the bedside. Occasionally, CT/MRI may be needed. Ventilation/ perfusion scans have very limited use in the palliative care setting.
Disease management should include physical, psychological, social, and spiritual factors as an interdisciplinary team approach must be employed. Non-pharmacological interventions are the most effective such as the encouragement of exercise, breathing control, posture, and using a fan for facial cooling. These kinds of interventions require higher levels of support and patient education.
As for pharmacological management, opioids remain the class of medications with the best level of evidence of benefit in reducing subjective sensation of refractory breathlessness. However, there remains no systemic evidence of benefit from nebulized opioids. Opioids reduce the sensation of breathlessness by reducing the CO2 sensitivity in the medullary respiratory center.
Anxiety is a significant component and small doses of short-acting benzodiazepines can be offered (0.5-1mg eight to 12 hourly lorazepam). Long-acting drugs such as diazepams should be avoided.
Corticosteroids have been used in cases of stridor and SVC obstruction. However, in these cases, steroids must be used on a short-term basis and should be discontinued if there is no benefit.
Oxygen therapy is not always needed unless the patient is hypoxic at rest (SpO2 <90 %). In the palliative care setting, I found nebulized furosemide to be effective at times. Furosemide has a mild bronchodilator effect and there is some evidence of systemic absorption when administered by a nebulizer.
How are you managing breathlessness with your patients? I'm interested in hearing how patients with shortness of breath are managed in the rural/regional community.
- Currow DC, et al. (2009)Advances in the pharmacological management of breathlessness. Curr Opin Support Palliat Care. Jun; 3(2):103-6.
- Department of Health and Human Services Tasmania (2010). Care Management Guidelines: Breathlessness.
- Vora V. (2004). Breathlessness: A palliative care perspective. Indian Journal of Palliative Care.