Clinical Review

Dyspnea in Malignancy

Dyspnea not only has a significant impact on the quality of life in oncologic patients but one that often intensifies with cancer progression—underscoring the importance of its recognition and treatment in the ED.

Emergency Medicine. 2015 September;47(9):392-400 | DOI: 10.12788/emed.2015.0009

Author(s):

Accounting for 3 to 4 million ED visits annually, this conditionis not only prevalent in oncologic patients, but typically intensifieswith disease progression.

References

Parshall MB, Schwartzstein RM, Adams L, et al; American Thoracic Society Committee on Dyspnea. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4):435-452.
Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data. 2007;(386):1-32.
Ekström MP, Abernethy AP, Currow DC. The management of chronic breathlessness in patients with advanced and terminal illness. BMJ. 2015;349:g7617.
Karnani NG, Reisfield GM, Wilson GR. Evaluation of chronic dyspnea. Am Fam Physician. 2005;71(8):1529-1537.
Moens K, Higginson IJ, Harding R; EURO IMPACT. Are there differences in the prevalence of palliative care-related problems in people living with advanced cancer and eight non-cancer conditions? A systematic review. J Pain Symptom Manage. 2014;48(4):660-677.
Peters SP. When the chief complaint is (or should be) dyspnea in adults. J Allergy Clin Immunol Pract. 2013;1(2):129-136.
Campbell ML. Dyspnea prevalence, trajectories, and measurement in critical care and at life’s end. Curr Opin Support Palliat Care. 2012;6(2):168-171.
Argulian E, Agarwal V, Bangalore S, et al. Meta-analysis of prognostic implications of dyspnea versus chest pain in patients referred for stress testing. Am J Cardiol. 2014;113(3):559-564.
van Mourik Y, Rutten FH, Moons KG, Bertens LC, Hoes AW, Reitsma JB. Prevalence and underlying causes of dyspnoea in older people: a systematic review. Age Ageing. 2014;43(3):319-326.
Scano G, Gigliotti F, Stendardi L, Gagliardi E. Dyspnea and emotional states in health and disease. Respir Med. 2013;107(5):649-655.
Murakami J, Ueda K, Sano F, Hayashi M, Tanaka N, Hamano K. Prediction of postoperative dyspnea and chronic respiratory failure. J Surg Res. 2015;195(1):303-310.
Manning HL, Mahler DA. Pathophysiology of dyspnea. Monaldi Arch Chest Dis. 2001;56(4):325-330.
Robinson LM. A Healthy 22-year-old woman with new onset dyspnea. J Emerg Nurs. 2010;36(2):146-147.
Ben-Aharon I, Gafter-Gvili A, Leibovici L, Stemmer SM. Interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. Acta Oncol. 2012;51(8):996-1008.
Guirimand F, Sahut d’izarn M, Laporte L, Francillard M, Richard JF, Aegerter P. Sequential occurrence of dyspnea at the end of life in palliative care, according to the underlying cancer. Cancer Med. 2015;4(4):532-539.
Fishbein D, Kearon C, Killian KJ. An approach to dyspnea in cancer patients. J Pain Symptom Manage. 1989;4(2):76-81.
Ost DE, Ernst A, Grosu HB, et al; AQuIRE Brochoscopy Registry. Therapeutic bronchoscopy for malignant central airway obstruction: success rates and impact on dyspnea and quality of life. Chest. 2015;147(5):1282-1298.
Ripamonti C, Bruera E. Dyspnea: pathophysiology and assessment. J Pain Symptom Manage. 1997;13(4):220-232.
Petersen S, Ritz T. The role of fearful beliefs in the relationship between situational self-awareness and report of breathing-related sensations. Br J Health Psychol. 2011;16(Pt 2):359-372.
Dudgeon DJ, Kristjanson L, Sloan JA, Lertzman M, Clement K. Dyspnea in cancer patients: prevalence and associated factors. J Pain Symptom Manage. 2001;21(2):95-102.
Reuben DB, Mor V. Dyspnea in terminally ill cancer patients. Chest. 1986;89(2):234-236.
Roberts DK, Thorne SE, Pearson C. The experience of dyspnea in late-stage cancer. Patients’ and nurses’ perspectives. Cancer Nurs. 1993;16(4):310-320.
Reddy SK, Parsons HA, Elsayem A, Palmer JL, Bruera E. Characteristics and correlates of dyspnea in patients with advanced cancer. J Palliat Med. 2009;12(1):29-36.
Hayen A, Herigstad M, Pattinson KT. Understanding dyspnea as a complex individual experience. Maturitas. 2013;76(1):45-50.
Bruera E, Schmitz B, Pither J, Neumann CM, Hanson J. The frequency and correlates of dyspnea in patients with advanced cancer. J Pain Symptom Manage. 2000;19(5):357-362.
