Dyspnea is an extremely common symptom among cancer
patients. Like pain, it is inherently subjective and is best defined as the
perception of difficulty in breathing, or an uncomfortable awareness of
breathing. Although it may be associated with one or more physiologic
disturbances (such as hypercapnia, hypoxia, obstructive or restrictive patterns
on pulmonary function tests, or various abnormalities on chest imaging studies),
it is not strongly associated with any specific abnormality and may occur in the
absence of any. Patient self-report is the gold standard for assessment and may
range from mild breathlessness on exertion to a terrifying sense of suffocation.
Drs. Thomas and von Gunten provide a lucid overview of dyspnea and describe
the management approach preferred by palliative-care specialists. They make
several points that deserve emphasis.
Goals of Care
Effective management of dyspnea is predicated on good communication, a clear
understanding of the goals of care, and a comprehensive assessment. A style of
communication that is unhurried, calm, and compassionate may itself be
therapeutic in the context of a distressing symptom. Ongoing assessment should
be linked to education of the patient and family about the symptom and its
treatment. A plan for accessing care on an around-the-clock basis is extremely
important in addressing this symptom, which may be experienced as a harbinger of
The goals of care frame the extent of the evaluation and define the
appropriateness of various therapeutic strategies. For patients who appear to
have relatively long life expectancies and goals that include functional
restoration, the evaluation of potentially treatable primary causes may be
extensive, and a full range of primary and symptomatic treatments may be
considered. Specialists in pulmonary medicine may be consulted in such cases.
For those with short life expectancies, the goals of care usually stress
symptom control over functional gains, and evaluation may be limited to
approaches that carry a minimum burden. It is in this population that the role
of sedation as a therapeutic approach to address refractory symptoms has gained
the strongest support.
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2. Cherny NI, Portenoy RK: Sedation in management of refractory symptoms:
Guidelines for evaluation and treatment. J Palliat Care 10:31-39, 1994.
3. Bruera E, MacMillin K, Pither J, et al: The effects of morphine on dyspnea
of terminal cancer patients. J Pain Symptom Manage 5:341-344, 1990.
4. Dudgeon DJ, Lertzman M, Askew GR: Physiological changes and clinical
correlations of dyspnea in cancer outpatients. J Pain Symptom Manage 21:373-379,