Effectiveness Not Established
Bausewein, C., Booth, S., Gysels, M., & Higginson, I. (2008). Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database of Systematic Reviews (Online), 2(2), CD005623.doi: 10.1002/14651858.CD005623.pub2
The objectives of the study were to
- Determine the effectiveness of nonpharmacologic and noninvasive interventions to relieve breathlessness in patients suffering from primary and secondary cancer, chronic obstructive pulmonary disease, interstitial lung disease, chronic heart failure, and motor neuron disease
- Find out which intervention strategies are available, which are effective, and which participant groups benefit most from which interventions.
- Databases searched were The Cochrane Central Register of Controlled Trials; MEDLINE; EMBASE; CINAHI; British Nursing Index; PsycINFO; Science Citation Index Expanded; AMED; The Cochrane Pain, Palliative, and Supportive Care Trials Register; The Cochrane Database of Systemic Reviews; and Database of Abstracts of Reviews of Effectiveness.
- After the initial search, reference lists from key articles, texts, and websites also were searched.
- Authors with research in progress were contacted for unpublished data.
- Search keywords were dyspnoea, shortness of breath, breathlessness, difficulty of breathing, or laboured breathing.
- Included were randomized controlled and controlled clinical trials, including quasi-randomised trials and trials with double-blinding assessing the effectiveness of nonpharmacologic and noninvasive interventions to relieve breathlessness in participants with advanced stages of cancer, chronic obstructive pulmonary disease (COPD), interstitial lung disease (ILD), chronic heart failure (CHF), and motor neuron disease (MND).
- Studies were excluded if they examined any invasive interventions.
- Studies having the intervention compared against placebo or usual therapy were not included.
- Initially, 5,154 articles were retrieved; a final of 47 are included in this review.
- Two review authors assessed studies identified by the search for their relevance for inclusion.
- Breathlessness was validated by reliable rating scales such as visual analogue scales (VAS), numeric rating scales (NRS), categorical scales, and modified Borg scales.
- The Oxford Quality Scale was used to evaluate randomization, double blinding, description of withdrawal, and dropouts.
- The Method Score From Edwards was used for studies with less rigorous methodology.
- The Palliative Care National Institute of Clinical Excellence (NICE) guidelines were used to assess the grade of evidence.
The study reported on a sample of 2,532 participants in 47 studies categorized into single intervention or multi-component interventions.
The following single interventions were identified.
- Walking aids (seven studies)
- Distractive auditory stimuli (music) (six studies)
- Chest wall vibration (five studies)
- Acupuncture/acupressure (five studies)
- Relaxation (four studies)
- Neuro-electrical stimulation (three studies)
- Fan (two studies)
The following multi-component interventions were identified.
- Counseling and support (six studies)
- Breathing training (three studies)
- Counseling and support with breathing training (two studies)
- Case management (two studies)
- Psychotherapy (two studies)
A meta-analysis of the included studies was not possible due to hetereogeneity of the studies. Strong evidence suggests that neurologic muscular electrical stimulation and chest wall vibrations provide helpful relief of breathlessness in patients with COPD. However, the practical implications of the chest wall vibration interventions were only conducted in the respiratory laboratory. The evidence is moderately strong for walking aids having some benefits for patients with COPD with breathlessness by reducing the work of chest muscles. Moderate strength of evidence exists for breathing training being beneficial for breathless patients. Finally, not enough evidence exists to recommend usage of acupuncture, distractive auditory stimuli, relaxation, fan, counseling and support programs, or counseling and support programs in combination with relaxation and breathing training, case management, and psychotherapy.
Moderate evidence strength for walking aids and breathing retraining for COPD suggests these may be helpful interventions. Applicability in patients with cancer may be worth investigation.
- Nonpharmacologic interventions for breathlessness need further testing.
- Studies with sufficient sample size and power calculations are needed to be applicable to palliative care settings.
- In recent years, a significant research gap exists in cancer, ILD, CHF, and MND.
- The effectiveness of the chest wall vibration interventions should be retested outside the respiratory lab.
- The beneficial timing of neuro-electrical stimulation should be investigated and tested.
- Testing for whether acupressure or acupuncture alone or together has the best relief for breathlessness in patients is needed.
- More research is needed to study the long-term effect of nonpharmacologic interventions on ongoing problems in advanced disease until the end of life.
- Interventions should be developed for breathlessness at rest.
- Mixed approaches of interventions should be tested.
- New nonpharmacologic interventions related to breathless patients in advanced disease should be tested and investigated.
Research Evidence Summaries
Filshie, J., Penn, K., Ashley, S., & Davis, C.L. (1996). Acupuncture for the relief of cancer-related breathlessness. Palliative Medicine, 10, 145–150.doi: 10.1177/026921639601000209
An open pilot study to evaluate the possible therapeutic effect of acupuncture on breathlessness in patients with cancer
Intervention Characteristics/Basic Study Process:
A nurse observer remained with the patient for the first 90 minutes of the study.
- N = 20
- KEY SAMPLE CHARACTERISTICS: Patients with refractory cancer-related breathlessness
- Open pilot study
- Dyspnea was evaluated on two scales: visual analog scale (VAS) (0–10) and the BORG scale.
- The Hospital Anxiety and Depression Scale (HADS) was used once before the intervention.