Ripamonti C. Management of dyspnea in advanced cancer patients. Support Care Cancer. 1999;7(4):
233-243.
Hui D, Morgado M, Vidal M, et al. Dyspnea in hospitalized advanced cancer patients: subjective and physiologic correlates. J Palliat Med. 2013;16(3):
274-280.
Ripamonti C, Fulfaro F, Bruera E. Dyspnoea in patients with advanced cancer: incidence, causes and treatments. Cancer Treat Rev. 1998;24(1):69-80.
Dudgeon DJ, Lertzman M, Askew GR. Physiological changes and clinical correlations of dyspnea in cancer outpatients. J Pain Symptom Manage. 2001;21(5):373-379.
Swinburn CR, Wakefield JM, Jones PW. Relationship between ventilation and breathlessness during exercise in chronic obstructive airways disease is not altered by prevention of hypoxaemia. Clin Sci (Lond). 1984;67(5):515-519.
Rock LK, Schwartzstein RM. Mechanisms of dyspnea in chronic lung disease. Curr Opin Support Palliat Care. 2007;1(2):102-108.
Moy ML, Woodrow Weiss J, Sparrow D, Israel E, Schwartzstein RM. Quality of dyspnea in bronchoconstriction differs from external resistive loads. Am J Respir Crit Care Med. 2000;162(2 Pt 1):451-455.
Nakayama H, Shibuya M, Yamada M, Suzuki H, Arakawa M, Homma I. In-phase chest wall vibration decreases dyspnea during arm elevation in chronic obstructive pulmonary disease patients. Intern Med. 1998;37(10):831-835.
Killian KJ, Jones NL. Mechanisms of exertional dyspnea. Clin Chest Med. 1994;15(2):247-257
Gross NJ. Chronic obstructive pulmonary disease. Current concepts and therapeutic approaches. Chest. 1990;97(2 Suppl):19S-23S.
Lansing RW, Gracely RH, Banzett RB. The multiple dimensions of dyspnea: review and hypotheses. Respir Physiol Neurobiol. 2009;167(1):53-60.
Petersen S, Orth B, Ritz T. Awareness of breathing: the structure of language descriptors of respiratory sensations. Health Psychol. 2008;27(1):122-127.
Parshall MB, Meek PM, Sklar D, Alcock J, Bittner P. Test-retest reliability of multidimensional dyspnea profile recall ratings in the emergency department: a prospective, longitudinal study. BMC Emerg Med. 2012;12:6.
Tanaka K, Akechi T, Okuyama T, Nishiwaki Y, Uchitomi Y. Development and validation of the Cancer Dyspnoea Scale: a multidimensional, brief, self-rating scale. Br J Cancer. 2000;82(4):800-805.
Booth S. The management of dyspnoea in advanced cancer. Hosp Med. 1998;59(5):348-349.
Uronis HE, Shelby RA, Currow DC, et al. Assessment of the psychometric properties of an English version of the cancer dyspnea scale in people with advanced lung cancer. J Pain Symptom Manage. 2012;44(5):741-749.
Dudgeon DJ, Rosenthal S. Management of dyspnea and cough in patients with cancer. Hematol Oncol Clin North Am. 1996;10(1):157-171.
Currow DC, Smith J, Davidson PM, Newton PJ, Agar MR, Abernethy AP. Do the trajectories of dyspnea differ in prevalence and intensity by diagnosis at the end of life? A consecutive cohort study. J Pain Symptom Manage. 2010;39(4):680.
Acheson A, MacCormack D. Dyspnea and the cancer patient--an overview. Can Oncol Nurs J. 1997;7(4):209-213.
Dudgeon DJ, Lertzman M. Dyspnea in the advanced cancer patient. J Pain Symptom Manage. 1998;16(4):212-219.
Corner J, Plant H, A’Hern R, Bailey C. Non-pharmacological intervention for breathlessness in lung cancer. Palliat Med. 1996;10(4):299-305.
LeGrand SB, Walsh D. Palliative management of dyspnea in advanced cancer. Curr Opin Oncol. 1999;11(4):250-254.
LeGrand SB. Dyspnea: the continuing challenge of palliative management. Curr Opin Oncol. 2002;14(4):394-398.
Bruera E, Macmillan K, Pither J, MacDonald RN. Effects of morphine on the dyspnea of terminal cancer patients. J Pain Symptom Manage. 1990;5(6):341-344.
Held JL. Cancer care. Managing shortness of breath. Nursing. 1994;24(7):31.
Bruera E, de Stoutz N, Velasco-Leiva A, Schoeller T, Hanson J. Effects of oxygen on dyspnoea in hypoxaemic terminal-cancer patients. Lancet. 1993;342(8862):13-14.
Bailey C. Nursing as therapy in the management of breathlessness in lung cancer. Eur. J. Cancer Care (Engl.). 1995;4(4):184-190.
Beyea A, Winzelberg G, Stafford RE. To drain or not to drain: an evidence-based approach to palliative procedures for the management of malignant pleural effusions. J Pain Symptom Manage. 2012;(2):301-306.

