Psychoeducation/Psychoeducational Interventions

The objective of the systematic review was to assess the effectiveness of non-invasive interventions delivered by healthcare professionals in improving symptoms, psychological functioning, and quality of life.

Databases searched were Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, PsycINFO, AMED, British Nursing Index and Archive, and reference lists from relevant studies.

Search keywords were non-invasive interventions and lung cancer.

Randomized controlled trials and controlled clinical trials were included. The trials included involved

• Patients of any age or gender diagnosed with lung cancer
• Any stage of illness
• Any non-invasive intervention treatment or action performed by healthcare professional to enhance well-being or quality of life defined to include symptoms related to cancer.

A total of 20 references were retrieved. Two authors independently assessed all the references. Three of 15 studies included in this review were evaluated together in one category labeled “Nursing Interventions to Manage Breathlessness.” Of the three studies that focused solely on breathlessness, two studies previously were evaluated in the 2009 Putting Evidence Into Practice publication.  

The final number of studies included was 15. The breathlessness category included 165 patients with lung cancer. The sample range across studies was 22-109.

Patients had lung cancer with refractory breathlessness, the majority of which were not receiving active therapy. Patients received breathlessness rehabilitation, which focused on emotional as well as physical aspects of the symptom, or breathlessness training intervention, described as training in diaphragmatic breathing, pacing, anxiety management, and relaxation.

The three studies found that the intervention was effective in improving the sensation of breathlessness at best and also had beneficial effects on performance status, functional ability, and depression. Due to the stage of disease and limited life expectancy of those diagnosed with advanced lung cancer, rapid deterioration and attrition were seen in one of the studies.

The studies of breathlessness management indicate that nurse-led breathing programs may produce beneficial effects and should be encouraged.

The objective of the article was to review studies that evaluated nonpharmacologic interventions for breathlessness management in patients with lung cancer.

Databases searched were Cochrane Library, EMBASE, PubMed, Ovid, EBSCO Host as a search engine for CINAHL, Pre-CINAHL (2007), Health Source: Nursing/Academic Edition, and MEDLINE (all searched 1990-July 2007).

Search keywords were breathlessness, dyspnea, management, interventions, treatment, non-pharmacological, and lung cancer.

Nonpharmacologic interventions for breathlessness in patients with lung cancer were included.

Pharmacologic interventions for breathlessness, studies that did not include patients with lung cancer, descriptive studies, and studies not published in English literature were excluded.

One hundred sixty-nine abstracts were retrieved, 15 articles were reviewed, and five studies ultimately were included. Studies were eliminated based on selection criteria. Standardized abstraction procedures were used to evaluate included studies.

A total of 370 patients were in the five studies included [Corner (20), Bredin (103), Connors (14) , Hately (30), Moore (203)].

All studies included behavioral, psychological, and educational interventions, although the method of delivery varied between studies.

Evidence is moderately strong to suggest benefit of a counseling and supportive educational intervention to alleviate breathlessness in patients with lung cancer. While all studies showed benefit with a multicomponent nonpharmacologic intervention approach, whether all components are warranted or whether one component is more/less effective than another is inconclusive.

Studies were limited by small sample size or high attrition rates.

Nurses should consider providing support and counseling for breathing techniques, relaxation, and breathing retraining in patients with breathlessness and lung cancer.

Patients diagnosed with lung cancer were randomized to attend a nursing clinic offering interventions for breathlessness versus best supportive care. The intervention consisted of

• A detailed assessment of breathlessness, what hinders it, and what aids it
• Advice and support for patients and families on management of breathlessness
• Exploration of the meaning of breathlessness, disease, and their future
• Training in breathing control techniques, relaxation techniques, and distraction exercises
• Goal setting to complement breathing and relaxation techniques, to improve function and social activities, and to help develop coping skills
• Early identification of problems needing pharmacologic or medical intervention
• Clinic visits once a week up to eight weeks and not less than three weeks.

Control: received standard of care for breathlessness; best supportive care involved standard management and treatment available for dyspnea. Nurse specialists used and were taught the intervention in same way, using a practice guideline to ensure correct delivery of the intervention.

The study reported on a sample of 119 patients with lung cancer; the goal was to recruit 150 patients for 90% power. Data from 16 patients were lost because a center was dropped from the study. Final sample included 51 in the intervention group and 52 in the control group.

The study was conducted in nursing clinics in six hospital settings in London, United Kingdom.

The study design included randomization to either intervention or control group.

Outcome measures were conducted at baseline and at four and eight weeks.

