Booth, S., Moosavi, S.H., & Higginson, I.J. (2008). The etiology and management of intractable breathlessness in patients with advanced cancer: A systematic review of pharmacological therapy. Nature Clinical Practice Oncology, 5(2), 90-100.

The objective of this study was to discuss the evidence for our present understanding of the symptom of dyspnea and unanswered questions regarding the genesis and management of cancer-related breathlessness.

Databases searched were MEDLINE, CINAHL, and EMBASE (1966-2006). 

Search keywords were breathlessness, cancer, lung cancer, cancer, dyspnea/dyspnoea, intervention, management, and nonpharmacological.

Studies were included in the review if they were double-blind, randomized, randomized- controlled, or placebo-controlled trials, case reports, or uncontrolled trials that

• Defined the experience of breathlessness
• Assessed the effectiveness of pharmacologic and nonpharmacologic management to relieve breathlessness in patients with advanced cancer.

Older reviews were excluded.

Volume of studies retrieved, methods of study evaluation, and specific information about studies retrieved were not provided. Authors reviewed articles they deemed important to the science of dyspnea in patients with cancer and its management from the perspective of content experts.

The sample characteristics were not described.

• Listening to the patient and caregiver’s experience with dyspnea and creating an individualized breathlessness plan may be helpful in alleviating anxiety-related dyspnea.
• A fan directed at the face is inexpensive and showed efficacy in one study and may be ideal to manage a breathlessness crisis.
• Relaxation and diaphragmatic breathing techniques may aid in breathlessness and anxiety.
• Noninvasive ventilation may have a role in dyspnea symptom control in select patients but has been ill-defined.
• Safety of using opioids across populations of breathless patients with cancer needs to be tested by adequately powered epidemiologic studies.
• No controlled trials support use of phenothiazines or benzodiazepines for management of breathlessness, but authors suggest use of these agents as adjuncts to other therapies or when symptoms are refractory to other therapies.
• A fully powered multi-center randomized controlled international study is underway to test the efficacy of oxygen in reducing dyspnea.
• Heliox is best used after therapies have been rigorously applied and failed to elicit reduction in dyspnea.
• The use of antidepressants or inhaled furosemide for breathlessness in patients with advanced cancer requires systematic investigation.

Progression of the science of understanding breathlessness in patients with cancer requires collaboration between the research and clinical practice of cardiology, oncology, palliative medicine, social sciences, and physiology. Because dyspnea is a dynamic process that may manifest differently in unique populations and situations, possible variables should be well delineated and interventions should be varied to learn the most information about management of this complex symptom.

This review provides a summary of the evidence in multiple interventions, but the report is limited due to lack of provision of study sample characteristics and information regarding the search strategy and methods of evaluation of the strength of the evidence. These limit the level of confidence in findings and conclusions.

The first step to managing breathlessness is careful assessment of the patient and investigation of potential correctable etiologies of breathlessness. The interview should include a patient and caregiver accounting the dyspnea and its triggers, intensity, aggravating factors, alleviating factors, and response to pharmacologic and nonpharmacologic interventions.