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The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy

Abstract

Intractable breathlessness is a common, devastating symptom of advanced cancer causing distress and isolation for patients and families. In advanced cancer, breathlessness is complex and usually multifactorial and its severity unrelated to measurable pulmonary function or disease status. Therapeutic advances in the clinical management of dyspnea are limited and it remains difficult to treat successfully. There is growing interest in the palliation of breathlessness, and recent work has shown that a systematic, evidence-based approach by a committed multidisciplinary team can improve lives considerably. Where such care is lacking it may be owing to therapeutic nihilism in clinicians untrained in the management of chronic breathlessness and unaware that there are options other than endurance. Optimum management involves pharmacological treatment (principally opioids, occasionally oxygen and anxiolytics) and nonpharmacological interventions (including use of a fan, a tailor-made exercise program, and psychoeducational support for patient and family) with the use of parenteral opioids and sedation at the end of life when appropriate. Effective care centers on the patient's needs and goals. Priorities in breathlessness research include studies on: neuroimaging, the effectiveness of new interventions, the efficacy, safety, and dosing regimens of opioids, the contribution of deconditioning, and the effect of preventing or reversing breathlessness.

Key Points

  • Breathlessness is a common, poorly controlled symptom that is distressing for patients and their families, and should be actively managed

  • Make the best diagnosis possible of the cause(s) of breathlessness, treating appropriately depending on the patient's physical status and expressed wishes

  • All comorbidities should be optimally treated, with specialist advice sought when necessary

  • It is important to help patients learn a range of nonpharmacological techniques to control breathlessness and the anxiety and fear associated with it; every patient needs to know how to use a fan

  • Whenever possible, the oral route is preferable when using opioids for intractable breathlessness

  • Use sedation at the end of life for uncontrollable, distressing breathlessness and let patients know that this will be available if needed

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Figure 1: Different disease trajectories for different illnesses.
Figure 2: The central genesis of breathlessness.
Figure 3: Specialist physiotherapist demonstrating use of the fan to a volunteer.

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Acknowledgements

S Booth would like to thank Cicely Saunders International 'Improving Breathlessness Project', Macmillan Cancer Relief and Marie Curie Cancer Care who administer the SuPac grant which supports her post, The Sainsbury Family Charity, which funds the Breathlessness Intervention Service, and Dr Caroline Jolley, who has offered very helpful comments on the manuscript. We also thank Isla Kuhn, University of Cambridge Medical School Librarian, for help with search strategies and Jacquie Adie for managing the manuscript. Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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Correspondence to Sara Booth.

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The authors declare no competing financial interests.

Supplementary information

The causes of breathlessness in advanced cancer.

A table showing the causes of breathlessness in advanced cancer. (DOC 44 kb)

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Booth, S., Moosavi, S. & Higginson, I. The etiology and management of intractable breathlessness in patients with advanced cancer: a systematic review of pharmacological therapy. Nat Rev Clin Oncol 5, 90–100 (2008). https://doi.org/10.1038/ncponc1034

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