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Review Series: Palliation of dyspnea

Review Series: Palliation of dyspnea

Nonpharmacological interventions for managing respiratory symptoms in lung cancer

Chronic Respiratory Disease 9(2) 117–129 ª The Author(s) 2012 Reprints and permission:

sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1479972312441632 crd.sagepub.com

Review Series: Palliation of dyspnea Nonpharmacological interventions for managing respiratory symptoms in lung cancer Chronic Respiratory

Janelle Yorke 1 , Alison Brettle 1 and Alex Molassiotis 2


Patients with lung cancer experience significant symptom burden, particularly symptoms of a respiratory nature. Such symptom burden can be distressing for patients and negatively impact their functional status and quality of life. The aim of this review is to evaluate studies of nonpharmacological and noninvasive interventions for the management of respiratory symptoms experienced by patients with lung cancer. In total, 13 studies met the inclusion criteria for this r eview and included 1383 participants of which 1296 were lung cancer patients. The most frequently assessed and reported symptom was breathlessness (n ¼ 9 studies). Cough and haemoptysis were reported in one study. A variety of outcome measurement tools were used and a broad range of intervention strategies evaluated. Lack of consistency between studies impinged on the ability to combine studies. It is not possible to draw any firm conclusion as to the effectiveness of nonpharmacological interven tions for the management of respiratory symptoms in lung cancer. Nonpharmacological interventions may well have an important role to play in the management of some of the respiratory symptoms (or combinations of respiratory symptoms), but more work of higher quality is necessary in the future.


Lung cancer, complementary therapies, breathlessness, cough, nonpharmacological interventions


Patients with lung cancer experience significant symptom burden, particularly symptoms of a respira- tory nature. The symptom experience can vary widely among patients and generally is the result of the dis- ease and its progression or its treatments. 1 Respiratory symptoms, such as breathlessness, cough, wheeze, haemoptysis and hoarseness are reported by patients with lung cancer, occurring in 20% to 90% of patients. 2 Such symptom burden can be distressing for patients and negatively impact their functional status and quality of life (QOL). 35 There is limited work in the development and test- ing of nonpharmacological interventions for the man- agement of respiratory symptoms. Much of this work concerns breathlessness, but little or no work exists in relation to other respiratory symptoms. Breathless- ness is a complex subjective experience defined as an uncomfortable awareness or sensation of breathing. 6

Breathlessness represents one of the most common and distressing symptoms in lung cancer. 7 Patients with all stages of lung cancer, who report breathlessness, also experience a significantly lower QOL, 8 and those with the most severe breathlessness experience more pain and anxiety. 4,8,9 A longitudinal study of 105 patients with advanced lung cancer demonstrated that breath- lessness increased overtime, most dramatically during the first 3 months, while QOL declined over the same

1 School of Nursing, Midwifery and Social Work, University of Salford, Manchester, UK 2 School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK

Corresponding author:

Alex Molassiotis, School of Nursing, Midwifery and Social Work,

Jean McFarlane Building, University of Manchester, Oxford Road, Manchester M13 9LP Email: alex.molassiotis@manchester.ac.uk


Chronic Respiratory Disease 9(2)

period. 4 Optimal management of breathlessness broad range of psychosocial, behavioural, educational

requires a combination of pharmacological and non-

and environmental strategies may provide a more com-

pharmacological interventions. 10 The evidence base prehensive approach to ameliorating the effects of this for pharmacological interventions has been reported distressing symptom.

in several systematic reviews. 10,11 These reviews indi-

Other respiratory symptoms such as haemoptysis,

cate a limited evidence base for the use of opioids for hoarseness and wheeze are much less common than

symptom relief; benzodiazepines to relieve anxiety; breathlessness and cough. At presentation, up to and the use of oxygen. Pharmacological interventions 20% of patients report mild haemoptysis, 21 and alone often do not relieve breathlessness adequately approximately 9% of patients have reported haemop- and the use of drugs to treat breathlessness is some- tysis in the last 8 weeks of life. 22 While much less pre- times limited as they can cause adverse effects and valent than breathlessness and cough, haemoptysis require careful titrating. 10,12 As breathlessness is a sub- can be alarming for both patients and their families. jective experience, nonpharmacological interventions Intrusive interventions target bronchial vessels since as an adjunct to drug treatments offer promise for the these vessels supply the airways and are under higher

management of this distressing symptom.

