Breathlessness is a common and difficult problem in advanced cancer. It can completely dominate a patient’s life, causing physical disability, loss of independence and dignity and lowered self esteem. Breathlessness in cancer patients is seen as a distressing symptom, influenced by physical, psychological, emotional and social factors. The audience will gain awareness of the major causes of breathlessness and how it can be managed efficiently by the patient, their families and health care professional to maintain and promote quality of life. Thus, this presentation will enlighten the audience of the effects that breathlessness on patients with advanced cancer has on their physical, psychosocial and financial lifestyle.
This tutorial presentation will discuss the following key points:
– Definition of breathlessness
– Major causes of breathlessness
– Symptoms and signs of breathlessness
– Consequences of breathlessness and their influence on the patients lifestyle
– Assessment of breathlessness
– Management of breathlessness
– Ways of coping with breathlessness
Definition of breathlessness
There are many definitions that describe breathlessness or dyspnoea. The Australian Nurses’ Dictionary defines breathlessness as “difficult or laboured breathing”, whereas concerned patients describe it in prevailing images such as “a tight band or wall around the chest”, “breathing through cotton wool” or “Nuisance” (O’Driscoll, Corner & Bailey, 1999). Previously breathlessness has been distinct by its physiological parameters such as tumor infiltration, chest infections or pleural effusions and therefore has been managed accordingly.
It has been approached from the bio-medical model where there is great emphasis on the physical causes and factors that contribute to breathlessness rather than from the holistic model, which recognises psychological and emotional components that cause breathlessness. Only recently has breathlessness been understood as more than just a symptom of disordered breathing. It is now seen as a symptom where there is a complex interaction between physical, psychosocial and emotional factors (O’Driscoll, Corner & Bailey, 1999).
Major causes of breathlessness
The causes of breathlessness in advanced cancer are numerous and multifactorial, as it may be due to the cancer itself, the treatment given or due to coexisting conditions. Physical factors that cause breathlessness can be divided into four groups:
1. Direct tumour effects:
– intrinsic or extrinsic airway obstruction,
– pleural effusion,
– primary or metastatic tumour involvement
– superior vena cava syndrome
2. Indirect tumour effects:
– Pulmonary embolus
3. Treatment-related causes:
– pulmonary fibrosis secondary to radiation or chemotherapy
– chemotherapy induced cardiomyopathy
4. Causes unrelated to cancer:
– chronic obstructive airway disease
– congestive heart failure
– various bacterial, viral or fungal infections
All the above physical causes contribute to breathlessness in a patient with advanced cancer. However, since it has been recognized that not only physical factors but also psychological, social and emotional factors contribute to breathlessness, other non-physical causes have been found to provoke or exacerbate breathlessness. Those causes include:
– Fear of chocking
– Emotions such as crying, laughing or anger
– Environment, such as extremes of hot, cold and humid conditions
There are still more causes that interfere with a patients lifestyle. For example, many patients with advanced cancer get a sensation of breathlessness by simply participating in their daily activities of living. Shopping, housework, washing oneself and dressing are triggers of breathlessness in many cancer patients. Even walking, talking, eating and drinking are associated with causing breathlessness. The above shows that breathlessness has not only an immense impact on the physical well-being of a person but also on the psychosocial and emotional well-being.