Overview

Dyspnea, the subjective inability to breathe comfortably, is a common symptom, accounting for 3 to 4 million ED visits annually.^1,2 Dyspnea can be acute, subacute, or chronic, with chronic dyspnea defined as the presence of symptoms for more than 1 to 2 months, and subacute dyspnea as symptoms lasting for hours to days.^3,4

The reported prevalence of dyspnea based on etiology presenting to the ED is as follows: malignancy (16% to 77%), chronic heart failure (18% to 88%), chronic obstructive pulmonary disease (56% to 98%), or renal disease (11% to 82%).⁵ Irrespective of time course and etiology, dyspnea can be a debilitating symptom affecting up to 50% of patients admitted to acute, tertiary care hospitals, and a quarter of patients seeking care in the ambulatory setting.^6-13

Although dyspnea is common in patients with cancer, it is often underreported.^14-19 This article reviews the current information available regarding the epidemiology, pathophysiology, assessment, and treatment of dyspnea in the oncologic patient population. By providing insight into the unique nature of dyspnea for oncologic patients, this article illustrates why dyspnea is an important symptom to recognize, address, and treat.

Epidemiology, Background, and Recognition

Dyspnea has a significant impact on the quality of life for oncologic patients and often intensifies near the time of death. At one regional oncology center, dyspnea was present in 49% of general cancer patients.²⁰ The percentage and severity of dyspnea increases as a patient’s cancer progresses. The National Hospice Study found that dyspnea occurred in 70% of 1,754 terminally ill cancer patients studied during their last 6 weeks of life; more than 28% of these patients graded the distress that they felt from dyspnea as moderate to severe. The incidence of dyspnea was exceeded only by the incidences of pain and anorexia.²¹

A study conducted by Roberts et al²² showed that dyspnea is a very common, undertreated, and underrecognized condition. In 62% of patients reporting dyspnea, the symptoms had been present for greater than 3 months before patients received medical or nursing intervention. In the inpatient hospital setting, 77% of patients claimed on interview to experience dyspnea, but only 39% of cases were actually reported by nursing staff. In addition, Reddy et al²³ found that dyspnea can negatively influence activities of daily living in oncology patients. Moreover, as the patients’ dyspnea intensified, their ability to perform activities of daily living was increasingly affected.^23,24