pressure than pulmonary arteries. At present, there are

Cough presents a significant burden for people no clinical trials specifically evaluating the efficacy of with lung cancer and is reported to be present in these invasive interventions to treat haemoptysis in

40% to 70% of patients with lung cancer at initial pre- patients with lung cancer. Other, less common symp- sentation and as the disease progresses. 2 Cough may toms are also likely to cause distress, such as hoarse- exacerbate breathlessness 13,14 and has a profound ness and wheeze, and may also occur as a result of the effect on QOL, particularly its psychosocial aspects. 5,15 cancer or underlying comorbidity such as asthma and

In lung cancer, the aetiology for cough is multifactorial

COPD. In the context of lung cancer, it is not known

and can be the result of direct anatomic effects of the whether nonpharmacological interventions have a

cancer (obstruction), indirect effects of cancer (pleural

role to play in ameliorating the distressing effects of

effusion or pneumonitis secondary to radiation or che- these symptoms.

motherapy), or underlying chronic conditions (asthma,

Given the multitude of respiratory symptoms

COPD and postnasal drip). 16,17 There are few manage- patients can experience, alleviating discomfort and

ment options for cough in lung cancer that are evidence symptom distress often

requires several treatment

based. 18,19 One of the oldest medications for the con- modalities to reach an acceptable outcome. In addition,

trol of cough is codeine that suppresses the central ner- symptom incidence and distress levels may vary over vous symptoms responsible for triggering cough. 20 time and lung cancer treatment, making their manage-

Other pharmacological treatments are largely based ment challenging. Usually managed as isolated symp- on the use of antitussive drugs (cough suppressants) – toms, they often occur simultaneously. It may be that

opioids or nonopioids – for which the evidence base is

interventions that include behavioural, psychosocial

minimal or conflicting. A Cochrane review of interven- and/or educational strategies assist patients to better

tions (pharmacological and nonpharmacological) for cope with distressing symptomology.

cough in cancer concluded that research in this area was limited with poor quality and significant methodo-

The aim of this review is to evaluate studies of

nonpharmacological and noninvasive interventions

logical problems. 18 The Cochrane review reported that for the management of respiratory symptoms experi- a range of pharmacological treatments (e.g. codeine, enced by patients with lung cancer. We aimed to

morphine, dihydrocodeine, sodiumcromoglycate and include studies that incorporated a broad range of butamirate citrate linctus – cough syrup) showed some interventions including psychosocial, behavioural, improvements in cough, although all studies had sig- educational, complementary therapies and environ- nificant risk of bias. Molassiotis et al. 18 also included mental/service delivery strategies. studies that evaluated the efficacy of invasive treat- ments, such as brachytherapy and photodynamic ther-


apy, and reported encouraging results. No studies that evaluated the effectiveness of nonpharmacological and Searches were conducted on a range of electronic noninvasive interventions for the management of databases, covering a range of perspectives. These cough in cancer were included in the review as no stud- included Medline (Ovid interface; biomedical), Psy- ies were identified. 18 Interventions that encompass a chinfo (Ovid interface; psychological), Amed (Ovid

Yorke et al.


