Professional Practice Nursing Standards Symptom Management Guidelines: DYSPNEA

The Symptom Management Guidelines Developed by Professional Practice Nursing and Interdisciplinary colleagues at the BCCA are currently being reviewed and will be updated in 2011 Definition
Dyspnea: a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that varies in intensity. This experience derives from interactions among multiple physiological, psychological, social and environmental factors, and may induce secondary histological and behavioural responses. Dyspnea can be acute or chronic and may or may not be associated with tachypnea, hyperpnea, orthopnea, or hypoxia. - Related terms: breathlessness, shortness of breath
Lung cancer primary or metastatic Superior vena cava syndrome (SVCS) Malignant pleural effusion, atelectasis Pericardial effusion Pulmonary embolus Ascites Pathologic chest wall fractures Tracheal esophageal fistula Surgery (e.g. lobectomy, pneumonectomy) Radiation therapy to lung or chest (e.g. radiation - induced pneumonitis, pulmonary fibrosis, pericardial disease) Chemotherapy (e.g. chemotherapy induced pneumonitis, pulmonary toxicity, cardiomyopathy, anemia) Immunosuppressed patients with respiratory infection Anxiety, fear can be the cause or effect of dyspnea Airway obstruction, aspiration Chronic obstructive pulmonary disease (COPD), asthma, chronic bronchitis, emphysema Cardiac disease (e.g. congestive heart failure, cardiac ischemia, arrythmias) Neuromuscular disorders Chest wall deformity Obesity Pneumonia, bronchitis Pneumothorax Systemic infection Deconditioning overall decline in functional status resulting in exercise intolerance Smoking history Environmental factors (e.g. exposure to second hand smoke or other irritants, air pollution) Malnutrition Pain

Causative Factors
Cancer Related

Cancer Treatment Related

Psychosocial Other

Consequences
Respiratory distress Risk for decreased quality of life physical and psychological distress, problems maintaining adequate nutrition, limited physical and social activities, physical deconditioning Reduced ability to cough increased risk of infection Exacerbation of other symptoms such as pain, fatigue, loss of appetite, loss of concentration, sleep wake disturbance

The information contained in these documents is a statement of consensus of BC Cancer Agency professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk and is subject to BC Cancer Agency's terms of use, available at www.bccancer.bc.ca/legal.htm.

Page 1 of 9

Focused Health Assessment

GENERAL ASSESSMENT Contact & General Information
Physician name oncologist, family physician Dentist Pharmacy Home health care Other health care providers (e.g. home oxygen program) Allergies

SYMPTOM ASSESSMENT Normal

Have you had any previous breathing difficulties?

PHYSICAL ASSESSMENT Vital Signs

Include temperature, pulse, respiratory rate, blood pressure, oxygen saturation Note whether patient respirations are rapid, shallow, congested, or has periods of apnea Frequency as clinically indicated

Onset
When did your difficult breathing start? Did it start suddenly or gradually over the last few days? How long does your troubled breathing last? How often does it occur?

Provoking / Palliating
What brings it on? What makes it worse? (e.g. short of breath upon waking, walking hills, climbing stairs, carrying heavy items, getting dressed, emotions, everything) What makes it better (e.g. positioning)?

Consider Causative Factors

Cancer diagnosis and treatment(s) note type and date of last treatment Medical history Medication profile Recent lab or diagnostic reports (e.g. CBC, chest X- ray)

Observe General Appearance

Ability to complete full sentence Pallor, cyanosis, clubbing, diaphoresis Cough or sputum Accessory muscles use, chest wall movement, shape/abnormalities Peripheral edema bilateral or unilateral Generalized edema Abdominal ascites Vein distention

Quality (in last 24 hours)

When you experience the sensation of breathlessness, can you describe how it makes you feel? (e.g. hurts to breathe, inability to get enough air, tired, gasping, panting angry, panic, fear, claustrophobic) How bothersome is this symptom to you? (on a scale of 0 10, with 0 not at all and 10 being the worst imaginable) Are there any accompanying symptoms? Pain, fatigue, anxious feelings, worry, or depressed mood? Cough (with sputum), fever, chills, hemoptysis, chest tightness, palpitations, light headedness?