Symptoms and signs of breathlessness
Breathlessness is a symptom in itself. It is associated with difficult or distressed breathing and may be perceived as being life threatening, causing disability and leading to social withdrawal. However, it does not often occur in isolation. Other accompanying symptoms of breathlessness are:
Clinical signs of breathlessness are:
– exaggerated respiratory effort
– use of accessory muscles of respiration
– nasal flaring
– marked increase in the rate and depth of respirations
Consequences of breathlessness and their influence on the patients lifestyle
Consequences of breathlessness are restrictions that invade all aspects of every day life. Breathlessness can cause disruption of social activities and restrict a person in activities of daily living. Restrictions imposed by breathlessness are:
– unable to manage housework (ironing, washing, cooking)
– unable to work
– difficulty with personal hygiene
– breathlessness going to the toilet
– breathlessness preparing and eating meals
– difficulty going out in the evening to socialize
– difficulty in maintaining sexual relations
– difficulty with fulfilling the usual role within the family
Those restrictions can persuade a sense of being unable to fulfill a personal and social role in society. Many patients are now dependent on their families, which gives them a feeling of being out of control. Breathlessness can have social, financial, psychological and emotional effects on a persons life. As stated above, a person might not be able to fulfill the social role in the family and community as they used to. Being unable to work may put financial pressure on the breathless person since he or she is now dependent on the family or community. A patient with breathlessness due to advanced cancer might be worried about the future and family. Such patients may also express anger and frustration because their usual activities were impeded by breathlessness .
As one can see, the effect of breathlessness on quality of life in general is immense. Therefore, it is imperative to assess the causes of breathlessness adequately and holistically and treat them if possible. If the causes of breathlessness cannot be reversed, the symptom needs to be eased and coping strategies need to be implemented into the management of breathlessness.
Assessment of breathlessness
Dyspnoea is one of the most distressing and frightening symptoms that a patient with advanced cancer can experience and, like pain, can only be interpreted and reported by the person experiencing it. Therefore, breathlessness is a subjective sensation. The true effect that breathlessness has on a patient’s quality of life will be determined by their perception of the problem. The connotation of breathlessness to the patient may enhance his or her suffering. Many patients for example interpret breathlessness as a sign that the cancer is progressing and death is close. Objective signs such as the use of accessory breathing muscles do not necessarily equal the patient’s perception of breathlessness since numerous factors, including psychosocial and emotional issues can affect a patient’s experience of breathlessness.
In the assessment it is imperative that the patient’s report of breathlessness must be believed. Nurses should perform a thorough assessment of not only physical components but also of psychosocial, emotional and spiritual components of the symptom. Furthermore, the assessment of breathlessness in patients with advanced cancer should not be overlong, invasive or complicated since those patients have limited time left to them and therefore, the assessment should not detract from their quality of life. However, a systematic assessment is imperative since it aids in identifying the underlying processes that worsen or cause breathlessness. Only when the cause of breathlessness is identified can the patient be treated sufficiently. As the audience has learned previously, there are many physical causes of breathlessness. To identify those causes, physical assessment parameters include:
– Temperature to identify infections
– Sputum quantity and character
– Auscultation of lung sounds
– Respiratory rate
– Full blood count to identify anaemia
– Chest x-ray to identify pneumonia and pleural effusion
One successful tool of assessing breathlessness is the self-report visual analogue scale, which grades the patients perception of breathlessness. This tool is patient centered, quick and easy to use and has the sensitivity required to determine minute changes.
This tool is best used to measure the patients baseline previous to the treatment, during treatment and when the treatment plan changes. This will provide ongoing information of the efficiency of the treatment plan.
Other assessment tools have been developed such as the Borg Scale or the Dyspnoea Assessment Questionnaire. However, those assessment tools do not confine the patient’s subjective symptoms and the effects these symptoms have on the patients’ quality of life. Studies showed that the gold standard of reliable assessment is self-report and that the assessment needs to include the multidimensional aspects of the patient’s experience of breathlessness, as well as treatment interventions employed and their effectiveness. Therefore, psychosocial and spiritual assessment parameters include:
– the patients awareness of the diagnosis, illness stage and prognosis
– the patients values (what is most important for the patient in relation to treatment options)
– the patients preferences (e.g. should antibiotics be given for an infection at the end of life?)
– the patients expectations and desired outcomes from the treatment
– what breathlessness means to the patient and how it effects his or her entire life.