Differential Diagnosis

Studies demonstrate the presence of dyspnea in approximately 20% to 40% of patients at the time of diagnosis of advanced disease, with the percentage increasing to around 70% in the last 6 weeks of life.^25-27 Symptom grading is at least moderate in more than 28% of terminally ill cancer patients.²¹ Although common in oncology patients, dyspnea is difficult to diagnose because it is seldom explained by a single, specific organic etiology.^24,25,28 Extrinsic modulators that are difficult to quantify, such as psychological state, cultural background, and life experiences, can also attenuate the perception of dyspnea.^18,25

The cause of dyspnea in cancer patients can be broken down into four categories to aid in the differential diagnosis as described by Dudgeon et al²⁹ in 2001 (Table 1). The four categories consist of dyspnea as being directly due to the malignancy itself; indirectly due to the malignancy; a side effect of cancer treatment; or due to underlying lung and cardiac disease unrelated to the malignancy itself.^21,29

Etiology

Dyspnea Directly Due to Cancer. Dudgeon et al²⁹ reported that the top three malignancies that directly caused dyspnea are lung, head and neck cancer, and malignancies of genitourinary origin.²⁹ Reuben²¹ showed that 75% of patients with tumors involving the lung reported dyspnea at some point. Metastasis to the mediastinum, especially to the ribs, was associated with higher levels of dyspnea when compared to metastasis to lung.²⁹

Dyspnea Indirectly Due to Cancer. Dyspnea due to indirect causes such as anemia, pneumonia, and pulmonary emboli may be easier to rectify once diagnosed.

Dyspnea Due to Cancer Treatment. Treatment-related causes of dyspnea include the side effects of surgery and lung irradiation. Patients with a history of pneumonectomy, lobectomy, or pleurodesis report higher levels of dyspnea as do patients with a history of thoracic irradiation. Radiation pneumonitis can occur 6 to 12 weeks following treatment, and radiation fibrosis can occur 6 to 12 months following treatment.²⁹

Dyspnea Unrelated to Cancer. Other medical conditions that must be considered when diagnosing dyspnea include chronic obstructive pulmonary disease, asthma, and congestive heart failure. Psychological distress—described as anxiety and depression in the cancer population—may also cause the sensation of dyspnea.²⁵