Severity / Other Symptoms

Chest Auscultation
Assess breath sounds normal, decreased, or absent Assess for presence of adventitious sounds (e.g. crackles, wheezes)

Treatment
What do you do when you feel short of breath? What medications or other strategies are you using right now? How effective? Side effects? What medications or strategies have been effective in the past?

Assess Mental Status

Monitor level of consciousness, note any alterations in mental status (e.g. confusion, restlessness - may indicate CO2 retention or hypoxia)

Understanding / Impact on You

What activities are you unable to do? Are you able to sleep at night? Do you have to prop up on pillows to sleep? How does this affect your family?

Value
What do you believe is causing your dyspnea? What is your comfort goal or acceptable level for this symptom (0 10 scale)?

The information contained in these documents is a statement of consensus of BC Cancer Agency professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk and is subject to BC Cancer Agency's terms of use, available at www.bccancer.bc.ca/legal.htm.

Page 2 of 9

DYSPNEA GRADING SCALE

Adapted NCI CTCAE (Version 3.0)

GRADE 0 (Normal) Asymptomatic

GRADE 1 (Mild) Dyspnea on exertion, but can walk 1 flight of stairs without stopping

GRADE 2 (Moderate) Dyspnea on exertion but unable to walk 1 flight of stairs or 1 city block (0.1km) without stopping

GRADE 3 (Severe) Dyspnea with ADL

GRADE 4 (Life - threatening) Dyspnea at rest; intubation / ventilator indicated

GRADE 1 - GRADE 2

NON URGENT:
Support, teaching & follow-up care as required General Supportive Measures
Environmental considerations: Maintain calm atmosphere Promote cooler temperatures Promote ambient air flow directed at nose or mouth helps to stimulate the trigeminal nerve which provides a sense of relief from dyspnea (e.g. fresh air from open window or fan on low speed) Avoid smoking or being in an environment with smoke or known symptom triggers Use humidifier as necessary to promote patient comfort Stress management techniques Relaxation techniques may help to reduce anxiety, decrease oxygen consumption and respiratory rate. Examples include: Controlled breathing, visualization, music therapy Complete muscle relaxation, massage, therapeutic touch Yoga or Tai Chi As appropriate, consider use of assistive devices such as portable oxygen or a wheelchair to decrease physical activity that may exacerbate dyspnea Goal: To focus on avoiding/minimizing fatigue by finding the easiest ways of doing work, and balancing work with rest Principles and Tips for Energy Conservation Pacing Balance activities with rest Slow & steady pace uses less energy Planning Organize your time, methods, and space Priority setting Eliminate unnecessary tasks Ask for assistance Posture Change positions frequently Keep activities/work within easy range using correct body alignment Avoid bending and lifting Proficiency - Organization for work, use of equipment to maximize efficiency and minimize workload

Energy Conservation and Work Simplification

The information contained in these documents is a statement of consensus of BC Cancer Agency professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk and is subject to BC Cancer Agency's terms of use, available at www.bccancer.bc.ca/legal.htm.

