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Non-pharmacological intervention for breathlessness in lung cancer J Corner Director, Centre for Cancer and Palliative Care Studies, Institute of Cancer Research, London, H Plant Lecturer, Centre for Cancer and Palliative Care Studies, Institute of Cancer Research, London, R A’Hern Statistician, Royal Marsden NHS Trust, London and C Bailey Research Practitioner, Centre for Cancer and Palliative Care Studies, Institute of Cancer Research, London

Key words: breathing exercises; dyspnoea; lung neoplasms; nursing intervention (non-MeSH); rehabilitation

Objective - To evaluate the effect of non-pharmacological intervention for breathlessness in lung cancer on breathlessness ratings and patient functioning. Design - Randomised controlled pilot study. Setting - A nurse led clinic in a specialist cancer centre. Subjects - 20 patients with advanced small cell and non-small cell lung cancer. Intervention - Weekly sessions with a nurse research practitioner over 3-6 weeks using counselling, breathing re-training, relaxation and teaching coping and adaptation strategies. Main outcome measures - Visual analogue scale ratings of breathlessness, distress caused by breathlessness, functional capacity, ability to perform activities of daily living and the Hospital Anxiety and Depression Scale. Results - Improvements in median scores on all measures were observed in the intervention group with the exception of depression, compared with the control group where median scores were static or worsened. Distress from breathlessness was improved by a median of 53%, breathlessness at worst by 35% and functional capacity by 21 %. In contrast, distress in the control group worsened by a median of 10%. Significant improvements compared with the control group were observed in breathlessness at best (p < 0.02), breathlessness at worst (p < 0.05), distress caused by breathlessness (p < 0.01), functional capacity (p < 0.02) and ability to perform activities of daily living (p < 0.03) but were not observed for anxiety or depression. Conclusion Lung cancer patients suffering from breathlessness benefited from this rehabilitative approach to breathlessness management and strategies employed in this pilot study warrant further multicentre research. Macmillan nurses and palliative care teams are recommended to explore the potential of adopting similar approaches.

Address for correspondence: Prof J Corner, Director, Centre for Cancer and Palliative Care Studies, Institute of Cancer Research/Royal Marsden NHS Trust, London SW3 6JJ, UK.

300 Mots clés: exercices respiratoires; dyspnée; intervention de soins; rehabilitation

néoplasmes pulmonaires;

Objectif - Evaluer I’effet d’une intervention non-pharmacologique pour l’essoufflement provoqué par le cancer des bronches d’après la fréquence des essoufflements et le comportement du patient. - Une étude pilote contrôlée et sous forme de sondage. Méthodologie Cadre - Un dispensaire mené par une infirmière dans un centre pour cancéreux. Les sujets - 20 patients ayant de petites et bronches à un stade avancé du cancer.

grandes cellules cancéreuses des

Intervention - Des séances hebdomadaires avec une infirmière qui fait de la recherche sur 3 à 6 semaines utilisant une assistance socio-psychologique, de la rééducation pour respirer, de la relaxation ainsi qu’une aptitude à l’enseignement et des stratégies d’adaptation.

Principales mesures prises - Une échelle analogue visuelle de la fréquence des essoufflements, de la douleur causee par l’essoufflement, de l’aptitude fonctionnelle, de l’aptitude à accomplir des tâches de la vie quotidienne et l’Echelle de Dépression et d’Anxiété de l’Hôpital. Résultats Parmi les resultats moyens, on a observé des améliorations pour toutes les démarches au sein du groupe témoin où les résultats moyens n’ont pas bougé ou bien ont empiré. La douleur provoquée par l’essoufflement a connu une amelioration d’une moyenne de 53%, l’essoufflement de 35% au pire et l’aptitude fonctionnelle de 21 %. En revanche, au sein du groupe témoin, la douleur a empiré d’une moyenne de 10%. Comparé au groupe témoin, on a observé des améliorations considérables dans l’essoufflement au mieux (p < 0.02), au pis (p < 0.05), la douleur provoquée par l’essoufflement (p < 0.01), l’aptitude fonctionnelle (p < 0.02) et l’aptitude à accomplir des tâches de la vie quotidienne (p < 0.03) mais il n’y a pas eu d’améliorations ni pour l’anxiété ni pour la dépression. Conclusion - Les malades atteints du cancer des bronches souffrant d’essoufflement ont profilé de cette approche de rehabilitation en vue de contrôler l’essoufflement et ont profité des stratégies employées dans cette étude pilote justificative de davantage de recherche dans bien des centres. On recommande aux infirmières Macmillan et équipes de soins palliatifs d’explorer la possibilité d’adopter des démarches identiques.

as it directly affects the person’s ability to perform all activities of daily living, severely limits Breathlessness is a common and difficult symptom mobility and can provoke intense feelings of anxiety, in advanced cancer, experienced by around 30% of leaving patients socially isolated and fearful. There patients’ and is described as the subjective sensation is also evidence that patients with lung cancer of an uncomfortable awareness of breathing or receive little or no help or advice on how to cope difficult breathing. In lung cancer breathlessness is during attacks of breathlessness or how to adapt to particularly problematic, with around 13% of pa- living with the symptom.’ tients suffering from it at diagnosis and around 65% Treatment for breathlessness in advanced canof all lung cancer patients experiencing breathless- cer has focused on active procedures such as ness during the course of their illness.2 The effects of drainage of pleural effusions and also on pharmasuch breathlessness on quality of life can be enor- cological interventions aimed at reducing the