• VAS measuring breathlessness at worst and at best and distress caused by breathlessness
• World Health Organization (WHO) performance status scale
• HAD
• Rotterdam symptom checklist

The intervention group improved significantly at eight weeks in 5 of 11 items assessed.

• Breathlessness at best
• WHO performance status
• Level of depression
• Physical symptom distress and breathlessness from Rotterdam symptom checklist

Final sample included 51 in the intervention group and 52 in the control group. Attrition: 16 patients died, and 28 withdrew. Reasons for withdrawal: 1 improved condition, 16 had deterioration, 4 were unhappy with the assigned treatment arm, and 7 were for unknown reasons. Survival of patients who withdrew was significantly worse than the intervention arm (hazard ratio = 2.5; p < 0.05). Survival of all who withdrew versus nonwithdrawals was also significantly worse (p < 0.01). Overall survival of the intervention and control groups was not different. At baseline, both groups had high level of distress caused by breathlessness and associated functional impairment.

Overall conclusion is that patients attending nursing clinics for breathlessness experienced improvements in breathlessness, performance status, and physical and emotional status.

The analysis was based on the assumption that missing data from patients who withdrew because of poor outcomes were assigned a lower change score .The findings would have been more credible if outcomes were actually assessed. The method assumed that patients were able to show a change in either direction on rating scales, but patients who were on the extreme could only go in one direction. As stated in the Corner et al. (1996) pilot study, the contribution of each component of the intervention is unknown. Are all components needed to achieve the same outcome, or was one aspect of the intervention most significant?

To examine the effectiveness of a psychoeducational intervention (PEI) on the symptom cluster of anxiety, breathlessness, and fatigue compared with usual care.

Education on symptom management and coaching on the use of progressive muscle relaxation was delivered to patients one week prior to the start of radiotherapy (RT) and repeated three weeks after beginning RT. Symptom data were collected at four times points:  prior to the intervention and at three, six, and 12 weeks postintervention.

• In total, 140 patients (83% male, 17% female) with lung cancer receiving palliative RT were included.
• Patients were 16 years or older.
• Patients had stage III or IV lung cancer.

• Single site
• Outpatient
• RT unit of a publicly funded hospital in Hong Kong

The study was a randomized, controlled trial using a pre-/posttest design with two groups.

• Breathlessness was assessed using a 100-mm visual analog scale.
• Fatigue was measured with the intensity subscale of the revised Piper Fatigue Scale (PFS), consisting of 23 items. The instrument was translated into Chinese and found to be valid and reliable.
• Anxiety was measured using the Chinese version of the State-Trait Anxiety Inventory (STAI), consisting of 20 items for measuring immediate feelings of apprehension, nervousness, and worry.
• Functional ability was a secondary outcome measure, using the subscale of the Chinese version of the Short Form 36 (SF-36) Health Survey.

A significant difference (p = 0.003) was seen over time on the pattern of change of the symptom cluster between the PEI intervention and the usual care control group. Significant effects on patterns of changes in breathlessness (p = 0.002), fatigue (p = 0.011), anxiety (p = 0.001), and functional ability (p = 0.000) were found.

PEI is an effective treatment for relieving the symptom cluster of anxiety, breathlessness, and fatigue and each of the individually assessed symptoms.

• The study had a small sample size, with less than 100 participants.
• A high attrition rate was due to death.

The study provided evidence to support the symptom cluster of anxiety, breathlessness, and fatigue as interrelated, with assessment and management of those three symptoms as a cluster. Clarification of the nature of their interrelatedness is a potential area of further study. Education and counseling patients through nurses can be helpful in the management of these symptoms.

• Week 1: Breathing control and assessment
• Week 2: Review, relaxation, and anxiety management techniques
• Week 3: Review, energy conservation, goal setting, and lifestyle adaptation
• Week 4: Review and assessment
• Week 8: Review and re-assessment

This program was conducted for four years. The study was based on prior research conducted by Corner et al. (1996) and Bredin et al. (1999), also reported elsewhere in the table.

The study reported on a sample of 169 patients. All patients reported breathlessness as a symptom. Patients were referred from three sources to a physiotherapist-led breathlessness program for patients with intrathoracic malignancy. The three sources included an outpatient lung cancer clinic, the inpatient unit, or the community where they were referred by a specialist palliative care team. A screening questionnaire was used to identify the cause of breathlessness. If the cause was reversible, the patient received appropriate care. Only 14 of 169 completed the entire program.

The following tools were used at one, four, and eight weeks.

• Chronic Respiratory Disease Questionnaire
• Number counting
• VAS of breathlessness at worst and at best and distress related to breathlessness

Only 14 of 169 completed the entire program. The following are characteristics of the 14 who completed the program.

