Yamaguchi, T., Goya, S., Kohara, H., Watanabe, H., Mori, M., Matsuda, Y., . . . Tanaka, K. (2016). Treatment recommendations for respiratory symptoms in cancer patients: Clinical guidelines from the Japanese Society for Palliative Medicine. Journal of Palliative Medicine, 19, 925–935.

DOI Link

Purpose & Patient Population

PURPOSE: To comprehensively revise the society’s previously published guidelines regarding the management of respiratory symptoms (dyspnea, cough, death rattle) in patients with cancer by way of a validated methodology
 
TYPES OF PATIENTS ADDRESSED: All patients with cancer with respiratory symptoms

Type of Resource/Evidence-Based Process

RESOURCE TYPE: Evidence-based guideline, as well as expert consensus

PROCESS OF DEVELOPMENT: Twenty-six clinical questions were developed based on previous JSPM guidelines and a consensus meeting of task force members that included 10 palliative care physicians and 1 epidemiologist. A systematic literature review was completed for each clinical question. All articles underwent a primary and secondary screening process to provide evidence for each clinical question. All literature searches for each clinical question were performed independently by two task force members. Draft recommendation statements for each clinical question with rationale were written by two task force members. A modified Delphi method was used to examine the validity of each draft recommendation statement. The final version of recommendation statements were approved after two Delphi rounds and an external review.
 
DATABASES USED: PubMed, Cochrane Central Register of Controlled Trials (CENTRAL), Ichushi-Web of the Japan Medical Abstracts Society
 
INCLUSION CRITERIA: Articles published before August 2014 and written in English or Japanese. Controlled trials or systematic review including only patients with cancer were first searched and selected. If no or only one article was identified, the search was extended to observational studies including only patients with cancer. Again, if none was identified, then the search expanded to include controlled trials including only patients without cancer.

Phase of Care and Clinical Applications

PHASE OF CARE: End of Life/palliative care
 
APPLICATIONS: Pediatrics, elder care, palliative care

Results Provided in the Reference

No information was provided on the volume of evidence. The grading system developed by the Medical Information Network Distribution Service (MINDS) was used to evaluate the level of evidence, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used to evaluate the strengths of the recommendations.

Guidelines & Recommendations

Oxygen therapy
  • Oxygen therapy is recommended in patients with hypoxemia and not recommended in patients without hypoxemia.
  • Noninvasive positive pressure ventilation (NPPV) suggested to be used in patients with hypoxemia and hypercapnia
  • High-flow nasal cannula oxygen therapy suggested in patients with hypoxemia refractory to standard oxygen therapy
Opioids
  • Systemic morphine is recommended.
  • Systemic codeine/dihydrocodeine is recommended.
  • Nebulized morphine is not recommended.
  • Systemic fentanyl is not recommended.
Benzodiazepines
  • Benzodiazepines are not recommended to be used alone.
  • Benzodiazepines are recommended to be used in combination with opioids.
Nebulized furosemide
  • Nebulized furosemide is not recommended.
Corticosteroids
  • Caution against routine use of systemic corticosteroids without the consideration of the cause of dyspnea
  • Corticosteroids recommended for patients with lymphangitis carcinomatosa, superior vena cava syndrome, or major airway obstruction

Limitations

The authors declared that, because of the lack of rigorous evidence, most recommendations statements were based on level of evidence and mostly on expert consensus. Some evidence reviewed were not wholly based on patients with cancer. The authors were unable to find adequate information on treatment effect on quality of life and pharmaco-economic outcomes.

Nursing Implications

The low level of evidence on which these recommendations are based point to a need for stronger studies on the management of dyspnea in patients with cancer. More research is also needed to investigate the effect of recommended interventions for dyspnea on patient quality of life, as well as cost-effectiveness.