Dyspnea

Guidelines Author

Summary of Guidelines

Conclusions and Implications

ONS PEP Weight-of-Evidence Category: Likely to Be Effective

National Comprehensive Cancer Network (NCCN), 2006⁵

Practice Guidelines in Oncology—v.1.2006 Palliative Care (Dyspnea) were developed by an expert committee and are reviewed and updated annually. The NCCN Palliative Care Guidelines were developed from the collaborative efforts of these experts based on clinical experience and available scientific evidence.

Search strategy: not described

Outcomes measured: not described

Category 1: Uniform NCCN consensus exists, based on high-level evidence, that the recommendation is appropriate.

Category 2A: Uniform NCCN consensus exists, based on lower-level evidence, including clinical experience, that the recommendation is appropriate.

Category 2B: Nonuniform NCCN consensus exists (without major disagreement), based on lower-level evidence, including clinical experience, that the recommendation is appropriate.

Category 3: Major NCCN disagreement exists that the recommendation is appropriate.

All recommendations are category 2A unless otherwise noted.

1. All patients with cancer should be screened for palliative care needs at their initial visit, at appropriate intervals, and as clinically indicated.

2. Use of the NCCN Dyspnea Palliative Care Guidelines should be considered for patients in the following clinical situations: uncontrolled symptoms, moderate to severe distress related to cancer diagnosis and therapy, serious comorbid physical and psychosocial conditions, and advanced or progressive disease for which no effective curative therapy exists.

3. An estimate of life expectancy in terms of a year to months, months to weeks, or weeks to days should guide the use of specific palliative interventions.

4. Dyspnea management interventions are based on the following estimates of patient life expectancy.

a. With years to months to live: Include symptom intensity assessment followed by treatment of underlying causes or comorbid conditions using chemotherapy or radiation therapy, thoracentesis or pleurodesis, bronchoscopic therapy or bronchodilators, diuretics, antibiotics, or transfusions.

b. With a year to months to live: Include measures to relieve symptoms such as temporary ventilator support, if clinically indicated for severe yet reversible condition, and supplemental oxygen therapy.

c. With months to weeks to live: Include benzodiazepines for anxiety; opioids for cough or dyspnea; nonpharmacologic therapies, including fan, cooler temperatures, stress management, and relaxation therapy; and educational, psychosocial, and emotional support.

d. With weeks to days to live (dying patient): Use tachypnea or distress markers of potential dyspnea in noncommunicative patients to assess symptom intensity and focus on comfort. Include the measures listed in item c above to relieve symptoms and the following interventions.

• Reduce excessive secretions with medications (scopolamine, hyoscyamine, atropine).
• Use oxygen if patients indicate subjective report of relief.
• Withhold or withdraw the time-limited trial of mechanical ventilation as indicated by patient and family preferences, prognosis, and reversibility.
• Provide sedation as needed.
• Discontinue fluid support and consider using a low-dose diuretic if fluid overload may be a contributing factor to dyspnea.
• Provide anticipatory guidance for patients and families on the dying process and treatment of respiratory crisis.
• Provide emotional support.