References

Parshall MB, Schwartzstein RM, Adams L, et al; American Thoracic Society Committee on Dyspnea. An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. Am J Respir Crit Care Med. 2012;185(4):435-452.
Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data. 2007;(386):1-32.
Ekström MP, Abernethy AP, Currow DC. The management of chronic breathlessness in patients with advanced and terminal illness. BMJ. 2015;349:g7617.
Karnani NG, Reisfield GM, Wilson GR. Evaluation of chronic dyspnea. Am Fam Physician. 2005;71(8):1529-1537.
Moens K, Higginson IJ, Harding R; EURO IMPACT. Are there differences in the prevalence of palliative care-related problems in people living with advanced cancer and eight non-cancer conditions? A systematic review. J Pain Symptom Manage. 2014;48(4):660-677.
Peters SP. When the chief complaint is (or should be) dyspnea in adults. J Allergy Clin Immunol Pract. 2013;1(2):129-136.
Campbell ML. Dyspnea prevalence, trajectories, and measurement in critical care and at life’s end. Curr Opin Support Palliat Care. 2012;6(2):168-171.
Argulian E, Agarwal V, Bangalore S, et al. Meta-analysis of prognostic implications of dyspnea versus chest pain in patients referred for stress testing. Am J Cardiol. 2014;113(3):559-564.
van Mourik Y, Rutten FH, Moons KG, Bertens LC, Hoes AW, Reitsma JB. Prevalence and underlying causes of dyspnoea in older people: a systematic review. Age Ageing. 2014;43(3):319-326.
Scano G, Gigliotti F, Stendardi L, Gagliardi E. Dyspnea and emotional states in health and disease. Respir Med. 2013;107(5):649-655.
Murakami J, Ueda K, Sano F, Hayashi M, Tanaka N, Hamano K. Prediction of postoperative dyspnea and chronic respiratory failure. J Surg Res. 2015;195(1):303-310.
Manning HL, Mahler DA. Pathophysiology of dyspnea. Monaldi Arch Chest Dis. 2001;56(4):325-330.
Robinson LM. A Healthy 22-year-old woman with new onset dyspnea. J Emerg Nurs. 2010;36(2):146-147.
Ben-Aharon I, Gafter-Gvili A, Leibovici L, Stemmer SM. Interventions for alleviating cancer-related dyspnea: a systematic review and meta-analysis. Acta Oncol. 2012;51(8):996-1008.
Guirimand F, Sahut d’izarn M, Laporte L, Francillard M, Richard JF, Aegerter P. Sequential occurrence of dyspnea at the end of life in palliative care, according to the underlying cancer. Cancer Med. 2015;4(4):532-539.
Fishbein D, Kearon C, Killian KJ. An approach to dyspnea in cancer patients. J Pain Symptom Manage. 1989;4(2):76-81.
Ost DE, Ernst A, Grosu HB, et al; AQuIRE Brochoscopy Registry. Therapeutic bronchoscopy for malignant central airway obstruction: success rates and impact on dyspnea and quality of life. Chest. 2015;147(5):1282-1298.
Ripamonti C, Bruera E. Dyspnea: pathophysiology and assessment. J Pain Symptom Manage. 1997;13(4):220-232.
Petersen S, Ritz T. The role of fearful beliefs in the relationship between situational self-awareness and report of breathing-related sensations. Br J Health Psychol. 2011;16(Pt 2):359-372.
Dudgeon DJ, Kristjanson L, Sloan JA, Lertzman M, Clement K. Dyspnea in cancer patients: prevalence and associated factors. J Pain Symptom Manage. 2001;21(2):95-102.
Reuben DB, Mor V. Dyspnea in terminally ill cancer patients. Chest. 1986;89(2):234-236.
Roberts DK, Thorne SE, Pearson C. The experience of dyspnea in late-stage cancer. Patients’ and nurses’ perspectives. Cancer Nurs. 1993;16(4):310-320.
Reddy SK, Parsons HA, Elsayem A, Palmer JL, Bruera E. Characteristics and correlates of dyspnea in patients with advanced cancer. J Palliat Med. 2009;12(1):29-36.
Hayen A, Herigstad M, Pattinson KT. Understanding dyspnea as a complex individual experience. Maturitas. 2013;76(1):45-50.
Bruera E, Schmitz B, Pither J, Neumann CM, Hanson J. The frequency and correlates of dyspnea in patients with advanced cancer. J Pain Symptom Manage. 2000;19(5):357-362.
Ripamonti C. Management of dyspnea in advanced cancer patients. Support Care Cancer. 1999;7(4):
233-243.
Hui D, Morgado M, Vidal M, et al. Dyspnea in hospitalized advanced cancer patients: subjective and physiologic correlates. J Palliat Med. 2013;16(3):
274-280.
Ripamonti C, Fulfaro F, Bruera E. Dyspnoea in patients with advanced cancer: incidence, causes and treatments. Cancer Treat Rev. 1998;24(1):69-80.