Page 3 of 9

GRADE 1 - GRADE 2 Continued

NON URGENT:
Support, teaching & follow-up care as required Positioning
Goal: Avoid compression of chest and abdomen when positioning Positions to allow for optimal lung expansion and gas exchange: SITTING: sit upright with back against chair, with feet wide apart, leaning forward with arms on bedside table or on knees allows more space for lung expansion STANDING: lean with back to wall, feet slightly against the wall, with relaxed head and shoulders IN BED: elevate head of the bed, support and elevate arms with pillows OTHER: lean forward for support on banister for climbing stairs or shopping cart while shopping Goal: To decrease dyspnea and help regain control over their breathing. Instructing patients on breathing techniques can help them to remain calm when short of breath. The breathing techniques below prevent /reduce trapped air in lungs and help to inhale more fresh air. Diaphragmatic Breathing How? Put one hand on upper chest, and other on abdomen just above waist Breathe in slowly through the nose should feel hand on abdomen moving out Breathe out slowly through pursed lips should feel hand on abdomen moving in as you exhale Pursed Lip Breathing How? Breathe in slowly through your nose for 1 count Purse your lips as if you were going to whistle Breathe out gently through pursed lips for 2 slow counts let the air escape naturally and dont force air out of lungs Continue pursed lip breathing until feeling of breathlessness resolves SOS for SOB Help for Shortness of Breath (The Lung Association) How? Stop and rest in a comfortable position Get head and shoulders down Breath in and out through your mouth as fast as necessary Slowly begin to breathe out longer. Begin to slow breathing Begin to breathe through your nose Begin diaphragmatic breathing Stay in position for at least 5 minutes Activity as tolerated. Encourage, patients who are able, to exercise regularly to help maintain functional status and prevent deconditioning Upper and lower extremity exercises helps to improve endurance Upper extremity exercise improves respiratory muscle strength which can help with dyspnea Start with low- intensity and gradually increase as tolerated consider a referral to a physiotherapist is recommended to help determine optimal exercise and intensity Medications that may improve respiratory muscle function (e.g. theophylline, aminophylline, caffeine) Bronchodilators Corticosteroids for chemotherapy or radiation induced dyspnea, COPD Opioids (e.g. morphine, codeine, fentanyl) See Appendix A Pharmacological Management of Dyspnea

Techniques for Breathing Retraining and Control

Physical Activity

Pharmacological Management

The information contained in these documents is a statement of consensus of BC Cancer Agency professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk and is subject to BC Cancer Agency's terms of use, available at www.bccancer.bc.ca/legal.htm.

Page 4 of 9

GRADE 1 - GRADE 2 Continued

NON URGENT:
Support, teaching & follow-up care as required Patient Education and Follow-Up
Reinforce with patients when to seek immediate medical attention: - T 38 C - Acute onset of respiratory distress (severe dyspnea, unable to talk) - Acute onset of chest pain If breathing doesnt improve or begins to deteriorate: - Instruct patient/family to call back - Arrange for nurse initiated telephone follow up - Physician follow up in ambulatory care setting may be indicated Document assessment, intervention, and follow up plan Communicate to health care team as appropriate Patient Support Centre or telephone care for follow up Physiotherapist Respiratory Therapist (including assessment for home oxygen as necessary) Home Oxygen Program (requires physician prescription for oxygen therapy) Home health care

Possible Referrals

GRADE 3 OR previous dyspnea increasing over past few days

URGENT:
Requires medical attention within 24 hours Patient Assessment and Care
Consult with physician regarding the need for further patient assessment in an ambulatory care setting. If possible, treat underlying cause of dyspnea (See Appendix A). Facilitate arrangements as necessary. Dyspnea is a subjective experience that may not always correlate with laboratory results of respiratory status. Tests that may be indicated include: - Complete blood count (CBC) assess for anemia, neutropenia, infection - Serum electrolytes assess for any imbalances - Arterial blood gases assess oxygen and carbon dioxide levels in the blood - Chest X Ray assess for tumor involvement, pneumonia, pleural effusion or other. - If above not adequate, further evaluation may be required - Pulmonary function tests, CT scan, ventilation perfusion scans Oxygen therapy is effective for hypoxic patients. Trigeminal nerve stimulation through ambient air flow (e.g. fan, open window, cool cloth on face) is helpful for hypoxic and nonhypoxic patients Strategies for management energy conservation, positioning, breathing techniques Provide ongoing psychosocial and emotional support to patient/ family, encourage family members to do so Opioids (e.g. morphine, codeine, fentanyl) Other medications that may be prescribed: Anxiolytics/sedatives (e.g. lorazepam) Bronchodilators Diuretics (e.g. furosemide) Corticosteroids (e.g. dexamethasone, prednisone) See Appendix A Pharmacological Management of Dyspnea

Pharmacological Management

The information contained in these documents is a statement of consensus of BC Cancer Agency professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk and is subject to BC Cancer Agency's terms of use, available at www.bccancer.bc.ca/legal.htm.

