Breathing its typically taken for granted, not even noticed, unless the mere exchange of air becomes difficult. But patients with lung cancer who experience dyspnea are often all too aware of their breath.
Margaret Joyce, RN, PhD(c), AOCN, interim chief nursing officer at The Cancer Institute of New Jersey in New Brunswick, sought to learn more about dyspnea as part of her doctoral studies. She shared results of her preliminary research at the 34th annual Oncology Nursing Society Congress last spring.
Joyce and colleagues investigated the different aspects of dyspnea in patients with lung cancer: breathing effort and breathing distress, the patients reaction to the sensation of difficulty breathing.
Lung Cancer Connection
Dyspnea commonly occurs in patients with lung cancer. Thoracic surgeon James McCaughan, MD, a member of the American Cancer Societys Jersey Shore regions board of directors and medical director of the lung cancer program at Ocean Medical Center in Brick, N.J., says dyspnea is usually seen in patients with advanced or recurring disease. But many lung cancer patients experience difficulty breathing because of comorbid moderate to severe chronic obstructive pulmonary disease.
Sometimes thats how they present to us, says Gary Shelton, RN, NP, MSN, ANP-BC, AOCNP, an active, national member of the Oncology Nursing Society, and an oncology clinical nurse specialist and adult health nurse practitioner at the New York University Cancer Institute. [Dyspnea] sends them to their primary care [provider], and they end up with a diagnosis of lung cancer. Getting to the reason [for dyspnea] is part of the puzzle.
Dyspnea may result from the tumor itself, such as when it causes compression of the airway or superior vena cava; a malignant pleural effusion; or from a comorbid condition, including anemia or heart disease. Even the anxiety of a lung cancer diagnosis can contribute to the dyspnea, Shelton says.
Effort vs. Distress
Prior research indicated patients with COPD could differentiate between breathing effort and distress. Joyce enrolled 37 patients with advanced or locally advanced lung cancer. The team captured various characteristics, such as age, gender, anxiety levels, medications, and comorbid conditions, and administered multiple instruments asking patients to recall their breathing troubles and whether they experienced associated distress. Then the researchers analyzed the results.
They could tell the difference, and it is validating that there are two dimensions to the breathing problem, Joyce says. The good part of that is sometimes we cannot correct the breathing effort, or physical part, but we may be able to think of ways to control or lessen the breathing distress.
The study found that patients regularly taking morphine or a similar opioid medicine experienced less breathing effort and less distress than patients not taking the medications. Patients taking scheduled opioids reported less dyspnea than the group not on the drugs.
In addition, the investigators noted an association between state anxiety, which is situational, and breathing effort but not distress. Trait anxiety, a persons proneness to feel anxious, was not associated with effort or distress. Joyce plans to investigate in greater depth anxiety associated with dyspnea and what might decrease distress.
Dyspnea is a difficult symptom to manage, Joyce says. The interventions or what we have available to make it easier for people to breathe are very limited.
Managing the cause of the problem is the first step, McCaughan says. Palliative treatment would depend on the cause but may include a pleurodesis for a malignant effusion, or radiation or mechanically opening the airway under bronchoscopy for a compressed bronchus.
Opioids often are given to treat the symptom and improve quality of life. If used appropriately, the drugs do not hasten death, according to the National Cancer Institute.
Oxygen might be ordered if the patient is hypoxic. Patients also may benefit from nonpharmacologic measures.
I have seen so many patients do better after pulmonary rehab, McCaughan says. It doesnt increase lung capacity to a great degree, but it helps them feel better.
Pulmonary rehabilitation changes the mechanics of breathing, changing the pressure wave, McCaughan explains. Also, while the person is monitored, they are encouraged to walk farther and learn that they often can do more than they expected.
Increasing the air flow around a person makes them feel more comfortable, Joyce says. Sometimes cooler temperatures or promoting relaxation with distraction measures [will help].
Joyce explains that stimulation of a facial nerve by the air helps relieve the sensation of breathlessness and decreases the sense of claustrophobia that exists with dyspnea.
Changing position may allow greater lung expansion, so instructing patients to lean forward or to the side may help breathing. Some patients find pursed-lip breathing will help bring more air into the lungs.
Nurses also can provide emotional and psychosocial support and teach patients relaxation techniques and distraction to decrease their anxiety, which can escalate the problem.
Having a person in the room the presence of someone is a potential thing that might be helpful, Joyce says.
Shelton recommends talking with the patient about energy conservation not planning too much in one day, taking a 30-minute power nap, doing a little exercise to create energy, and eating protein and carbohydrates that are easy to digest. He encourages patients to delegate, such as letting a neighbor or family member pitch in to pick up groceries.
From a nursing point of view, Shelton says, some of the easiest things patients might not be thinking about.