Study Identifies Nonpharmacological Interventions Associated with Improved Breathlessness

December 23, 2020
Hannah Slater

Given the limited success and potential harms associated with pharmacological interventions, the researchers suggested that nonpharmacological interventions such as those identified in the study should be considered as first-line treatment options for managing breathlessness.

A systematic review published in JAMA Oncology identified several nonpharmacological interventions associated with improved breathlessness in adults with advanced cancer.1

In the inpatient setting, it was revealed that fans and bilevel ventilation used for a few minutes to hours improved breathlessness; integrative medicine and multicomponent interventions used for a few weeks to months improved breathlessness in the outpatient setting. Given the limited success and potential harms associated with pharmacological interventions, the researchers suggested that nonpharmacological interventions such as those identified in the study should be considered as first-line treatment options for managing breathlessness.

"Breathlessness, or dyspnea, is a common and distressing symptom in patients with advanced cancer," lead author Arjun Gupta, MD, chief medical oncology fellow at the Johns Hopkins Kimmel Cancer Center, said in a press release.2 "Breathlessness can be associated with and made worse by accompanying anxiety, and can severely impact quality of life and exercise capacity. In patients with advanced cancer, treating the underlying cause of breathlessness (such as the cancer itself) may provide incomplete symptom relief or may not be feasible. In these scenarios, treating the symptom of breathlessness may be indicated. However, patients in this situation are often vulnerable with limited time to recover, and a question that comes up for clinicians is, are the potential benefits of this intervention likely to outweigh the harms?"

"Traditionally, in the ward, medications such as opioids and benzodiazepines are often used to treat breathlessness. However, we did not know how well they really worked in patients with advanced cancer,” Gupta added. “Some of the data was extrapolated from patients with other conditions such as lung and heart disease. Medications can also cause side effects such as drowsiness and constipation. Therefore, we performed a comprehensive review of interventions (both nonpharmacological and pharmacological) to improve breathlessness."

In this study, investigators searched PubMed, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials from inception through May 2020 for published randomized clinical trials, nonrandomized controlled trials, and observational studies of the advantages and/or harms of nonpharmacological interventions on alleviating breathlessness in adults with advanced cancer. Importantly, only English-language studies were included in the analysis.

The key end points reported in the included studies were breathlessness, anxiety, exercise capacity, health-related quality of life, and harms.

Overall, 29 randomized clinical trials including 2423 participants were assessed. The trials evaluated a variety of interventions, such as respiratory (9 trials), activity and rehabilitation (7 trials), behavioral and psychoeducational (3 trials), integrative medicine (4 trials), and multicomponent (6 trials).

Ultimately, several nonpharmacological interventions were correlated with improved breathlessness, including fan therapy (standardized mean difference [SMD], -2.09; 95% CI, -3.81 to -0.37; I2 = 94.3%; P for heterogeneity = .02; moderate strength of evidence [SOE]) and bilevel ventilation (estimated slope difference, -0.58; 95% CI, -0.92 to -0.23; low SOE), lasting for a few minutes to hours, in the inpatient setting. Moreover, in the outpatient setting, nonpharmacological interventions associated with improved breathlessness were acupressure and reflexology (low SOE), as well as multicomponent interventions such as combined activity and rehabilitation, behavioral and psychoeducational, and integrative medicine, (low SOE) lasting for a few weeks to months.

Regarding safety, 5 of the 29 randomized clinical trials studied (17%) reported adverse events (AEs), though AEs and study dropouts were uncommon.

Moving forward, the researchers suggested critical steps in implementing the current study findings will involve updating guidelines, educating health care workers, and increasing confidence among both patients and caregivers. However, an individualized approach to managing breathlessness in patients with advanced cancer is necessary.

“Given the prevalence and burden of breathlessness in advanced cancer, breathlessness is an important and fertile area for further investigation,” the authors wrote. “Clear definitions and comprehensive assessments and end points for assessing breathlessness and breathlessness-related distress could add value to future studies.”

Reference:

1. Gupta A, Sedhom R, Sharma R, et al. Nonpharmacological Interventions for Managing Breathlessness in Patients With Advanced Cancer. JAMA Oncology. doi: 10.1001/jamaoncol.2020.5184

2. Fans may relieve breathlessness associated with advanced cancers [news release]. Published December 10, 2020. Accessed December 14, 2020. https://www.eurekalert.org/pub_releases/2020-12/jhm-fmr120920.php#:~:text=Fans%20may%20relieve%20breathlessness%20associated%20with%20advanced%20cancers,-Medications%20have%20limited&text=Blowing%20air%20from%20a%20fan,Hopkins%20Kimmel%20Cancer%20Center%20investigators.

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