• Referred from the outpatient setting
• Had radical treatment
• Etiology of the breathlessness was either treatment-related or because of other causes but not from progression of disease.
• Median survival was 630 days

Of the 14 who completed the program, pre- and post-assessment scores showed modest improvement, but it was not statistically significant. The majority did not complete the program. One hundred thirty-one patients (85%) were seen at least once and anecdotally had subjective benefit. Of those who did not complete the program, some had progressive disease and were too ill to participate or died before being seen. Median survival was 95 days.

Patients with intra-thoracic cancer may benefit from a formal nonpharmacologic program. Patients who are frail and/or on palliative care may need a more flexible program.

One hundred fifty-five patients did not complete the program because of progressive disease and associated shorter survival. The small subset who did complete the program did not show significant improvement in dyspnea measures. Dropout rate was 82% versus 41% in the Corner study and 43% in the the Bredin study. Interventions in the three studies were similar. The difference in dropout rate for this study compared to Bredin and Corner’s studies is explained by the fact that the patients in this study were older and were recruited from the totality of patients with lung cancer presenting to the cancer center.

The intervention included weekly sessions with a nurse research practitioner, lasting one hour, using counseling, breathing retraining, relaxation, and the teaching of alternate coping and adaptation strategies. The interventions are the same as those commonly used to treat patients with chronic pulmonary disease. Patients were randomized either to an intervention group or control group. The intervention group met over a three- to six-week period. Additional follow-up sessions were available if necessary. The number of sessions was not stated. The control group received usual nursing care such as breathing assessment with documentation in the medical record.

The study reported on a sample of 20 patients with lung cancer. The patients had completed either chemotherapy or radiotherapy and were experiencing breathlessness.

The study was conducted in a nurse-led clinic in a specialist cancer center.

Randomized, controlled pilot study

• A 10-point VAS measuring three time frames (best, worst, and usual) to rate breathlessness over the previous week
• Distress caused by breathlessness
• Functional Capacity Scale
• HADS

Median scores on all measures were improved. Distress from breathlessness improved 53%, breathlessness at worst improved 35%, and functional capacity improved by 21%. Distress in the control group worsened by a median of 10%. Significant improvements compared with the control group were observed in breathlessness at best (p < 0.02) and at worst (p < 0.5), distress caused by breathlessness (p < 0.01), and functional capacity (p < 0.02). Improvements were not observed for anxiety or depression.

The study demonstrates that patients with lung cancer and breathlessness benefit from a rehabilitative approach.

The effect of time and attention on a weekly basis independent of intervention is unknown. The contribution of each component of the intervention is unknown. Are all components needed to achieve the same outcome, or was one aspect of the intervention most significant? The study had a small sample, and baseline data show that the intervention group rated distress caused by breathlessness higher than did the control group.

The study is valuable as a pilot study with an aim to test feasibility.

To evaluate the effects of a specialized breathlessness intervention service compared to usual care

The breathlessness intervention service (BIS) was a multidisciplinary complex intervention including nonpharmacologic and pharmacologic interventions to support patients with advanced disease and dyspnea. The BIS used first-stage interventions such as positioning to reduce the work of breathing, education, individualized exercise plans, relaxation techniques, sleep hygiene, cognitive behavioral therapy approaches, and other supports. Second-stage interventions applied concurrently included opioids, antidepressants, anxiolytics, etc. Patients referred to this service were randomly assigned to the intervention or to a wait-list control group. Study measures were obtained at baseline and after the intervention. Interviews were done before randomization, at two weeks, and at five weeks. The interviews were recorded and transcribed verbatim for analysis. A final qualitative analysis was done from 20 intervention transcripts that were purposefully sampled to obtain a diverse group from those who improved and did not improve.

• N = 54 (47 completed five-week evaluations, 39 respondents)
• MEAN AGE = 69 years (SD = 11.5 years)
• MALES: 59%, FEMALES: 41%
• KEY DISEASE CHARACTERISTICS: Lung cancer was most prevalent

• SITE: Single site  
• SETTING TYPE: Not specified    
• LOCATION: United Kingdom

• PHASE OF CARE: Active antitumor treatment
• APPLICATIONS: Palliative care 

Randomized, controlled trial

• Distress scores caused by breathlessness
• Hospital Anxiety and Depression Scale (HADS)
• Chronic Respiratory Questionnaire (CRQ)
• Numeric Rating Scale (NRS) for distress
• EuroQol Five Dimensions Questionnaire (EQ 5-D) for generic health status

Patients in the intervention group had greater reductions in breathlessness (1.68 versus 0.23 points, p = 0.049). There were no other significant differences in outcomes for patients or caregivers between study groups. Interventions identified as helpful were providing and teaching the use of a handheld fan, encouraging exercise, coaching in breathing techniques and positioning, medication changes, and referrals to other services. Total costs were lower for the intervention group, and a cost effectiveness analysis showed a 66.4% likelihood that the intervention would result in lower cost and better outcomes in terms of reduced distress from breathlessness. Scores for mastery of symptom management did not change significantly.

