- Dyspnea is one of the most common and distressing symptoms affecting patients with advanced cancer.
- In a meta-analysis that included over 10,000 patients with advanced cancer, 10%–70% of patients reported dyspnea.a
- The burden of dyspnea is further compounded by other related symptoms such as fatigue, anxiety, and depression, resulting in functional limitation, compromised quality of life, and increased informal (family) caregiver burden.
- In the advanced cancer setting, the presence of dyspnea, particularly at rest, indicates a poor prognosis (typically less than a few months) and has important clinical implications.
- First, a patient’s prognosis could significantly impact recommendations regarding assessments and treatments.
- Second, clinicians need to routinely engage in serious illness conversations with the patients and their caregivers to ensure prognostic understanding, discuss how dyspnea should be managed (e.g., cancer treatments, palliative options), and support advance care planning.
a Solano JP, Gomes B, Higginson IJ: A Comparison of Symptom Prevalence in Far Advanced Cancer, AIDS, Heart Disease, Chronic Obstructive Pulmonary Disease and Renal Disease. Journal of Pain and Symptom Management 31:58-69, 2006
|Type||Benefit/harm||Evidence Quality||Strength of Recommendation|
|EB||Evidence-based||B||Beneﬁts outweigh harms||H||High||Strong|
|CB/FC||Consensus-based/Formal consensus||H||Harms outweigh beneﬁts||I||Intermediate||Moderate|
|IC||Informal consensus||B/H||Relative balance of beneﬁts and harms||L||Low||Weak|
|GPS||Good Practice Statement||U||Beneﬁts/harms ratio uncertain||Ins||Insufficient|
1. Screening and Assessment
- Clinicians should perform systematic assessment of dyspnea at every inpatient and outpatient encounter in patients with advanced cancer using validated patient-reported outcome measures. (GPS)
- For patients who are unable to self-report, clinicians should use a validated observation measure. (GPS)
- 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. (GPS)
Note: Examples of validated and easy-to-use assessment tools are provided in the Supplement.
2. Treatment of Underlying Causes
- 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. (GPS)
- Patients with dyspnea due to underlying malignancy (e.g., lymphangitic carcinomatosis, atelectasis due to large pulmonary mass, malignant pleural effusion) may benefit from cancer-directed treatments if consistent with their wishes, prognosis, and overall health status. (GPS)
- Patients with underlying co-morbidities such as COPD or heart failure should have the management of these conditions optimized. (GPS)
3. Referral to Palliative Care
- Patients with advanced cancer and dyspnea should be referred to an interprofessional palliative care team where available. (Strong recommendation; EB-I)
4. Non-pharmacologic Interventions
- Airflow interventions such as directing a fan at the cheek (trigeminal nerve distribution) should be offered. (Moderate recommendation; EB-I)
- Standard supplemental oxygen should be available for patients with hypoxemia who are experiencing dyspnea (i.e., SpO2 ≤90% on room air). (Moderate recommendation; EB-I)
- Supplemental oxygen is not recommended when SpO2 >90%. (Moderate recommendation; EB-I)
- 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. (Moderate recommendation; EB-L)
- A time-limited therapeutic trial of non-invasive ventilation, if available, may be offered to patients who have significant dyspnea despite standard measures and do not have contraindications. (Moderate recommendation; EB-L)
- Other non-pharmacologic measures such as breathing techniques, posture, relaxation, distraction, meditation and education/self-management, physical therapy, and music therapy may be offered. (Weak recommendation; EB-L)
- Acupressure/reflexology, if available, may be offered. (Weak recommendation; EB-L)
- Evidence remains insufficient for a recommendation for or against pulmonary rehabilitation in patients with advanced cancer and dyspnea.
5. Pharmacologic Interventions
- Systemic opioids should be offered to patients with dyspnea when non-pharmacologic interventions are insufficient to provide dyspnea relief. (Moderate recommendation; EB-L)
- Short-acting benzodiazepines may be offered to patients who experience dyspnea-related anxiety and continue to experience dyspnea despite opioids and other non-pharmacologic measures. (Weak recommendation; EB-L)
- Systemic corticosteroids may be offered to select patients with airway obstruction or when inflammation is likely a key contributor to dyspnea. (Weak recommendation; EB-L)
- Bronchodilators should be used for palliation of dyspnea when patients have established obstructive pulmonary disorders or evidence of bronchospasm. (Weak recommendation; EB-L)
- Evidence remains insufficient for a recommendation for or against the use of anti-depressants, neuroleptics, or inhaled furosemide for dyspnea.
- 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. (Moderate recommendation; IC-L)
Table 1. Definitions
|Advanced cancer||The American Cancer Society deﬁnes advanced cancer as “cancers that cannot be cured” and metastatic cancer as tumors that “have usually spread from where they started to other parts of the body.” However, not all advanced cancers are metastatic. For example, brain tumors may be considered advanced because they are often not curable, even in the absence of metastasis.|
In this guideline, particular emphasis was placed on studies including patients with advanced cancer. Other patient populations were also considered when formulating the recommendations.
|Dyspnea||The American Thoracic Society deﬁnes dyspnea as “a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.” In this guideline, dyspnea is considered to be equivalent to “breathlessness” and “air hunger.”|
|High Flow Nasal Cannula (HFNC)||Delivers a humidiﬁed, heated, air oxygen blend (allowing from 21%–100% fraction of inspired oxygen) generating up to 60 liters/minute flow rates through a large diameter nasal cannula.|
|Hypercapnia||PaCO2 ≥45 mmHg|
|Hypoxemia||Oxygen saturation (SpO2) <90% while breathing room air at rest, which is equivalent to PaO2 of <60 mmHg.|
|Morphine equivalent daily dose (MEDD)||The total dose of opioid use per 24-hour period, taking into account both the scheduled and rescue doses. To facilitate this calculation, different opioids can be converted to oral morphine equivalents using standardized ratios. 15 mg of oral morphine is equivalent to 3.75 mg of oral hydromorphone, 5 mg of oral oxymorphone, 10 mg of oral oxycodone and 15 mg of hydrocodone. Parenteral opioids are generally 2–3× as strong as their oral counterparts.|
|Non-invasive ventilation||The American Thoracic Society and European Respiratory Society Guideline deﬁnes non-invasive ventilation as "noninvasive variable positive airway pressure (most commonly 'bilevel') devices consisting of a higher inspiratory positive airway pressure and a lower expiratory pressure as well as continuous positive airway pressure (CPAP) delivered using various nasal, oronasal, and facial interfaces."|
|Standard supplemental oxygen||Conventional oxygen therapy delivered via nasal cannula or face masks — can achieve flow rates of up to 15 liters/minute.|
Table 2. Supplemental Oxygen Use
|Dyspnea/respiratory distress||Oxygen saturation||Oxygen indicated||Other interventions indicated|
|Present||<90%||Yes, start low||Yes, to treat underlying cause of hypoxemia|
|Present||≥90%||No, however, airflow alone can be beneﬁcial||Yes, to treat underlying cause of dyspnea|
|Absent||<90%||Yes, for oxygenation purpose, unless last days of life||Yes, to treat underlying cause of hypoxemia|
|Absent||≥90%||No, consider withdrawal if in use||No|