Page 5 of 9

GRADE 3 Continued OR previous dyspnea increasing over past few days

URGENT:
Requires medical attention within 24 hours Patient Education and Follow-Up
Provide ongoing education to patients/family Effective use of any prescribed medications role of medication, administration of medications (e.g. how to use inhalers correctly), importance of regular dosing and break through medications Reinforce with patients when to seek immediate medical attention: - T 38 C - Acute onset of respiratory distress (severe dyspnea, unable to talk) - Acute onset of chest pain If breathing doesnt improve or begins to deteriorate: - Instruct patient/family to call back - Arrange for nurse initiated telephone follow up - Physician follow up in ambulatory care setting may be indicated Document assessment, intervention, and follow up plan Communicate to health care team as appropriate Patient Support Centre or telephone nursing follow - up Respiratory therapist Physiotherapist Home oxygen program Physiotherapist Home health nursing (home care) Pain and Symptom Management/ Palliative Care (PSMPC)

Possible Referrals

The information contained in these documents is a statement of consensus of BC Cancer Agency professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk and is subject to BC Cancer Agency's terms of use, available at www.bccancer.bc.ca/legal.htm.

Page 6 of 9

GRADE 4 Or the presence of the following: T 38 C, acute respiratory distress (sudden onset of dyspnea, unable to speak, lie flat, air hunger), new acute onset of chest pain

EMERGENT:
Requires IMMEDIATE medical attention Patient Assessment and Care
If patient at home, instruct patient to call 911. Notify physician of nursing assessment, and need for admission to hospital. If possible, treat underlying cause of patients dyspnea (See Appendix A). Facilitate arrangements as necessary. Dyspnea is a subjective experience that may not always correlate with laboratory results of respiratory status. Tests that may be indicated include: - Complete blood count (CBC) assess for anemia, neutropenia, infection - Serum electrolytes assess for any imbalances - Arterial blood gases assess oxygen and carbon dioxide levels in the blood - Chest X Ray assess for tumor involvement, pneumonia, pleural effusion or other. - If above not adequate, further evaluation may be required - Pulmonary function tests, CT scan, ventilation perfusion scans If dyspnea severe, open airways (e.g. endobronchial stents, radiation therapy) If copious secretions: - Normal saline or humidified air may help to loosen secretions - Suctioning may be indicated Oxygen therapy is effective for hypoxic patients. Trigeminal nerve stimulation through ambient air flow (e.g. fan, open window, cool cloth on face) is helpful for hypoxic and nonhypoxic patients Strategies for management positioning, relaxation techniques (e.g. imagery, Provide ongoing psychosocial & emotional support to patient/family, encourage family members to do so Opioids (e.g. morphine, codeine, fentanyl) as severity of dyspnea increases, consider higher doses of opioids or shifted to another route (e.g. oral to sublingual, rectal, or Transdermal) Other medications that may be prescribed: Anxiolytics/sedatives (e.g. lorazepam) Diuretics (e.g. furosemide) Corticosteroids (e.g. dexamethasone, prednisone) Anticholinergics (e.g. scopolamine, atropine) to help manage secretions See Appendix A Home Health Nursing Home oxygen program Respiratory therapist Physiotherapist Pain and Symptom Management/Palliative Care (PSMPC)

Pharmacological Management

Possible Referrals

RESOURCES Cancer Management Guidelines Chemotherapy Protocols

Pain and Symptom Management: http://www.bccancer.bc.ca/HPI/Nursing/References/SupportiveCare/Pain/default.htm BCCA Guidelines regarding Bleomycin-Associated Lung toxicity (included in Respiratory Care Manual) http://www.bccancer.bc.ca/HPI/ChemotherapyProtocols/default.htm

The information contained in these documents is a statement of consensus of BC Cancer Agency professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk and is subject to BC Cancer Agency's terms of use, available at www.bccancer.bc.ca/legal.htm.