A broad history is essential to an accurate assessment of breathlessness in patients with advanced cancer. The nature, onset, duration and severity as well as associated symptoms, exacerbating or relieving activities and responses to previously used medications should be recorded. Such a history can reveal many underlying pathological problems. For example, sudden onset of dyspnoea may be a sign for infection or pulmonary embolism, whereas a gradual onset may be a sign for the development of pleural effusion.
One can see that a broad assessment is vital to minimize distress and disability associated with breathlessness. It is only understandable that a thorough assessment of breathlessness takes some time, especially if the patient has a limited concentration span or is in fact breathless and unable to communicate for long periods.
Management of breathlessness
The management and treatment of breathlessness is best directed at the underlying causes, e.g. infection, asthma, pleural effusion or tumor obstruction. Some causes of breathlessness are reversible and some are not. The most common reversible causes of breathlessness are bronchospasm, infections and anaemia, which can be treated successfully with bronchodilators, antibiotics and blood transfusions respectively. Other causes, such as tumor activity, superior vena cava obstruction and pleural effusion can also be reversed to a specific extend. The use of radiation and chemotherapy can result in symptom relief. Pleural taps are effective in draining pleural effusions.
Sometimes it is not possible to reverse the causes of breathlessness, therefore, pharmacological and non-pharmacological interventions are used to ease the symptoms. Morphine has been found to be extremely effective in the treatment of breathlessness. It aids in the relaxation of respiratory muscles and also can calm the panicking patient. Usually, morphine for the treatment of breathlessness is administered similarly to, and often concurrent with the treatment of pain.
Although many patients and health care professionals alike show fear of side effects, this should not prevent the appropriate use of morphine to ease breathlessness. It is now known that morphine does not hasten death in breathless cancer patients; it rather reduces anxiety and physical and psychological distress. However, side effects like heavy sedation can occur when morphine is used, therefore, it is imperative to inform the patient and their families about those side effects so they can make informed decisions. It is also vital to use appropriate aperients when taking morphine to avoid constipation.
Other drugs, such as anxiolytics are often used to relieve breathlessness. Those drugs have a sedative and calming effect, which can alleviate anxiety associated with breathlessness. Anxiolytics include Diazepam, Lorazepam, Midazolam and Haloperidol. Steroids such as Dexamethasone are also used frequently in the treatment of obstructive breathlessness where there is a blockage in the lymphatic drainage of the lungs resulting in lung stiffness and impaired oxygen diffusion. O’Connor and Aranda (2003) suggest that Steroids contribute to a better sense of well-being and can increase appetite.
Non-pharmacological measures can also be of great value. The administration of oxygen for example can significantly reduce breathlessness in some patients with advanced cancer. However, it should be noted that oxygen causes a dry mouth, therefore, thorough mouth care is imperative with oxygen use. Another concerning issue with the use of oxygen is that it interferes with activities of daily living, such as mobility, eating, drinking and speech. It is important to encourage the patient not to become dependent on upon their oxygen supply as this can severely limit their lifestyle. It is furthermore crucial to educate the patient and their family that it is forbidden to smoke near the oxygen device since this is a major hazard.
Management of breathlessness should be initiated at an early stage to enable the patient and their families to learn how to cope with breathlessness and associated symptoms. The nurse plays an important role in the non-pharmacological management of breathlessness since he or she is the person that teaches the patient and family how to cope with breathlessness. Nursing management of breathlessness includes teaching the patient and their families coping strategies such as:
– relaxation, which helps to reduce anxiety and fear
– massage of hands and feet, which can reduce stress and allows family and carers to be involved in the patients care.
– use of aromatherapy, which has calming and anti-depressant effects
– breathing exercises (pursed-lip breathing, diaphragmatic breathing)
Part of the nursing management is to establish a therapeutic relationship with the patient and family. Active listening to the patients fears, exploring the patients beliefs, values and feelings in association with their breathlessness, advocating the patient in treatment decisions, teaching coping strategies and helping in setting realistic goals are all part of the therapeutic relationship between the nurse and the patient and their families.