Management Of Breathlessness In Lung Cancer

MANAGEMENT OF BREATHLESSNESS IN LUNG CANCER

Breathlessness is one of the most common symptoms of advanced cancer, particularly lung cancer. Reported incidence varies between 30% - 70%(J. Carner).30% of all the patient experience it during some part of their illness and it goes as high 79% with lung cancer. (Mora Kearney).

Despite being prevalent it is most of the time not recognised by the health professional, when it is really serious. May be due to the fact that patient sometimes do not come early as they may think it is part of their illness.

Breathlessness can exist alone but most of the time it's a clusters of symptoms which includes anxiety, fear (Lenzetal 1997)

To be able to help patient with this problem it is necessary to know what exactly it means to be having breathlessness. As only if we know what is the mechanism behind it, then only proper care can be provided to the patient, Higginson and McCarthy 1989 reported that relief from this symptom remained poor as compared to other symptom such as pain etc.

Management of breathlessness is a vast area which consist of pharmacological and nonpharmocological approach, depending upon the need of the patient. Within this assignment I will aim to discuss the use of pharmacological as well as nonpharmocological intervention from the nursing point of view. With the help of evidence and various studies I will try to discuss the incidence and various factor involved in the mechanism of breathlessness. Alongside this I will try to examine how various drug may help in relieving the distressing symptom and how training of nurses, better communication with the patient may help. Lastly I will examine recommendation for future practice in my clinical area to improve the patient experience and to provide better management of breathlessness through the use of training and assessment tools to facilitate this process.

Roberts, Tharne @ Pearson(1993) have stated, nurses being more closed to the patient can identify, interpret and intervene in Breathlessness Management.

Dyspnoea or Breathlessness is a distressing and debilitating symptom for patient with other primary or metastatic lung cancer that increase in severity with the progression of disease (Escalenate et al 1966). It is difficult to define breathlessness but most patient describe it as uncomfortable awareness of breathing or difficult breathing. At time it can be frightening and powerful experience and patient may think that its their last breath.

Breathing is a complex involuntary process which involves close co-ordination between chemical changes, neurological signals and musculoskeletal response including the lung tissue. Precise origin of the sensation of breathlessness is poorly understood. The factors which are thought to contribute to the feeling are:-

a) Mechanical-which means obstruction to the airflow which may be within the airways or may be due to external compression. This lead to increase in respiratory effort to achieve adequate airflow.

Breathing pattern can be altered as a result of changes in concentration of carbon dioxide and oxygen in the blood which in turn stimulate brainstem, the centre for respiration.

There is evidence to show that emotional upset may also contribute to a exacerbate breathing (Sarna 1993, tana 2002).There are other studies which gave similar result (guftel 1986, Milligan etal 1996).

The cause of breathlessness in lung cancer patient can be cancer related such as obstruction, metastases, airway collapse, pleural effusion, consolidation, phneumothasaso etc or it can be treatment related such as radiation, damage to lung, phemonities, pneumonectomy. Apart from these it can be related to Co marshiel such as ischemic heart disease, cardiac failure, COPD, asthma, anaemia.

Understanding the nature of breathlessness is important as it helps in nursing the patient and in providing proper care.

As mentioned earlier management of breathlessness involves pharmacological and non pharmacological approach It involves close coordination between physician, nurses and health care workers. In managing the case a proper assessment help in identifying the cause of the symptom so its very important to obtain detail history, clinical examination should be carried out by physician, X-ray and other necessary test to identify the immediate cause and to give treatment which might help in reducing the symptom. Obtaining a detailed history is an art and sometime can be very difficult but over the time patient may trust nurse more and develop trusting relationship which will help in the management. Carner and O'driscoll's VAS (visual analogue scale) has been used in various studies and shown to be a sensitive tool assessing intensity of the symptom (predin 1999). It consists of horizontal, 100 mm line with rating from 0 to 10. With 0 being the best and 10 the worst reading. These scales have the advantage of being simple to use and provide objective measures of the person's breathlessness which can be repeated to assess any benefit following medical or non medical intervention. But for some patient who are already in very advanced stage this scale may not be very helpful. Depending up on the severity of the symptom it can be decided which type of intervention will be most suitable. Radiotherapy and chemotherapy can help in improving breathlessness in 40% Ð'- 70% of the case although the effect may be short lived. Careful selection of the patient should be made to see whether they are fit for radiotherapy & chemotherapy.

Chemotherapy alone has been shown in some studies to be beneficial in improving the breathlessness.

Identifying the specific cause of breathlessness during the course of examination will help in fast management of the symptom for e.g. if the patient has developed pleural effusion then simply aspiration of the effusion is the definitive treatment and if it recurred then plurodesis may prevent further development of effusion. Similarly if the cause is pericardial effusion then it can be drained in specialised centre.

Breathlessness due to the obstruction of SVCO can be managed by single dose radiotherapy followed by high dose steroid to reduced radiotherapy induced oedema and inflammatory process. Other comorbedty factors such as any cardiovascular problem, COPD should be dealt with properly with the help of appropriate medication and to refer to other subspecialties if necessary.

Various drugs have been used in the management of breathlessness. The important and the most frequently used are morphine, benzodiazepines (lorazepam & diazepam).