Page 7 of 9

RESOURCES Continued Nursing Practice References (Available internally only to BCCA staff) Patient Education Resources
H:\EVERYONE\nursing\REFERENCES AND GUIDELINES\BCCA Nursing Practice Reference Manual: - 0 70: Home Oxygen Program - 0 70: Appendix B: Patient Handout on Home Oxygen Therapy - R 150: Medication Delivery via small volume nebulizer or metered dose inhaler (MDI) - R 180: Oxygen Delivery - R 190: Pulse Oximetry - R 200: Transport of Patients Receiving Oxygen Therapy Managing Symptom Side Effects Breathlessness: http://www.bccancer.bc.ca/PPI/copingwithcancer/symptoms/breathlessness/default.htm - Understanding Breathlessness: http://www.bccancer.bc.ca/PPI/copingwithcancer/symptos/breathlessness/understandingdyspnea .htm - Professional Management: http://www.bccancer.bc.ca/PPI/copingwithcancer/symptoms/breathlessness/pmgt.htm - Self Care: http://www.bccancer.bc.ca/PPI/copingwithcancer/symptoms/breathlessness/scare.htm h:/everyone/patienteducation/BCCAgenericpamphlets/dyspnea BC Cancer Agency, Respiratory Care Manual Fraser Health Authority, Palliative Care Guidelines - Dyspnea: http://www.fraserhealth.ca/media/Dyspnea.pdf Fair pharma care Extended health plan BC palliative benefits plan

Additional Resources in BC

Date of Print: January: 2010 Revised: November, 2010 Contributing Authors: Vanessa Buduhan RN MN, Rosemary Cashman, RN MSc(A), MA (ACNP), Elizabeth Cooper RN BScN, CON(c), Karen Levy RN MSN, Ann Syme RN PhD (C) Reviewed By: Pam Taheem, RN, Vancouver Centre, BC Cancer Agency Dr. Heidi Martins, BC Cancer Agency Dr. Chris Lee, Medical Oncologist, Fraser Valley Centre, BC Cancer Agency

The information contained in these documents is a statement of consensus of BC Cancer Agency professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk and is subject to BC Cancer Agency's terms of use, available at www.bccancer.bc.ca/legal.htm.

Page 8 of 9

Appendix A
The most common Pharmacological Management of dyspnea is: Systemic opioids (morphine).They reduce ventilatory demand by decreasing central respiratory drive Oral or parenteral routes are recommended Nebulized morphine is not recommended for the management of dyspnea

Other Treatment Recommendations for Underlying Causes of Dyspnea

Underlying Cause of Dyspnea
Airway obstruction Anemia (severe) Anxiety Asthma, Chronic obstructive pulmonary disease (COPD) Cardiac congestive heart failure (CHF), coronary artery disease (CAD), arrhythmias Effusions pericardial, peritoneal, pleural Fatigue / Deconditioning / Weakness Infection pneumonia, bronchitis, pericarditis Lymphangitic Carcinomatosis Lung damage from cancer treatment: Radiation or chemotherapy pneumonitis, pulmonary fibrosis Pain (which may exacerbate dyspnea) Primary or Metastatic Lung Tumor Pulmonary Embolus Pulmonary Secretions Superior Vena Cava Syndrome (SVCS)

Treatment of Choice
Radiation therapy, stents, or corticosteroids may be indicated Blood transfusion may be indicated for Hgb 80 gm/l and with symptoms Non- pharmacological interventions +/- sedatives/anxiolytics Bronchodilators to help open constricted airways (e.g. metered dose inhalers, nebulizers, steroids, anticholinergics) Conventional cardiac medications (e.g. beta- blockers, calcium channel blockers, diuretics) as prescribed Drainage may be required if fluid accumulation significant Activity to tolerance, pulmonary rehabilitation exercises may be beneficial Consider referral to physiotherapist Antibiotics, antifungals, antivirals as prescribed to treat infections that may contribute to dyspnea Steroids, diuretics as prescribed Corticosteroids (e.g. glucocorticoids) may be beneficial

Appropriate analgesics as prescribed Chemotherapy, palliative radiation therapy Anticoagulants (e.g. heparin, warafin sodium) as prescribed Anticholinergics (e.g. scopolamine, atropine) used to reduce pulmonary secretions Radiotherapy, steroids, glucocorticoids SVCS may be considered an oncological emergency if signs and symptoms present consult oncologist immediately.

The information contained in these documents is a statement of consensus of BC Cancer Agency professionals regarding their views of currently accepted approaches to treatment. Any clinician seeking to apply or consult these documents is expected to use independent medical judgement in the context of individual clinical circumstances to determine any patient's care or treatment. Use of these documents is at your own risk and is subject to BC Cancer Agency's terms of use, available at www.bccancer.bc.ca/legal.htm.

Page 9 of 9