Johnson, M.J., Kanaan, M., Richardson, G., Nabb, S., Torgerson, D., English, A., . . . Booth, S. (2015). A randomised controlled trial of three or one breathing technique training sessions for breathlessness in people with malignant lung disease. BMC Medicine, 13, 213-015-0453-x.

To test whether three breathing training sessions are better than one in patients with intrathoracic malignancy experiencing breathlessness

Participants were randomized to receive either one or three hour sessions of training in four techniques (breathing control, pacing/prioritizing, relaxation, and anxiety management). Those randomized to three sessions had the sessions at intervals spaced one week apart. All participants received written and DVD/video reinforcement material and a telephone call from their therapist a week after the final session. The training was provided by the professional who would normally be responsible for completing such training at the given clinical site and included physiotherapists, occupational therapists, and a lung cancer clinical nurse specialists. At two sites, the professionals were described as being a part of a specialist palliative care breathlessness intervention service. Outcomes were measured at week 4 and compared to baseline.

• N = 156   
• MEAN AGE = 69 years
• AGE RANGE = 38–92 years
• MALES: 60%, FEMALES: 40%
• CURRENT TREATMENT: Immunotherapy
• KEY DISEASE CHARACTERISTICS: Patients had intrathoracic cancers (primary or secondary), refractory breathlessness with a self-reported intensity of less than or equal to 3 of 10 on a numerical rating scale (NRS), an expected prognosis of less than three months (clinician estimated), and no prior experience with breathing training.  
• OTHER KEY SAMPLE CHARACTERISTICS: Of note, only 3% of the participants had a non-lung cancer diagnosis (categorized in the study as “other”), 8% had mesothelioma, and 89% had primary lung cancer.

• SITE: Multi-site   
• SETTING TYPE: Multiple settings    
• LOCATION: England, Scotland, and Wales. Settings varied from hospitals, various outpatient oncology/lung/palliative/care outpatient clinics, to hospice units and patients’ homes.

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care

• Randomized, controlled trial

• Patient reported worst breathlessness over last 24 hours as reports on a 1–10 NRS (primary outcome)
• Average intensity of breathlessness, distress due to breathlessness, coping with breathlessness, and satisfaction of breathlessness care as self-reported on a 0–10 NRS
• Injustice and catastrophizing scale
• Chronic Respiratory Questionnaire–Self-Administered Survey (CRQ-SAS)
• Hospital Anxiety and Depression Scale (HADS) 
• Karnofsky Performance Status Score
• EQ-5D and EQ visual analog scale (EQ VAS) for health status
• Brief COPE
• Clinical Global Impression of Change and health service utilization

• Primary outcome: Worst breathlessness as self-reported at week 4 was reduced in both groups with no significant difference between groups.
• Secondary outcomes: The average intensity of breathlessness and coping with breathlessness were similar between arms; distress and sense of mastery over breathlessness were worse in the three-session arm.

No evidence exists that three sessions of breathing training for patients with intrathoracic malignancy with breathlessness were beneficial, and no increased distress and mastery over breathlessness occurred in those receiving three sessions over one. A single session of training is recommended if breathing training is used for breathlessness.

• Risk of bias (no control group)
• Findings not generalizable
• While the study included only those with a prognosis of less than or equal to three months, 30 participants died over the eight weeks they were followed (greater than 10% of participants). While they were not dropouts, this number suggests that the prognostic inclusion criteria was difficult to control for but also that follow-up is missing on a number of the patients. Also, most of the participants had lung cancer, so study results may not be generalizable to other populations.

This study does not assess the effectiveness of breathing training over the standard of care for patients with cancer. If breathing training is considered based on other factors and other evidence, the nurse should be aware that this study does not support use of more than one session.