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.

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• Authors with research in progress were contacted for unpublished data.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.