This complex psychoeducational and pharmacologic intervention was associated with reduced distress from breathlessness. No effects on patient or caregiver distress, anxiety, or depression were found.

• Small sample (< 100)
• Risk of bias (no blinding)
• Risk of bias (no appropriate attentional control condition)
• Other limitations/explanation: With this complex, multicomponent intervention, it was not possible to determine which aspects were most effective in achieving improved outcomes.

Individual interventions such as opioid use have been shown to reduce dyspnea, so it was not possible to determine the relative value and utility of the combined interventions examined here. These study findings suggested that multicomponent, complex interventions to improve symptoms of breathlessness can be cost effective and improve outcomes.

To determine the feasibility and usefulness of providing brief behavioral interventions to manage dyspnea in patients with advanced lung cancer

Participants received two 30-minute intervention sessions by the same nurse practioner, the second session provided within four weeks of the first. Two nurse practioners were trained in psychoeducation, behavioral techniques, and relaxation. The first session consisted of the nurse practioner explaining cognitive behavioral therapy and the effects of breathlessness, triggers, physiological factors, and behavioral responses on patients. Patients were taught pursed lip breathing, how to use a battery-operated fan, postural techniques, relaxation exercises, diaphragmatic breathing, and meditation. Participants were provided MP3 players with a recording of the guided breathing exercises to practice at home. The second intervention session consisted of reviewing and reinforcing the above instruction, answering questions, and identifying problems or obstacles.

• N = 32   
• AGE = 63.34 years
• MALES: 43.7%, FEMALES: 56.3%
• CURRENT TREATMENT: Other
• KEY DISEASE CHARACTERISTICS: Advanced lung cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Eastern Cooperative Oncology Group (ECOG) performance status of 0–2, ongoing outpatient oncology treatment, English language literacy, and Modified Medical Research Council Dyspnea Scale (MMRCDS) score of less than or equal to 2 

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Scheduled visits in an outpatient infusion suit and a follow-up appointment or telephone call

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

• Pre/post design

Participants completed three measurements: the MMRCDS, the Functional Assessment of Cancer Therapy–Lung Trial Outcome Index (FACT-L TOI), and the Hospital Anxiety and Depression Scale (HADS) at baseline and again postassessment (six weeks after enrollment). Also used was the enrollment rate/study completion rate to examine feasibility.

Fifty-seven patients were referred to the study with 32 patients enrolled. Four patients could not complete it and one withdrew, leaving 27 participants completing all study procedures (84%). First intervention sessions were provided in the infusion suite, and half of the second sessions were provided in the infusion suite and half over the phone. Participants reported reduction in dyspnea (MMRCDS) over time and improvement in quality of life (QOL) (FACT–L TOI) and depression (HADS), but no significant differences in anxiety. Results were unchanged for all outcomes when adjusting for primary and secondary analyses for the line of chemotherapy.

This study demonstrates the feasibility and possible benefit of providing brief behavioral interventions to patients with advanced lung cancer to decrease breathlessness, improve QOL, and decrease depression. The study showed that a potential barrier may be the availability of resources and time for staff in cancer centers to provide education and training to patients. With a small sample size and pre/post design, larger randomized controlled studies are needed to determine intervention effectiveness.

• Small sample (< 100)
• Risk of bias (no control group)
• Risk of bias (sample characteristics)
• Unintended interventions or applicable interventions not described that would influence results
• Findings not generalizable
• Patients may have simultaneously responded to chemotherapy resulting in decreased breathlessness.
• Recruitment limited to clinician referral
• Homogenous sample limited the generalizability of results.
• The racial makeup was 93% Caucasian, and 63% were college graduates.
• Participants consisted of only patients with lung cancer.

Dyspnea, which impairs QOL, is a common symptom in patients with advanced lung cancer. Oncology nurses are in unique position to assess dyspnea and how it relates to patient distress and overall QOL. Nurses trained in strategies and interventions to decrease dyspnea are also in a unique position to provide this education to their patients.

