Putting Evidence into Practice®: evidence-based interventions for cancer-related dyspnea

Clinical Journal of Oncology Nursing,  April, 2008  by Wendye M. DiSalvo,  Margaret M. Joyce,  Leslie B. Tyson,  Ann E. Culkin,  Kathleen Mackay

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Despite the common occurrence of cancer-related dyspnea, a paucity of literature is available for review, especially research literature that reports interventions to control dyspnea. The Oncology Nursing Society's Putting Evidence Into Practice[R] (PEP) initiative organized a team of nurses to examine the literature, rank the evidence, summarize the findings, and make recommendations for nursing practice to improve patient outcomes. Pharmacologic and nonpharmacologic agents have been used to treat dyspnea. Patients who received parenteral or oral immediate-release opioids demonstrated a benefit in the reduction of breathlessness; thus, parenteral or oral opioids are recommended for practice. Five interventions are listed in the effectiveness not established category and include extended-release morphine, midazolam plus morphine, nebulized opioids, the use of gas mixtures, and cognitive-behavioral therapy. This article critically examines the evidence, provides nurses with the best evidence for practice, and identifies gaps in the literature and opportunities for further research.

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The Oncology Nursing Society (ONS) extended its commitment to integrate evidence into oncology nursing practice through the ONS Putting Evidence into Practice[R] (PEP) initiative. As a result, oncology nurses now have expanded resources that detail the best practices based on current evidence to manage or control several common symptoms encountered by patients with cancer.

Evidence typically is generated by research studies such as randomized controlled trials, meta-analyses, and integrated reviews, but other nonresearch sources such as clinical expertise, knowledge of pathophysiology, patient preferences, and cost effectiveness can contribute to the evidence base (Goode, 2000). The ONS PEP initiative targets interventions that independently fall within the scope of nursing practice or are integral to nursing care rendered in collaboration with other healthcare providers. The patient outcomes of such interventions are labeled nursing-sensitive patient outcomes and are critical to demonstrate and measure nurses' contribution to quality patient care (Given et al., n.d.).

The links between improving nursing-sensitive patient outcomes and ONS PEP evolve as ONS teams initially develop symptom measurement summaries and research existing evidence and apparent gaps in the evidence for each symptom. The evidence is separated into six categories: recommended for practice, likely to be effective, benefits balanced with harms, effectiveness not established, effectiveness unlikely, and not recommended for practice. ONS is making substantial efforts to communicate this information to practicing nurses by creating a Web-based Outcomes Resource Area (www.ons .org/outcomes), producing pocket cards for each symptom that detail the evidence, and publishing the results of each evidence synthesis. This article is is part of the communication plan to disseminate evidence about nursing-sensitive patient outcomes from interventions for cancer-related dyspnea to help oncology nurses make informed clinical decisions to improve patient care and outcomes. Dyspnea was chosen as a priority symptom for the PEP initiative because it is a common symptom encountered by patients with cancer.

Dyspnea

Dyspnea has many definitions, all of which are similar and describe an uncomfortable awareness of breathing. The American Thoracic Society (1999) uses a broad definition to include the interplay of physiologic and behavioral factors and states that dyspnea is "a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, social, and environmental factors, and may induce secondary physiological and behavioral responses" (p. 322). Dyspnea not only is a physical symptom but also can adversely affect quality of life (Smith et al., 2001). It is a distressing symptom for patients and a difficult one for caregivers to manage.

Dyspnea is a prevalent symptom that patients with a variety of cardiopulmonary diseases experience. In the general cancer population, dyspnea is estimated to occur in 15%-55% at diagnosis to 18%-79% during the last week of life (Ripamonti & Fusco, 2002). Dyspnea occurs in up to 60% of patients with cancer and may be caused by a tumor occluding the airway (Beckles, Spiro, Colice, & Rudd, 2003).

The causes of dyspnea in patients with cancer are many and can be attributed directly to the disease or manifestations of the disease and its treatments or be unrelated (see Figure 1). A visual analog scale (VAS) may be a useful tool in assessing the symptom of dyspnea. The optimal treatment of dyspnea includes the use of specific therapies as appropriate to reverse the causes of dyspnea as well as palliative therapies to treat irreversible causes. The nursing-sensitive interventions for dyspnea discovered through this search included two broad categories: (a) pharmacologic interventions, including oral, parenteral and nebulized opioids, other medications, and oxygen therapy, and (b) nonpharmacologic interventions, including complementary and alternative approaches.