Fan/Increasing Airflow

Fan/Increasing Airflow

PEP Topic 
Dyspnea
Description 

Increasing airflow and movement to the face has been suggested as an approach to relieve breathlessness. Use of a handheld fan for this purpose was evaluated for management of dyspnea.

Effectiveness Not Established

Research Evidence Summaries

Bausewein, C., Booth, S., Gysels, M., Kuhnbach, R., & Higginson, I.J. (2010). Effectiveness of a hand-held fan for breathlessness: A randomised phase II trial. BMC Palliative Care, 9, 22.

doi: 10.1186/1472-684X-9-22
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Study Purpose:

The objective of the study was to determine effectiveness and acceptance of use of a handheld fan to relieve breathlessness in patients with advance chronic obstructive pulmonary disease (COPD) and cancer.

Intervention Characteristics/Basic Study Process:

Patients were randomly assigned to the fan or control groups. Control patients were given a wristband and instructed to wear it constantly and pull it at short intervals when breathless. Patients in the intervention group were given a handheld fan, shown how to use it (aimed at the central part of the face), and given a booklet with instructions for use. Data were collected at baseline and by monthly postal questionnaires for six months or until the patient died.

Sample Characteristics:

  • The study reported on a sample of 36 evaluable patients.
  • The mean age was 65.6 years (SD = 8.8 years).
  • Of the sample, 51% were males and 49% were females.    
  • Thirty percent of patients randomized had advanced cancer.
  • The number of those completing the trial is not described.
  • Types of cancer are not described.

Setting:

The study was conducted in an unspecified single site in the United Kingdom.

Phase of Care and Clinical Applications:

  • Patients were undergoing end-of-life care.
  • The study has clincal applicability for end-of-life and palliative care.

Study Design:

The study was a randomized controlled trial.

Measurement Instruments/Methods:

A modified Borg scale was used.

Results:

  • Twenty-nine percent in the intervention group and 41% in the control group initially randomized died before completion of the study, and missing data across groups were an average of 55%. 
  • After two months, no significant differences in outcomes were seen between groups.
  • Of 23 patients in the intervention group at two months, 9 considered it helpful and 14 did not. 
  • Power analysis showed that sample size at two months was sufficient to detect an effect size of 2.5, but the actual effect size seen was .08, showing no meaningful effect.

Conclusions:

This study shows that use of a handheld fan for breathlessness was not effective.

Limitations:

  • The study had a small sample size of less than 100.
  • The control condition used may not have been useful . 
  • This study demonstrates the difficulty in providing an appropriate control condition with nonpharmaceutical types of interventions and the difficulty in attempting to evaluate longer term results in patients with advanced disease.  
     

Nursing Implications:

Findings do not show any benefit of a handheld fan to help patients with the sensation of breathlessness.

Galbraith, S., Fagan, P., Perkins, P., Lynch, A., & Booth, S. (2010). Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. Journal of Pain and Symptom Management, 39(5), 831-838.

doi: 10.1016/j.jpainsymman.2009.09.024
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Study Purpose:

The objective of this study was to investigate whether a handheld fan reduces the sensation of breathlessness in patients with dyspnea.

Intervention Characteristics/Basic Study Process:

Room temperature and humidity were controlled, and the fan was directed to either face or leg for five minutes. This was followed by a 10-minute washout followed by repeat intervention, as crossover dyspnea scores were collected at baseline, at completion of each 5-minute intervention, and after 10-minute washout of each intervention. Additional data collected included pulse rate and oxygen saturation after each 5-minute use of the fan and each 10-minute washout.

Sample Characteristics:

  • The study reported on a sample of 49 participants.
  • The mean age was 71.3 years, with a range of 33–90 years.
  • Of the sample, 27 were females and 23 were males.
  • Diagnoses included chronic obstructive pulmonary disease (26), lung cancer (primary or secondary) (11), asthma (8), heart disease (15), bronchiectasis (7), pneumonitis (4), other (20), and multiple diagnoses (26).
  • Other key characteristics included patients in the United Kingdom with refractory breathlessness.
  • Patients were permitted to be on opioids, corticosteroids, and sedatives.
  • Exclusion criteria included use of continuous or short-burst oxygen during the study period and hemoglobin less than 10 gm/dl.

Setting:

The study was conducted in an inpatient medical center and a hospice setting in the United Kingdom.

Phase of Care and Clinical Applications:

  • Patients were undergoing end-of-life and palliative care.
  • The study has clinical applicability for late effects and survivorship.

Study Design:

The study had a randomized, controlled, crossover design.

Measurement Instruments/Methods:

Visual analogue scale (VAS) 10 cm for dyspnea was used. Anchors were no shortness of breath to worst shortness of breath. VAS calculations were performed by a noninvestigator.

Results:

Only eight participants perceived benefits of the fan to the face at the conclusion of 5 minutes, but 19 participants perceived benefit at the end of the 10-minute washout. The eight who initially perceived benefit did register reduction in benefit during the washout period. A significant difference in VAS scores was seen between the two treatment arms with reduction in breathlessness when the fan was directed to the face (p = 0.003).

Conclusions:

Use of a fan pointed at the face may reduce the sensation of breathlessness in a controlled temperature and humidity environment.

Limitations:

  • Washout period of 10 minutes did not appear adequate because the benefit of the fan on the face for some resulted in sustained reduction of dyspnea at the end of 10 minutes. Because washout time may have been incomplete, the results of the second arm of the study may have been biased, and no actual control period in the study existed. 
  • The study had a relatively small sample size of less than 100.
  • Results were found with temperature and humidity control, not just fan use.

Nursing Implications:

Handheld fans are inexpensive and easy and permit empowerment of patient initiation of symptom management. This study suggests that this intervention, in a controlled temperature and humidity condition, will decrease the sensation of dyspnea. Patients may continue to experience benefit from the intervention even after its discontinuation, so it may be extremely helpful as bridge management when awaiting onset of an intervention such as a pharmacologic agent.

Systematic Review/Meta-Analysis

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
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Purpose:

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.

Search Strategy:

  • 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.

Literature Evaluated:

  • 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.

Sample Characteristics:

The study reported on a sample of 2,532 participants in 47 studies categorized into single intervention or multi-component interventions.

Results:

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.

Conclusions:

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.

Nursing Implications:

  • 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.

Guideline/Expert Opinion

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
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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.

Included were

  • 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.

Limitations:

  • 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.

Nursing Implications:

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.


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