What are the NCCN treatment guidelines for dyspnea in palliative cancer care?

Updated: Aug 13, 2018
  • Author: Winston W Tan, MD, FACP; more...
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Answer

The NCCN guidelines for treatment of dyspnea in cancer patients are based on estimates of the patient’s life expectancy. [6] For patients with a life expectancy of years to months to weeks, the NCCN recommends assessment of symptom intensity followed by treatment of underlying causes or comorbid conditions with measures such as the following:

  • Chemotherapy and/or radiation therapy
  • Procedure to reduce or remove cardiac, pleural or abdominal fluid
  • Bronchoscopic therapy
  • Bronchodilators, diuretics, steroids, antibiotics, or transfusions
  • Anticoagulants for pulmonary emboli

For symptomatic relief, the following interventions may be used, as appropriate:

  • Oxygen therapy for hypoxia
  • Educational, psychosocial, and emotional support for patients and family
  • Nonpharmacologic therapies including fans, cooler temperatures, stress management, relaxation therapy, and comfort measures
  • If the patient is opioid naïve, morphine; if dyspnea is not relieved by morphine and is associated with anxiety, add benzodiazepines
  • Noninvasive positive-pressure ventilation (ie, continuous positive airway pressure [CPAP], biphasic positive airway pressure [BiPAP]) if clinically indicated for a severe reversible condition

For patients with a life expectancy of weeks to days, the following measures may be used, in addition to the interventions listed above:

  • When assessing symptom intensity, use physical signs of distress as potential indications of dyspnea in noncommunicative patients
  • Withhold, withdraw, or initiate a time-limited trial of mechanical ventilation as indicated by patient and family preferences, prognosis, and reversibility
  • Provide sedation as needed
  • Provide guidance for patient and family regarding dying and respiratory failure
  • Provide emotional and spiritual support

If fluid overload is a contributing factor, interventions include the following:

  • Decrease/discontinue enteral or parenteral fluid
  • Consider low-dose diuretics
  • If opioid naïve, morphine
  • Benzodiazepines
  • Scopolamine to reduce excessive secretions

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