Palliation of dyspnea in ES-SCLC: Identifying etiology and targeted treatment

Research shows that dyspnea, or “air hunger,” is one of the most distressing symptoms in patients with lung cancer. Combined with fatigue, anxiety, and depression, quality of life plummets.

Dyspnea typically increases in prevalence and intensity in the last weeks or days of life, and its presence predicts poor outcomes. 

Impacts of dyspnea in ES-SCLC

The treatment of dyspnea in patients with advanced cancer is highly personalized and influenced by a patient’s prognosis.

According to the American Society of Clinical Oncology (ASCO) "clinicians need to routinely engage in serious illness conversations with the patients and their caregivers to ensure prognostic understanding, discuss how dyspnea should be managed (eg, cancer treatments and palliative options), and support advance care planning.”^[]

Localized disease manifests as cough, wheezing, dyspnea, and hemoptysis, and superior vena cava syndrome.^[] Metastases seed the contralateral lung, brain, liver, bone, bone marrow, and adrenal glands in about two-thirds of patients, according to researchers writing in Pulmonary Therapy.^[]

In cases of extended-stage small-cell lung cancer (ES-SCLC) and other types of advanced lung cancer, dyspnea, fatigue, depression, and anxiety are the main symptoms linked to decreased quality of life.

The Pulmonary Therapy authors conducted a study on the patient experience with SCLC. They found that shortness of breath was a constant concern in these patients, which worsened with exertion and coughing. Patients typically complained of trouble getting enough oxygen, difficulty in taking deep breaths, and impairments in mobility.

One participant said, “The shortness of breath is always, always, always there with any type of exertion at all (sometimes accompanied by coughing)… even though it’s very bothersome, it’s something I can relieve more easily than the coughing: I can sit down and rest.” 

"Around the house, it’s a very long walk from my bedroom to the kitchen," the patient added.

“[The patients] expressed sadness and aggravation about the quality of their lives. The impact of treatment was considered worthwhile by the majority of patients if it gave them more time, although they also wanted to be independent,” wrote the authors.

Screening guidelines

Validated outcome measures will suffice in patients who cannot self-report. (Validated assessment tools are available through ASCO.)

Patients should receive a comprehensive evaluation for the severity, chronicity, potential causes, triggers, and associated symptoms, along with emotional and functional impacts of dyspnea.

Treating dyspnea

Treatment is based on underlying causes. In patients with potentially reversible dyspnea, caused by common issues such as anemia, airway obstruction, pleural effusion, pneumonia, asthma, COPD exacerbation, pulmonary embolism, or treatment-induced pneumonitis, treatment should be goal-concordant and align with patient wishes, prognosis, and overall health status.

The same is true for patients with an underlying malignancy, such as atelectasis secondary to a large pulmonary mass, malignant pleural effusion, or lymphangitic carcinomatosis.

Referral to an inter-professional palliative care team is recommended in patients with advanced cancer and dyspnea.

Interventions

In patients with ES-SCLC and other forms of advanced cancer, ASCO recommends various non-pharmacologic interventions, with each supported by various strengths of recommendation. Such treatments are personalized based on assessment and patient presentation. These include the following evidence-based recommendations.

(Categorization of the below points are defined as such—evidence quality: intermediate; strength of recommendation: moderate)

• Fan aimed at the cheek at the level of the trigeminal nerve distribution 

• Standard supplemental oxygen for patients with hypoxemia who are experiencing dyspnea defined as SpO2 ≤ 90% on room air (supplemental oxygen is not covered by payors unless the patient has an Sp02 of 88% or less)

(Categorization of the below points are defined as such—evidence quality: low; strength of recommendation: moderate)

• Time-limited therapeutic trial of high-flow nasal cannula oxygen therapy can be made available to patients who have severe dyspnea and hypoxemia despite standard supplemental oxygen.

• Time-limited therapeutic trial of noninvasive ventilation can be offered to patients who have significant dyspnea despite standard measures and lack contraindications.

(Categorization of the below point is defined as such—evidence quality: low; strength of recommendation: weak)

• Breathing techniques, posture, relaxation, distraction, meditation, self-management, physical therapy, and music therapy, along with acupressure and reflexology

It should be noted, there is insufficient evidence either for or against pulmonary rehabilitation in patients with advanced cancer and dyspnea.

(Categorization of the below point is defined as such—evidence quality: low; strength of recommendation: moderate)

• Prescription of systemic opioids to treat dyspnea when nonpharmacologic interventions are insufficient to provide dyspnea relief 

(Categorization of the below points are defined as such—evidence quality: low; strength of recommendation: weak)

• Short-acting benzodiazepines for patients who experience dyspnea-related anxiety and continue to struggle with dyspnea after opioids and other nonpharmacologic measures 

• Systemic corticosteroids for select patients with airway obstruction or when inflammation plays a major role in the dyspnea 

• Bronchodilators for palliation of dyspnea when patients exhibit established obstructive pulmonary disorders or evidence of bronchospasm

The following recommendation is based on informal consensus (evidence quality: low; strength of recommendation: moderate)

• Continuous palliative sedation in patients with dyspnea that is refractory to all standard treatment options and all palliative options, and those that are expected to live only days.

There is insufficient data to recommend for or against the prescription of antidepressants, neuroleptics, or inhaled furosemide for dyspnea.