Potential patients were referred to a highly experienced palliative care physiotherapist clinic. Patients were seen by the physiotherapist at three sessions, each lasting as long as 90 minutes. Intervention consisted of breathing retraining, simple relaxation techniques, activity pacing, and psychosocial support.

The study reported on a sample of 30 patients with non-small cell lung cancer, small cell lung cancer, or mesothelioma (pleural effusion excluded) who experienced breathlessness not less than one month after completion of any active treatment; 68 patients were referred, 17 did not fulfill the criteria, 4 declined, and 2 were too ill to treat. Forty-five entered the study, and 15 deteriorated or died before completion. The median age was 71 years; 24 were men, and 6 were women.

The study was conducted in an outpatient clinic in the United Kingdom.

• Uncontrolled study
• Nonrandomized
• Referred patients

Tools completed by the therapist at each visit

• Current Respiratory Symptoms—adapted from two scales (Medical Research Council and Respiratory Symptom Questionnaire); patients were asked to score how often they were breathless, ranging from most or all the time to less than once a week
• Functional Capacity Scale adapted from above tools; patients scored their ability to climb hills or stairs without breathlessness to experiencing breathlessness at rest
• Sputum production scale

Self-assessment tools completed by patients at baseline and following the intervention (four to six weeks)

• Rotterdam symptom checklist
• VAS: breathing at worst and at best in the proceeding 24 hours as well as distress caused by breathlessness (0–10 where 10 = extreme distress)
• Things that improve breathing (in the clinic, patients were taught techniques and coping strategies likely to improve their feeling of breathlessness); the patients were asked to score 20 helpful strategies at baseline and at the last visit on a VAS (1–10 where 10 = extremely helpful).
• Quality-of-life questionnaire
• Therapist recorded patients’ verbatim comments in free narrative form and added own comments.

Statistical analysis of baseline data on 12 patients who were unable to complete the study compared to 30 patients who completed the study showed significantly lower Functional Capacity Scale scores (p = 0.04) at first assessment. For patients who completed the study, a highly significant (p < 0.001) change in frequency of reported breathlessness was found. A decrease existed in reported breathlessness, from 97% reporting it at least once or twice a day, 73% several times a day, and 27% most of the time to 27% experiencing dyspnea several times a day and 3% most of the time at the final visit. A statistically significant change was seen between study entry and completion (p < 0.001) in functional capacity. Overall, 19 improved function, 9 remained stable, and 2 deteriorated.

No change in sputum production was found.

Rotterdam symptom checklist:

Significant changes were seen in the physical distress scores and activity levels (no p value given). Change in psychological distress scores were borderline.

Degree of breathlessness:

Significant improvement (p < 0.001) was found in all three parameters—breathing at best, breathing at worst, and distress caused by breathlessness.

Intervention strategies:

On study entry, patients were asked to score 20 strategies that were likely to improve feelings of breathlessness. Examples of interventions include activity pacing, abdominal breathing, slowing down, relaxation exercises, not worrying, accepting the situation, and positive thinking.

Patients reported that all of the techniques they learned were helpful and improved breathlessness. Patients reported that massage and the use of bronchodilator drugs were not helpful.

Quality of life:

Significant improvements were seen in decrease in time spent lying down (p = 0.02), improved bodily strength (p = 0.03), and increase in things that made patients happy (p = 0.04). Patients reported an increased ability to do things and improved quality of life.

Qualitative data:

The following themes were extracted from the narrative data: difficulty adjusting, issues around death, effects of treatments, and therapies’ impact on daily life.

The study was uncontrolled. A major limitation of the study is that it is a nonrandomized trial of referred patients. Impossible to know are the implied bias in patients who were referred or the true effect of the intervention without a control group. It was based on a prior study, with the time period shortened because of the loss of patients in the earlier study’s sample.

To assess the effectiveness of a short-term breathlessness support service in facilitating breathlessness mastery in patients with advanced disease

• N = 105 (53 assigned to the breathlessness support service, and 52 assigned to the standard care group)  
• AVERAGE AGE = 67 years
• MALES: 58%, FEMALES: 42%
• KEY DISEASE CHARACTERISTICS: Patients were included if they experienced refractory breathlessness on exertion or rest despite optimum treatment of their underlying disease; advanced diseases including cancer, chronic obstructive pulmonary disease (COPD), chronic heart failure, interstitial lung disease, and motor neuron disease were included; willing to participate in home physiotherapy and occupational therapy; able to provide informed consent
• OTHER KEY SAMPLE CHARACTERISTICS: Patients were excluded if they experienced breathlessness of unknown etiology, had a primary diagnosis of chronic hyperventilation syndrome, were completely homebound despite the offer of free clinic transport, or were within two weeks of treatment for an acute exacerbation.