- Pain, anxiety, and relaxation VASs also were employed before acupuncture and at five time points after acupuncture.
- Respiratory rate, pulse, and oxygen saturation were measured.
Compared to pretreatment levels, significant changes existed in breathlessness, relaxation, and anxiety VAS scores up to six hours after acupuncture, with p values of < 0.005, < 0.005, and < 0.001, respectively. No correlation was found between the anxiety score on the HADS and the effect of acupuncture on breathlessness (r = –0.14). A significant decrease existed in respiratory rate sustained for 90 minutes following acupuncture (p < 0.02). No significant changes in pulse rate or oxygen saturation (p > 0.1) were found.
Treatment contamination is a possibility, considering the nurse‘s presence and communication following the intervention. Whether the acupuncture or the individual care was more effective is unclear.
Further investigation in a randomized study is warranted.
Vickers, A.J., Feinstein, M.B., Deng, G.E., & Cassileth, B.R. (2005). Acupuncture for dyspnea in advanced cancer: A randomized, placebo-controlled pilot trial [ISRCTN89462491]. BMC Palliative Care, 4, 5.doi: 10.1186/1472-684X-4-5
Intervention Characteristics/Basic Study Process:
Treatment consisted of two phases: acupuncture and acupressure. Patients were randomized to receive a single session of true or placebo acupuncture. Semi-permanent acupuncture studs then were inserted, and patients applied pressure to the studs twice a day to provide ongoing stimulation to acupuncture points.
- N = 47 (25 randomized to acupuncture and 22 to placebo)
- KEY DISEASE CHARACTERISTICS: Patients with lung or breast cancer presenting with dyspnea
- SETTING TYPE: Inpatient and outpatient
- LOCATION: Memorial Sloan-Kettering Cancer Center
- Randomized, placebo-controlled pilot trial
- Dyspnea was assessed with a 0–10 numerical rating scale immediately before and after acupuncture treatment and daily for a week thereafter.
Dyspnea scores were slightly higher for patients receiving true versus placebo acupuncture immediately after and for the one week daily follow-up, but the difference was not statistically significant.
Acupuncture technique as used in this trial is unlikely to have an effect on dyspnea.
- Two modifications of the trial existed: the first was to only include patients with non-zero dyspnea scores and the second changed one acupoint on the wrist, which caused pain in several patients. Protocol changes are problematic to the conclusion about the intervention.
- Patients only received one acupuncture treatment as opposed to several, which may be more effective.
- Accrual to the study was slow and limited by refusal by patients who deemed themselves too ill to participate.
Parshall, M.B., Schwartzstein, R.M., Adams, L., Banzett, R.B., Manning, H.L., Bourbeau, J., . . . American Thoracic Society Committee on Dyspnea. (2012). An official American Thoracic Society statement: Update on the mechanisms, assessment, and management of dyspnea. American Journal of Respiratory and Critical Care Medicine, 185(4), 435-452.doi: 10.1164/rccm.201111-2042ST
Purpose & Patient Population:
- The objective was to update the 1999 ATS consensus statement on dyspnea based upon new knowledge of neurophysiology and increasing interest in dyspnea as a patient-reported outcome.
- Included were patients who experience dyspnea from any etiology.
Type of Resource/Evidence-Based Process:
A multidisciplinary group of international experts determined the overall scope of these guidelines according to group consensus. This was followed by evidence reviews in key topic areas conducted by committee members with relevant expertise, and all group members agreed on final content.
Databases searched were PubMed and CINAHL (1999- 2009).
Search keywords were dyspnea, breathlessness, and respiratory sensation, with additional keywords according to specific sections. Reference lists of the articles were hand-searched.
- Mechanisms underlying dyspnea
- Instruments used to measure dyspnea
- The clinical approach to patients who complain of dyspnea
- The treatment of dyspnea that persists despite maximal treatment of underlying pathologic processes responsible for breathing discomfort
- Topics that should be in the focus of future research.
The exclusion criteria were not clearly described.
Phase of Care and Clinical Applications:
- Patients were undergoing multiple phases of care.
- The guidelines have clinical applicability for elder care and palliative care.
Results Provided in the Reference:
- Results were not clearly defined.
- Literature was summarized in a general fashion with strong referencing, but levels and strength of evidence were not noted.
Guidelines & Recommendations:
- Evidence describing the pathophysiology and measurement of dyspnea was comprehensive and well referenced.
- Management of refractory dyspnea despite aggressive assessment and attempts to control the etiology was the focus of the treatment section of the document.
- Therapies with strong evidence to support use include opiates, but adverse effects may interfere with acceptance.
- Therapies with limited evidence to support use include oxygen therapy, nebulized morphine, nebulized furosemide, heliox, anxiolytics, pulmonary rehabilitation, inspiratory respiratory muscle training, chest wall vibration, cool air movement on the face, noninvasive ventilation, acupuncture, and acupressure.
- The consensus document does not use systematic review techniques.
- Although dated 2012, key high-level evidence articles used in the ONS PEP review process (Cochrane Reviews) were not included in the references.
- In these guidelines is limited reference to patients with cancer.
These consensus guidelines from a respected professional organization fill an important void in the literature by describing the pathobiology and measurement instruments for dyspnea. The brief review of treatment options provides information for clinicians to consider for patients with refractory dyspnea.