Introduction

mous,

301

perception of breathlessness, for example using weekly sessions with a nurse research practitioner opioids.4 However, there is some evidence to (each session lasting approximately one hour) suggest that such strategies may not be effective in over 3-6 weeks. Further follow-up sessions were alleviating the symptom. Higginson and McCarthy5 available if required. Sessions were used to make found that while pain appeared to be alleviated in a detailed assessment of the patients’ breathlesspatients following referral to a specialist symptom ness, their disease and their feelings about the control team, breathlessness actually worsened as future. They were given advice and support on the illness progressed, despite the intervention of methods of managing breathlessness and involvthe support team. ing family members. Breathing re-training was A number of studies are under way in the UK undertaken with the patient and goals were set exploring different therapeutic interventions for each week to assist the patient to learn breathing and relaxation techniques. Once integrated into cancer induced breathlessness, particularly different preparations of morphine. These tend to be daily life, these techniques would enable patients used relatively late in the course of the symptom, to expand their range of activities. The control with severe breathlessness being the trigger for group received detailed assessments of their intervention. This study aimed to investigate breathlessness during outcome assessment interwhether a nursing approach to intervention could views. They were encouraged to talk freely about be developed and evaluated using non-pharma- their breathlessness and their disease but were not cological approaches. These could be used earlier offered breathing re-training or counselling. Outcomes were assessed using three ten-point in the course of the disease and would focus on and for visual of life functional ability analogue scales to rate breathlessness over maximising quality from breathlessness. the week (’breathlessness at best’, ’breathcancer suffering previous patients lung lessness at worst’ and ’distress caused by Method breathlessness’). The Functional Capacity Scale&dquo; was used to assess ability to walk distances and An intervention strategy based on rehabilitation climb stairs and an activities of daily living checktechniques used in chronic pulmonary disease was list identifies difficulties in performing activities developed.’9 This included counselling, breathing (maximum score 14). Patients also completed the re-training, relaxation and teaching coping and Hospital Anxiety and Depression Scale.’2 Indepth adaptation strategies. The aim of this approach interviews were conducted to explore the experito increase the individual’s tolerance to restricted lung function, to increase fitness and confidence to cope with attacks of breathlessness and to reduce the disability caused by the symptom. Since in lung cancer breathlessness occurs in the context of an imminently life threatening illness, an integrated model of breathlessness management was adopted. The emotional experience of breathlessness was considered inseparable from its physical cause and therefore the intervention strategy both acknowledged the emotional meaning of the symptom and offered breathing re-training as a strategy for managing it.’° Patients with small cell and non-small cell lung cancer, who had completed chemotherapy or radiotherapy and were suffering from breathlessness, were approached and asked if they would agree to be randomised either to attend a nursing clinic using the intervention strategy or to be followed up as a control group. Patients randomised to the intervention group attended

was

ence

of breathlessness. Both groups

were

assessed

entering the study, at four weeks and at three months. Longer follow-up was not possible due to disease progression and/or death. on

Results

Thirty-four patients had consented to take part in the randomised study when randomisation was stopped in response to requests from medical and nursing staff who felt that they had observed a clear benefit from the intervention strategy. Nineteen of these were randomised to the intervention group and 15 to the control group. The median age was greater by 14 years in the control group, but this is unlikely to have confounded the treatment effect. Fourteen patients (eight from the intervention group and six from the control group) had to withdraw from the study due to deterioration, reflecting the limited prognosis for the majority of patients with lung cancer. The

302

patients who withdrew from the study was 49 days, compared with 200 days for the 20 patients available for analysis (p < 0.001, log rank test). The characteristics of these patients are shown in Table 1. There was no median survival of the 14

evidence of a survival difference between the intervention and control groups considering all patients (intervention to control hazard ratio: 0.89, 95% CI (0.4-2.01), ns) or the first 20 patients (intervention to control hazard ratio: 0.69, 95% CI (0.2-2.35), ns). Figure 1 shows scores on key variables for each subject in the two groups plotted against time, a procedure recommended for serial measurements of small samples.&dquo; Baseline data show that the intervention group rated distress caused by breathlessness higher than the non-intervention group (Mann-Whitneyp 0.03), had greater difficulty in performing activities of daily living (Mann-Whitney p 0.01) and had higher levels of anxiety, although no scores for either group reached the level of case anxiety. No other significant differences were observed between the two groups. Median scores for breathlessness at best, breathlessness at worst, distress caused by breathlessness, functional capacity and difficulty in performing activities of daily living reduced over time in the =

=

Table 1 Charateristics of the

sample

intervention group (see Table 2). The intervention a median improvement in breathlessness at worst of 35%, a median improvement in distress caused by breathlessness of 53%, a median improvement of 17% in functional capacity and a median reduction in difficulty in performing activities of daily living of 21 %. Using Wilcoxon tests improvements in breathlessness at worst (p 0.02), distress caused by breathlessness and functional capacity (p (p 0.02) 0.03) were shown to be significant for the three months after patients entered the study. The median scores of the non-intervention group were static or worsened over the same period and changes were not

group showed

=

=

=

Table 2 Improvements from baseline in intervention and control groups, and difference in improvement between the two groups

*p

=