Dudgeon DJ, Lertzman M, Askew GR. Physiological changes and clinical correlations of dyspnea in cancer outpatients. J Pain Symptom Manage. 2001;21(5):373-379.
Swinburn CR, Wakefield JM, Jones PW. Relationship between ventilation and breathlessness during exercise in chronic obstructive airways disease is not altered by prevention of hypoxaemia. Clin Sci (Lond). 1984;67(5):515-519.
Rock LK, Schwartzstein RM. Mechanisms of dyspnea in chronic lung disease. Curr Opin Support Palliat Care. 2007;1(2):102-108.
Moy ML, Woodrow Weiss J, Sparrow D, Israel E, Schwartzstein RM. Quality of dyspnea in bronchoconstriction differs from external resistive loads. Am J Respir Crit Care Med. 2000;162(2 Pt 1):451-455.
Nakayama H, Shibuya M, Yamada M, Suzuki H, Arakawa M, Homma I. In-phase chest wall vibration decreases dyspnea during arm elevation in chronic obstructive pulmonary disease patients. Intern Med. 1998;37(10):831-835.
Killian KJ, Jones NL. Mechanisms of exertional dyspnea. Clin Chest Med. 1994;15(2):247-257
Gross NJ. Chronic obstructive pulmonary disease. Current concepts and therapeutic approaches. Chest. 1990;97(2 Suppl):19S-23S.
Lansing RW, Gracely RH, Banzett RB. The multiple dimensions of dyspnea: review and hypotheses. Respir Physiol Neurobiol. 2009;167(1):53-60.
Petersen S, Orth B, Ritz T. Awareness of breathing: the structure of language descriptors of respiratory sensations. Health Psychol. 2008;27(1):122-127.
Parshall MB, Meek PM, Sklar D, Alcock J, Bittner P. Test-retest reliability of multidimensional dyspnea profile recall ratings in the emergency department: a prospective, longitudinal study. BMC Emerg Med. 2012;12:6.
Tanaka K, Akechi T, Okuyama T, Nishiwaki Y, Uchitomi Y. Development and validation of the Cancer Dyspnoea Scale: a multidimensional, brief, self-rating scale. Br J Cancer. 2000;82(4):800-805.
Booth S. The management of dyspnoea in advanced cancer. Hosp Med. 1998;59(5):348-349.
Uronis HE, Shelby RA, Currow DC, et al. Assessment of the psychometric properties of an English version of the cancer dyspnea scale in people with advanced lung cancer. J Pain Symptom Manage. 2012;44(5):741-749.
Dudgeon DJ, Rosenthal S. Management of dyspnea and cough in patients with cancer. Hematol Oncol Clin North Am. 1996;10(1):157-171.
Currow DC, Smith J, Davidson PM, Newton PJ, Agar MR, Abernethy AP. Do the trajectories of dyspnea differ in prevalence and intensity by diagnosis at the end of life? A consecutive cohort study. J Pain Symptom Manage. 2010;39(4):680.
Acheson A, MacCormack D. Dyspnea and the cancer patient--an overview. Can Oncol Nurs J. 1997;7(4):209-213.
Dudgeon DJ, Lertzman M. Dyspnea in the advanced cancer patient. J Pain Symptom Manage. 1998;16(4):212-219.
Corner J, Plant H, A’Hern R, Bailey C. Non-pharmacological intervention for breathlessness in lung cancer. Palliat Med. 1996;10(4):299-305.
LeGrand SB, Walsh D. Palliative management of dyspnea in advanced cancer. Curr Opin Oncol. 1999;11(4):250-254.
LeGrand SB. Dyspnea: the continuing challenge of palliative management. Curr Opin Oncol. 2002;14(4):394-398.
Bruera E, Macmillan K, Pither J, MacDonald RN. Effects of morphine on the dyspnea of terminal cancer patients. J Pain Symptom Manage. 1990;5(6):341-344.
Held JL. Cancer care. Managing shortness of breath. Nursing. 1994;24(7):31.
Bruera E, de Stoutz N, Velasco-Leiva A, Schoeller T, Hanson J. Effects of oxygen on dyspnoea in hypoxaemic terminal-cancer patients. Lancet. 1993;342(8862):13-14.
Bailey C. Nursing as therapy in the management of breathlessness in lung cancer. Eur. J. Cancer Care (Engl.). 1995;4(4):184-190.
Beyea A, Winzelberg G, Stafford RE. To drain or not to drain: an evidence-based approach to palliative procedures for the management of malignant pleural effusions. J Pain Symptom Manage. 2012;(2):301-306.

Dyspnea in Malignancy

Dyspnea not only has a significant impact on the quality of life in oncologic patients but one that often intensifies with cancer progression—underscoring the importance of its recognition and treatment in the ED.

References

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