A 64-year-old man who was diagnosed with mesothelioma of his left lung 18 months ago has been experiencing deterioration in his breathing recently. Having had first- and second-line chemotherapy further anti-cancer treatment it is unlikely more anti-cancer treatment will be offered and besides the patient is reluctant to have more treatment. He is currently not able to leave the house due to breathlessness; he is struggling with washing and dressing and is generally feeling very low due to his incapacity.
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1. What should be included as part of this gentleman’s assessment?
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Given the potentially multi-factorial causes and the multi-dimensional impact, assessment should be holistic comprising the physical, psychological, social and spiritual domains and a detailed history should be taken including known disease status. In addition, assessment should identify any symptoms of anxiety and depression, the impact of breathlessness on the patient’s lifestyle, the patients (and family’s) coping strategies and the meaning and implications of the symptom for the patient
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2. What is the likely cause of his increasing breathlessness and what can be done about it?
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Following a thorough assessment liaise with medical teams to treat any identified potentially reversible causes, for example, infection, pleural effusion, arrhythmias, anaemia or heart failure.
Anti-cancer treatment with surgery, chemotherapy or radiotherapy may be possible and it could provide more long-term palliation for the breathlessness, although the gentleman has made it clear he does not wish to have any further treatment. It is worth talking to him again about options to ensure he is making an informed decision. Discussion at the tumour site multi-disciplinary team should be considered.
If breathlessness is unresolved, a combination of pharmacological and non-pharmacological interventions should be discussed and offered to the patient, the aim being to change the experience and perception of breathlessness rather than changing the underlying pathology.
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3. What interventions would you advise for this gentleman?
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Controlled breathlessness techniques include positioning, pursed lip breathing, breathing exercises and coordinated breathing training. Supported high side lying, upright sitting with arms supported on pillows, sitting leaning forwards with arms supported on pillows and standing leaning forwards with arms supported on a wall or windowsill are suggested positions that can have a significant effect on breathing. Gaseous exchange is reduced with hyperventilation, pursed lip breathing can overcome this as it promotes a fully exhaled breath, and breathing exercises such as diaphragmatic or deep breathing are considered to be effective in helping the lungs to function optimally and promote feelings of relaxation and stress reduction.
Energy conservation can be achieved through better planning of everyday activities. It is possible to carry out some activities sitting down rather than standing, for example, dish washing, ironing and gardening. A variety of aids are also available to make everyday activities easier.
Relaxation techniques are an essential component of a Breathlessness Training Programme as breathlessness and anxiety are closely interlinked. Cognitive behavioural therapy, self-hypnosis, relaxation techniques such as progressive muscular relaxation or visualisation are all examples of suggested methods.
Handheld fans directed towards the face can significantly reduce breathlessness. It has been clearly demonstrated that oxygen does not have an added advantage over normal air in improving breathlessness and the effectiveness of a handheld fan directed against the cheek showed significant improvement in the sensation of breathlessness.
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4. Would you refer this gentleman to any other services or healthcare professionals?
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Correct answer:
Referral to a physiotherapist and an occupational therapist to support relaxation, breathing techniques or addressing necessary adaptations is recommended. A local hospice or specialist respiratory service may offer a breathlessness programme that includes access to both.
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5. Would you prescribe oxygen therapy for this gentleman?
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Oxygen can result in a varied response from individuals. It is useful for correcting hypoxia but breathlessness is not always related to hypoxia; it has been clearly demonstrated that oxygen does not have an added advantage over normal air in improving breathlessness.
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6. What on-going follow-up and support would you consider for this gentleman?
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It is likely the gentleman is now entering the latter stages of his disease. To help manage existing and potential symptoms and to prepare for end-of-life referral to a specialist, palliative care service is recommended.