• SITE: Multi-site    
• SETTING TYPE: Multiple settings    
• LOCATION: South London

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

This was a single-blinded, randomized, controlled trial. Research nurses and interviewers were blinded to the treatment allocation. Participants, the trial coordinator, and the trial administrator were aware of the treatment allocation.

• Chronic Respiratory Disease Questionnaire (CRDQ)
• London Chest Activity of Daily Living (LCADL) scale
• EQ-5D and EQ Visual Analog Scale (VAS)
• Palliative Care Outcome Scale (PCOS)
• Hospital Anxiety and Depression Scale (HADS)
• Spirometry to assess pulmonary function
• Pulse oximetry to assess oxygen saturation
• Severity of breathlessness in the previous 24 hours on a numeric scale (0–10)

An integrative approach to managing breathlessness within a support service improves patient mastery of breathlessness.

• Findings not generalizable
• Other limitations/explanation: One limitation of the study was a possible placebo effect because participants were not blinded to their specific treatment groups. The authors also suggested that although nurse researchers were blinded to the intervention groups, they may have been able to determine which treatment group participants were assigned based on the existence of breathlessness equipment in their homes (thereby potentially biasing their interviews). In addition, the authors noted that their inclusion and exclusion criteria prevented the inference of study results to patients in the last month of life. Finally, the authors noted that the short-term nature of outcome follow-up restricted their assessment of care costs and long-term survival.

Additional research and education on the structure and process of an integrative breathlessness support service for patients with advanced cancer is warranted.

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.

The objective of the article is to report on strategies that patients with breathlessness find helpful and provide a review of current evidence about the role of nonpharmacologic interventions in managing dypsnea.

This article reports a secondary analysis of data from a trial in which self-report items were used to assess the impact of dyspnea on daily activities, feelings about breathlessness, and strategies adopted by patients. Authors also review the findings of several systematic reviews of nonpharmacologic interventions for breathlessness involving patients with chronic obstructive pulmonary disease (COPD) as well as lung cancer.

• The article reported on a sample of 144 patients.
• The mean age was 67.9 years (SD = 9.6 years).
• The sample was 60% males and 40% females.
• Patients involved in self-report of strategies all had cancer. 
• Most data from systematic reviews involved primarily patients with COPD.

The multi-site study was conducted in an unspecified setting in Australia.

• Patients were undergoing end-of-life care.
• The article has clinical applicability for palliative care.

Descriptive

• Author-designed self-report instrument based on an assessment guide developed in the UK
• Likert-type scoring on a 4-point scale

About half of patients reported that breathlessness had some effect on feelings of panic, fear, and anger. Activity modification was the most frequently used strategy.  Cognitive coping strategies were used by 80% of respondents. Other strategies included breathing exercises and environmental modifications. The most helpful strategies related to activity modification. Of those who used coping and breathing exercises, 60% said they were helpful. Breathing retraining was found to be effective but is mainly studied in COPD. Exercise program findings are inconclusive, and interventions to reduce anxiety have had some positive outcomes. Other interventions such as music, distraction, and complementary medicine have insufficient evidence.

Patients in this study reported that activity management was helpful to manage dyspnea.

• Risk of bias (no control group)
• Risk of bias (no blinding) 
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition) 
• Risk of bias (sample characteristics)
• Measurement validity/reliability questionable
• The likert scale used is questionable in terms of lack of differentiation in terms used for degree of effect.
• Findings reported from systematic reviews were mainly from COPD cases, and few included patients with lung cancer. 
• Other cancers were not included.

Findings suggest that educating appropriate patients about activity management can be helpful for them to manage symptoms of dyspnea. Limited evidence exists about the effects of other nonpharmacologic approaches that are effective for patients with cancer.

To test the feasibility of a new nonpharmacologic intervention to manage the symptom cluster of respiratory distress including breathlessness, cough, and fatigue in patients with lung cancer

Participants received psychoeducational counseling, which consisted of controlled breathing techniques, cough-easing techniques, acupressure, and supplementary information. Participants attended two one-hour face-to-face teaching sessions, the second session given one week after the first, and then received a telephone call two weeks after the second session. The interventions were delivered by a complementary therapy team. The training for the team consisted of one three-hour face-to-face session and a follow-up refresher at the half point of the trial. Participants were asked to complete a daily diary for the first four weeks and then weekly until week 12. Participants were also asked to assess and document the usefulness of each core component or intervention; and to practice breathing and calming techniques twice a day, use education for identifying warning signs of a cough, use a modified swallow technique and relaxed throat breathing, apply pressure to identified acupressure points for one minute at least twice a day, and review information in an information packet.

