Management of Dyspnea in Advanced Cancer

Publication Date: February 1, 2021
Last Updated: March 14, 2022

Recommendations

Screening and assessment

1.1. Clinicians should perform systematic assessment of dyspnea at every inpatient and outpatient encounter in patients with advanced cancer using validated patient-reported outcome measures.
(good practice statement)
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1.2. For patients who are unable to self-report, clinicians should use a validated observation measure.
(good practice statement)
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1.3. Whenever possible, patients with dyspnea should undergo a comprehensive evaluation for the severity, chronicity, potential causes, triggers, and associated symptoms, as well as emotional and functional impact.
(good practice statement)
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Treatment of underlying causes

2.1. Patients with potentially reversible, common etiologies of dyspnea such as pleural effusion, pneumonia, airway obstruction, anemia, asthma, chronic obstructive pulmonary disease (COPD) exacerbation, pulmonary embolism, or treatment-induced pneumonitis should be given goal-concordant treatment(s) consistent with their wishes, prognosis, and overall health status.
(good practice statement)
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2.2. Patients with dyspnea because of underlying malignancy (eg, lymphangitic carcinomatosis, atelectasis because of large pulmonary mass, malignant pleural effusion) may benefit from cancer-directed treatments if consistent with their wishes, prognosis, and overall health status.
(good practice statement)
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2.3. Patients with underlying comorbidities such as COPD or heart failure should have the management of these conditions optimized.
(good practice statement)
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Referral to palliative care

3.1. Patients with advanced cancer and dyspnea should be referred to an interprofessional palliative care team where available.
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Nonpharmacologic interventions

4.1. Airflow interventions such as directing a fan at the cheek (trigeminal nerve distribution) should be offered.
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4.2. Standard supplemental oxygen should be available for patients with hypoxemia who are experiencing dyspnea (ie, SpO2 ≤ 90% on room air).
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4.3. Supplemental oxygen is not recommended when SpO2 > 90%.
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4.4. A time-limited therapeutic trial of high-flow nasal cannula oxygen therapy, if available, may be offered to patients who have significant dyspnea and hypoxemia despite standard supplemental oxygen.
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4.5. A time-limited therapeutic trial of noninvasive ventilation, if available, may be offered to patients who have significant dyspnea despite standard measures and do not have contraindications.
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4.6. Other nonpharmacologic measures such as breathing techniques, posture, relaxation, distraction, meditation, self-management, physical therapy, and music therapy may be offered.
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4.7. Acupressure or reflexology, if available, may be offered.
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4.8. Evidence remains insufficient for a recommendation for or against pulmonary rehabilitation in patients with advanced cancer and dyspnea.
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Pharmacologic interventions

5.1. Systemic opioids should be offered to patients with dyspnea when nonpharmacologic interventions are insufficient to provide dyspnea relief.
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5.2. Short-acting benzodiazepines may be offered to patients who experience dyspnea-related anxiety and continue to experience dyspnea despite opioids and other nonpharmacologic measures.
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5.3. Systemic corticosteroids may be offered to select patients with airway obstruction or when inflammation is likely a key contributor of dyspnea.
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5.4. Bronchodilators should be used for palliation of dyspnea when patients have established obstructive pulmonary disorders or evidence of bronchospasm.
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5.5. Evidence remains insufficient for a recommendation for or against the use of antidepressants, neuroleptics, or inhaled furosemide for dyspnea.
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5.6. Continuous palliative sedation should be offered to patients with dyspnea that is refractory to all standard treatment options and all applicable palliative options, and who have an expected life expectancy of days.
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Recommendation Grading

Overview

Title

Management of Dyspnea in Advanced Cancer

Authoring Organization

Publication Month/Year

February 1, 2021

Last Updated Month/Year

February 12, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Male, Female, Adult

Health Care Settings

Ambulatory, Home health, Hospital, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant, social worker

Scope

Management

Diseases/Conditions (MeSH)

D004417 - Dyspnea

Keywords

dyspnea, Clinical Guideline, Advanced cancer, air hunger

Supplemental Methodology Resources

Data Supplement, Evidence Tables