Fan/Increasing Airflow

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• Authors with research in progress were contacted for unpublished data.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

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.

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.

• 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.

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

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

The study was a randomized controlled trial.

A modified Borg scale was used.

• 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.

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

• 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.  
   

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

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

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.

• 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.

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

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

The study had a randomized, controlled, crossover design.

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.

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).

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

• 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.

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.

To determine the effect of fan therapy on dyspnea in patients with terminally ill cancer.

Fan therapy consisted of directing a fan to blow air for five minutes across the region innervated by the second/third trigeminal nerve branches. Control was directing a fan to blow air for five minutes to legs. Intervention delivered after a washout period for opioids.

• N = 40   
• AGE: Average age = 69 years
• MALES: 55%  
• FEMALES: 45%
• CURRENT TREATMENT: Had to be getting no cancer treatment
• KEY DISEASE CHARACTERISTICS: Metastatic or locally advanced cancer, ECOG score of 3 or 4
• OTHER KEY SAMPLE CHARACTERISTICS: Dyspnea while sitting or laying at rest, O₂ saturation of 90% or greater

• SITE: Single site
• SETTING TYPE: Inpatient palliative care unit    
• LOCATION: Hospital in Chiba, Japan

• PHASE OF CARE: End of life
• APPLICATIONS: Palliative care

Randomized controlled trial

ESAS-r (ESAS-revised): used NRS for dyspnea (0-10 scale) (primary measure),  facial temperature, respiratory rate, peripheral O₂ saturation, and heart rate (secondary measures)

Improvement in dyspnea for the treatment arm was seen with mean NRS scores that changed by -1.35 in the treatment arm versus a change of -0.1 in the control arm (p < 0.001) and the number of patients who experienced a greater than one or two-point reduction on their NRS was greater (80%) when compared to the control group (25%). There was also a reduction noted in drowsiness in the treatment group. Significant secondary outcomes included that the mean change in drowsiness on NRS was 0.4 for the treatment group versus -0.45 for control (p = 0.01) and facial temperature was significantly lower after the intervention for the treatment group (reduction of 1.43 degrees C) versus control (reduction of 0.01) (p = 0.003)

The authors conclude that the study presents evidence that fan therapy is effective for the treatment of dyspnea in terminally ill patients with cancer.

• Small sample (< 100)

This study has significant implications for nursing as it provides an intervention for dyspnea that could be wholly within the ability of nurses to deliver and could be taught to families. It is also an intervention with little risk and could offer patients some control.

To measure the effect of using electrical fans as a nonpharmacologic nursing treatment to relieve dyspnea among Chinese patients with progressive cancer

The study used a single-blinded trial whereby the participants, dyspneic patients with advanced cancer, were allocated randomly to either the experimental group or the control group. For ethical reasons, both groups were given the same nursing or medical interventions when dyspnea transpired, which included oxygen therapy, rescue medications, and semi-Fowler's positioning. The participants in the experimental group received the fan therapy when dyspneic, which involved the use of an electrical fan directed to the face with a low flow rate for five minutes. Baseline demographics, medical diagnosis, hemoglobin levels, and drug treatments were recorded before the intervention was made. Furthermore, clinical parameters including a numeric rating scale (NRS), respiratory rate (RR), and SpO2 were taken before and after each use of the fan therapy.

• N = 30   
• AGE = Adults
• MALES: 47%, FEMALES: 53%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: The main cancer diagnosis of the participants was carcinoma of the lung.
• OTHER KEY SAMPLE CHARACTERISTICS: Other diagnoses included colorectal, stomach, breast, and prostate cancers as well as lymphoma. Of the patients, 96.7% required chronic oxygen therapy during the study. All patients were Chinese. Inclusion criteria included patients capable of expressing that they had dyspnea and baseline dyspnea level on numeric rating scale (NRS) of 3 or higher. Excluded patients had a fever or acute shortness of breath, and were mentally incompetent or unwilling to participate.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: Hospice and Palliative Care Center of Kiang Wu Hospital, China

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Elder care, palliative care 

• Randomized, control trial

• Verbal NRS from 0–10 signifying “no shortness of breath” to “very severe shortness of breath.” Patients were shown a colored picture with words and figures along with numbers on the rating scale, and respondents either pointed to picture or stated a number aloud. 
• Finger pulse oximeter indicating the SpO2 and RR

In the experimental group, participants' self-reported breathlessness score was 6.13 and 4.6 before and after intervention, respectively, demonstrating a 1.53 improvement after the intervention (p < 0.01). However, other measurement parameters comprising the RR and SpO2 exhibited no significant improvement (p > 0.05). After recording the second assessment postintervention for the experimental group, the control group was given the fan therapy. No substantial change in self-reporting, RR, and SpO2 was noted.

The results of this randomized, control trial showed a significant improvement in self-reporting of breathlessness among the participants in the intervention group using fans. Since dyspnea is a subjective symptom, self-report in improvement of dyspnea demonstrates a positive outcome despite no improvement in RR or SpO2.

• Small sample (< 100)
• Risk of bias (no appropriate attentional control condition)
• Measurement/methods not well described
• Measurement validity/reliability questionable
• Subject withdrawals ≥ 10% 
• Subjects all were Chinese, so results may not be generalizable to the general population.
• The authors concluded that the control group did not demonstrate improvement in dyspnea when offered the fan later because it was not offered immediately; this would need to be further tested prior to making that assumption.

These findings shed light on new interventions that nurses could use to alleviate dyspnea in their patients with cancer. In addition, because the intervention is cheap and practical (no needed training), it could be one of the most ideal interventions for a nurse to use. Further studies incorporating larger and culturally diverse sample sizes are recommended for validation. People of Chinese heritage may ascribe to the belief that, in Chinese medicine, a “cold pathogen” may attack and harm the body; as a result, they may be concerned that prolonged exposure to fan therapy may give them a cold or a headache; therefore, they may be resistant to its use for reasons not related to efficacy in mitigating dyspnea.

• 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.

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.

• Patients were undergoing multiple phases of care.
• The guidelines have clinical applicability for elder care and palliative care.

• Results were not clearly defined.
• Literature was summarized in a general fashion with strong referencing, but levels and strength of evidence were not noted.

• 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.

• 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.

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.