• N = 101   
• AGE = 67.7 years
• MALES: 47%, FEMALES: 53%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Primary lung cancer
• OTHER KEY SAMPLE CHARACTERISTICS: Participants with an expected prognosis of at least three months, a World Health Organization (WHO) performance status of 0–2, and who were bothered with two of the cluster symptoms (breathlessness, cough, fatigue)

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Two specialist cancer settings and two general hospitals in northern England

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

• Randomized, controlled trial comparing the intervention group and the control group

Participants were randomized to either the control arm or intervention (RDSI) arm. Outcome assessments were collected at baseline, week 4, and week 12 at the end of the study. Breathlessness was measured using numerical rating scales and the dyspnea-12 scale, cough was assessed using the Manchester Cough in Lung Cancer scale (MCLC), and fatigue was assessed using Functional Assessment of Cancer Therapy–Fatigue (FACIT-F). In addition, the EQ-5D-3L was used to describe the value of quality of life (QOL), and the Hospital Anxiety and Depression Scale (HADS) was used to measure anxiety and depression.

Numerical rating scales were scored lowest for ease of use and relevance, and EQ-5D-3L was scored best for ease of use and relevance. Patients rated dyspnea-12 better for ease of completion and relevance, and EQ-5D-3L and HADS demonstrated a positive pattern in improvement for the intervention group. Participants reported a high adherence to interventions with breathing exercises and acupressure, and the lower use of cough-easing techniques was likely related to the lower number of participants bothered by cough in the intervention group. The majority of participants responded favorably to breathing exercises in responses, stating that it was useful at least a little bit, and cough and acupuncture responses also were favorable but had a higher number of responses saying that it was not useful at all. No significant difference existed in breathlessness between groups.

This study demonstrated the feasibility and acceptability of nonpharmacologic interventions to manage symptoms of breathlessness, cough, and fatigue in patients with lung cancer. The study gave insight to the best tools/instruments to measure outcomes for larger trials that will determine improved patient outcomes with interventions. This study also revealed patients' willingness to learn new strategies and complete study requirements for data collection. The results trended better outcomes in the treatment group, but the trial was not large enough to draw conclusions.

• Small sample (< 100)
• Risk of bias (no blinding)
• Findings not generalizable
• Subject withdrawals ≥ 10% 
• The sample size calculation indicated that a larger sample size is needed to determine whether or not the intervention resulted in improved patient outcomes and is cost-effective compared to the control group.

Nurses play an important role in identifying and managing patients with the respiratory distress symptom cluster. The study suggests the potential role for nurses to educate patients or to refer patients to complementary practioners who will instruct them on breathing techniques, cough-easing techniques, and acupressure.

The objective of the guidelines is to provide palliative care practice guidelines for patients with cancer, facilitating the appropriate integration of palliative care into oncology practice.

These are consensus-based guidelines.

Included in the guidelines are multiple phases of care with palliative care applications. 

The NCCN made recommendations on the following symptoms.

Anorexia
Nutritional support, including enteral and parenteral feeding, should be considered. Appetite stimulants such as megestrol acetate and corticosteroids can be used when appetite is an important aspect of quality of life.

Chemotherapy-Induced Nausea and Vomiting (CINV)
Recommendations include prochlorperazine, haloperidol, metoclopramide, or benzodiazepines. Adding 5-HT₃ receptor agonists, anticholinergics, antihistamines, corticosteroids, antipsychotics, and cannabinoids also can be considered. Palliative sedation can be considered as a last resort.

Constipation
Increase fluid intake, dietary fiber, and physical activity. Opioid-induced constipation should be anticipated and treated prophylactically with laxatives.

Dyspnea
Pharmacologic interventions include opioids or benzodiazapines. Scopolamine, atropine hyoscyamine, and glycopyrrolate are options to reduce excessive secretions.

Pain
Do not reduce opioid dose for symptoms such as decreased blood pressure or respiratory rate. Palliative sedation can be considered for refractory pain.

Sleep/Wake Disturbances
For refractory insomnia with no underlying physiologic cause, pharmacologic management includes diazepam, zolpidem, and sedating antidepressants. Cognitive behavioral therapy may be effective. If present, restless leg syndrome can be treated with ropinirole.

