Support Care Cancer (1997) 5:94-99

© Springer-Verlag 1997

Margaret Farncombe Dyspnea: assessment and treatment

Presented as an invited lecture Abstract Dyspnea, or breathless- plained of significant shortness of

at the 8th International Symposium:
Supportive Care in Cancer,
Toronto, Canada, 19-22 June 1996
M. Farncombe, M.D. 1
Queensway-Carleton Hospital,
3045 Baseline Road,
Nepean, Ontario, Canada
Mailing address:
34 Southview Crescent,
Nepean, Ontario K2E 5R3, Canada
Fax: (613) 225-6744
ness, is a very distressing and pre-
valent symptom for patients with
terminal cancer. Assessment for
this symptom is generally poorly
conducted, and it is therefore fre-
quently underdiagnosed and inade-
quately treated. This paper out-
lines several tools found in the lit-
erature that may be beneficial to
us in assessing this symptom. There
will also be a full report on the ap-
plication of these scales as used in
a hospital audit of all in-patients at
the Queensway- Carleton Hospital
in Nepean, Ontario, during the
month of June 1995. Results of this
hospital audit revealed that 33% of
all patients in hospital complained
of some degree of breathlessness
on both the Linear Analogue Scale
Assessment and the Borg Scale.
However, when the Modified Med-
ical Research Council Dyspnea
Scale and the Oxygen Cost Dia-
gram Scale were used 75.6% and
78.5% respectively now com-
breath interfering with their quality
of life. We also found that patients
experiencing dyspnea were 39%
more likely to complain of other
symptoms than patients with no
shortness of breath and were 55%
more likely to report other symp-
toms as being severe. A short sec-
tion will also outline the medical
and nursing management of dysp-
nea and will include a discussion of
possibly correcting the cause of
breathlessness, environmental is-
sues, and pharmacological manage-
ment of dyspnea. It is advocated
that during the terminal stages of a
patient's illness, when assessment
tools are no longer feasible or pos-
sible, that a "breathing comforta-
bly" approach be adopted for pa-
tient and family comfort.
Key words Dyspnea .
Assessment. Management -
Breathing comfortably

It remains unclear why the symptom of dyspnea in

Introduction
Dyspnea, the sensation of labored or difficult breath-
ing, is a subjective experience that varies with the indi-
vidual patient. It is a complex symptom with physiolog-
ical, psychological and social components. Even though
patients and families refer to it as one of the most de-
vastating symptoms experienced, it is still underdiag-
nosed, undertreated and certainly poorly researched.
cancer patients receives so little interest. It is certainly
not because it is not a prevalent symptom, as 50-70%
[7, 17] of all cancer patients will experience dyspnea
during the last 6 weeks of life. It is a symptom that is
more common than pain, and dyspnea usually worsens
as the disease progresses. It is also reported that ap-
proximately 40% of children who die of cancer experi-
ence dyspnea during their illness [13].
 95

dyspnea, whether secondary to cancer or to other, non-

Etiology malignant, illnesses, it may be appropriate to use re-
peated chest X-rays, 02 saturation, blood gases and
The etio]ogy of dyspnea is very complex and includes
pulmonary function tests to assess the extent of the dis-
complications of the primary disease in patients with
ease and to follow progress. However, in the palliative
lung cancer and metastases from other cancers. It may
care population it may be more appropriate to assess
also involve the development of pleural effusions, pul-
the subjective complaints and question patients about
monary emboli, infection, or lymphangitic spread, or
their degree of breathlessness and the limitations in ex-
any combination of these complications. Frequently,
ercise capabilities secondary to this complaint.
the worsening of dyspnea is also secondary to other,
The literature does give us some tools to use in this
less obvious, etiologies. For example, abdominal dis-
assessment, but they are very nonspecific as to which is
ease and ascites or even constipation can decrease the
the most appropriate in what situation and what combi-
lung volume and therefore cause worsening of dyspnea.
nations of tools are the most effective. The Palliative
Also, often little attention is paid to the fact that pa-
Care Service at the Queensway-Carleton Hospital in
tients with profound cachexia have muscle wasting and
Nepean, Ontario, a community hospital, conducted a
weakness of the respiratory muscles similar to that
complete hospital audit of all in-patients, during the
found in other muscles of the body. This increases the
month of June, 1995, in an effort to assess the number
work of breathing, and causes profound fatigue. Dysp-
of patients experiencing dyspnea, and the severity of
nea may also be secondary to treatment such as surge-
this complaint. We also wished to compare assessments
ry, chemotherapy, often with fluid overload, and radio-
done by patients with those done by their attending
therapy, which frequently results in fibrotic changes in
nurses and physicians.
lung tissue.
The most common tumors to cause dyspnea are
those of the lung, breast, colon and rectum and prostate
[12~, 17]. In patients with cancer of the pancreas dyspnea
The Queensway-Carleton Hospital Dyspnea Survey
is a prognostic factor. Research reports show that pa-
All patients on medical and surgical wards were sur-
tients with cancer of the pancreas without breathless-
veyed: in all, 142 patients in the hospital were asked to
ness can be expected to survive approximately 5
complete the following assessment scales:
months, whereas for those who do have shortness of
breath, without any underlying respiratory or cardiac 1. Linear Analogue Scale Assessment (LASA) [10, 11]
disease, the expected survival is approximately 2 (Fig. 1)
months [15].
2. Borg Category Scale [2, 16] (Fig. 2)
Major importance in the determination of the etiolo-
gy of dyspnea attaches to the fact that dyspnea or wor- 3. Modified Medical Research Council Dyspnea Scale
sening of breathlessness is frequently multifactorial and (MMRCDS) [19] (Fig. 3)
a result of the occurrence of several of the factors dis-
4. Oxygen-Cost Diagram [19] (Fig. 4) and
cussed. It is also important that the etiology of worsen-
ing of dyspnea is often unknown in spite of investiga- 5. A Questionnaire of Concurrent Symptoms develop-
tions to ascertain the reason. ed in house. Since our review of all available literature
The etiology of dyspnea must include an assessment failed to identify the existence of any validated tool
of the physical, emotional, and social components of that adequately served the required purpose, we under-
dyspnea. As breathlessness is a very frightening symp- took development of our own questionnaire. In the
tom to many it can cause profound anxiety, and this in questionnaire we asked patients to rate other symp-
turn worsens the breathlessness. It can, therefore, not toms being experienced (ie., pain, gastrointestinal, cen-
be explained by examining lung function alone. The eti- tral nervous system and general complaints) on a scale:
ology of dyspnea in palliative care patients, however, is none, mild, moderate or severe. This is as yet an unval-
only important insofar as it facilitates intervention in idated tool (Fig. 5).
improving symptom control.

(Indicate the amount of shortness of breath you are having

Assessment at the appropriate place on the line below)

No shortness Shortness of breath

In palliative care the etiology may be less important of breath as bad as can be
than an appropriate assessment. There is little research
to help us determine what is needed in the assessment
of shortness of breath. In newly diagnosed cases of Fig. 1 The Linear Analogue Scale Assessment (LASA)