• Recommendations are predominantly consensus- rather than evidence-based. 
• Recommendations are generally based on low-level evidence. 
• Recommendations regarding CINV seem particularly out of date and are not in concert with current evidence.

Recommendations provide expert opinion/consensus-level suggestions for management of various symptoms. Many recommendations, such as those for CINV, do not agree with current evidence in these areas.

Objectives were to

• Present evidence that will contribute to the improvement of palliative care at the end of life.
• Answer questions regarding critical elements.
• Identify patients who could benefit from palliative approaches.
• Identify treatment strategies that work for pain, dyspnea, and depression.
• Identify elements important in advance care planning, collaboration and consultation, and assessment and support aspects helpful to caregivers.

Included were patients with any disabling or symptomatic condition at the end of life.

The guideline was based on a systematic evidence review, done by others, in an Agency for Healthcare Research and Quality evidence report. The guideline does not address nutritional support, complementary and alternative therapies, or spiritual support because evidence related to these areas does not often appear in the literature. Specific procedures for grading the evidence and recommendations are not described.

The guideline was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians. Evidence and recommendations were graded using the clinical practice guidelines grading system (GRADE).

Databases searched were MEDLINE and the Database of Abstract Reviews of Effects (January 1990–November 2005); citations from the review by the National Consensus Project for Quality Palliative Care (2003) also were searched.

Search keywords were cancer, congestive heart failure, and dementia. The full description of search terms is published elsewhere.

The guideline outlines the strength of GRADE recommendations and includes a brief description of the supporting evidence for each recommendation.

Critical Elements for End-of-Life Care: Elements identified are preventing and treating pain and other symptoms; supporting families and caregivers; ensuring continuity of care; ensuring respect for patients as people and informed decision making; ensuring well-being, including consideration of existential and spiritual concerns; and supporting function and duration of survival.

Identifying Patients Who Could Benefit From Palliation: No evidence tools have been validated or effectively shown to predict optimal timing. Decisions should be based on each patient's symptoms and preferences.

Treatment Strategies:

• Pain
  • Evidence is strong in support of the use of nonsteroidal anti-inflammatory drugs, opioids, bisphosphonates, and radiotherapy or radiopharmaceuticals for pain, with bisphosphonates used for bone pain specifically.
  • Insufficient evidence exists to evaluate the usefulness of acupuncture or exercise for pain control.
  • Palliative care teams may be moderately beneficial in providing pain management.
• Dyspnea
  • Evidence shows a valuable effect of morphine.
  • Nebulized opioids show no additional benefit over oral opioids.
  • Evidence regarding the use of oxygen is equivocal.
  • Studies that evaluated facilitated communication or palliative care consultation showed no effect.
• Depression
  • Evidence suggests that long-term use of tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions are beneficial for patients with cancer who are depressed.
  • Evidence is mixed regarding the benefit of guided imagery and exercise in the defined patient population.
  • Evidence showed that care coordination had no effect.

Important Elements for Advance Care Planning: Evidence shows that extensive multicomponent interventions, goal-oriented interviews with palliative care providers, and proactive communication involving skilled discussants can reduce unnecessary services, without causing harm, and increase the use of advance directives.

Collaboration and Consultation: Use and patient-centered outcomes improve when multidisciplinary teams include nurses and social services providers, address care coordination, and use facilitated communication.

Supporting Caregivers: Evidence regarding the effects of palliative care teams for caregivers is mixed.

The following were graded as strong recommendations with moderate quality of evidence.

• Patients with serious illness at the end of life should be regularly assessed for pain, dyspnea, and depression.
• For patients with cancer, clinicians should use therapies with proven effectiveness to manage pain. These therapies include nonsteroidal anti-inflammatory drugs, opioids, and bisphosphonates.
• Clinicians should use therapies with proven effectiveness to manage dypsnea. These therapies include opioids (for unrelieved dyspnea) and oxygen (for the relief of short-term hypoxemia).
• Clinicians should use therapies with proven effectiveness to manage depression in patients with cancer. These therapies include tricyclic antidepressants, selective serotonin reuptake inhibitors, and psychosocial interventions.
• Clinicians should ensure that advance care planning occurs for all patients with serious illness. Such planning includes the preparation of advance directives.

• Several authors had grants from the Agency for Healthcare Research and Quality or pharmaceutical companies.
• Financial support for this guideline was entirely from the American College of Physicians.

The guideline provides clear guidance in several areas of end-of-life care and symptom management and identifies the relevant evidence and strength of the evidence. The guideline may not apply to all patients and is not intended to override clinical judgment. In addition to recommending medication interventions for depression, the guideline recommends psychosocial interventions.