interface; complementary and allied health, Cinahl (EBSCO interface; nursing and allied health), Cochrane Library (Wiley; systematic reviews and randomised controlled trials (RCTs) in health care). A combina- tion of thesaurus and free text terms were combined to maximise sensitivity for the following keywords including lung cancer, symptoms, psychological therapies and complementary therapies. No date or research methodology restrictions were applied. Studies were included in the review if they were a report of a RCT or quasi-experimental designs. Patients of either gender and any age with lung cancer at any stage, including primary and secondary malig- nancy, were included. If an article included a hetero- geneous group, then the study was only included if greater than 70% of participants had a diagnosis of lung cancer. We included articles that reported one or more respiratory outcomes (including breathless- ness, cough, haemoptysis, wheeze, or hoarseness) as a primary or secondary outcome. Such outcomes were required to be reported as a separate outcome, either on a symptom-specific questionnaire – for example, a Visual Analogue Scale (VAS) 23 or Numerical Rating Scale (NRS) 24 or extracted from a questionnaire that contains symptom-specific items (e.g. Symptom Distress Scale (SDS)). 25 Due to the low number of studies that reported single symptoms, except breathlessness, we extended our inclusion criteria to inc lude studies that reported

Description of included studies

In total, 13 studies 2739 met the inclusion criteria for this review and included 1383 participants of which 1296 were lung cancer patients. Please see Table 1 for detailed information on the included studies. The most frequently assessed and reported symptom was breathlessness (n ¼ 9). 2734,39 Cough was included as a single outcome measure in one study 35 and hae- moptysis was reported separately in the same study. No other respiratory symptoms related to lung cancer were reported as a single outcome measure in any included studies. Studies included in the review were categorised and reported in terms of respiratory symp- tomatology: (a) studies reporting breathlessness as a single outcome measure; (b) studies reporting cough as a single outcome measure; (c) studies reporting hae- moptysis as a single outcome measure; and (d) studies that reported combined/overall symptom scores.


Breathlessness was the primary outcome for six studies 27,28,3032,39 and was a secondary outcome in three studies. 29,33,35 This section presents details relating to the method of breathlessness assessment used in the review studies and types of interventions evaluated, where breathlessness was measured as a single symptom.

combined/overall symptom scores – this included Methods of breathlessness assessment. A variety of studies that only reported, for example, a total score methods were used to assess breathlessness (see

for the SDS and Rotterdam Symptom Checklist. 26


Table 2 for a description of the instruments used). Six studies used VAS 23 and two studies used NRS. 24 The scaling range used for the VAS and NRS measures was 0–10, except for Chan et al. 29 who used 0–100

Searches resulted in 1289 records that were uploaded and Connors et al. who did not specify a scaling range. onto endnote, de-duplicated and filtered for relevance The majority of studies measured breathlessness to the review question. A additional three studies were intensity on a VAS or NRS at ‘best’ or ‘worst’ breath-

located by checking reference lists of relevant systema- lessness over the preceding 24-h period. In a feasibility tic reviews. This process resulted in 54 articles that RCT, Barton et al. 27 used area under the curve analysis were further scrutinised for relevance to this review. and concluded that the NRS measures of ‘worst’ and Studies were further excluded because they were ‘average’ breathlessness over the past 24 h were the reviews or opinion articles (n ¼ 15), case studies or most useful assessments. The majority of studies that descriptive studies (n ¼ 11). Other studies were applied the VAS and NRS to assess the intensity of excluded because the sample was heterogenous or breathlessness also used the same scaling method to respiratory symptoms were not grouped. Noncancer assess distress associated with breathlessness. 27,28,3033

participants or cancer patients with mixed aetiology

The European Organisation for Research and

or respiratory symptoms were not included as an out- Treatment of Cancer–lung cancer quality of life ques-

come measure (n ¼ 10). Further five studies were tionnaire (EORTC-LC13) 41 is a multidimensional

excluded because the intervention was not classified QOL instrument that contains three items relating to

as nonpharmacological.

breathlessness. Moore et al. used the EORTC-LC13

Significant difference in Symptom Distress Score Significantly improved breathlessness but not cough and haemoptysis at 3 months, none at 6 months Patient: significant improvements in functional well-being, symptoms; Care- giver: significant improvements in anxiety and self-efficacy Fatigue was the most severely distressing symptom; multivariate model ¼ chemotherapy and systematic nursing assessment were associated with less symptom distress over time SDS – no significant difference between groups No effect – 95% CI excludes the prespecified

Significant improvements compared with the control in breathlessness at best (p < 0.02) and worst (p < 0.05), distress caused by breathlessness (p < 0.01)

EORTC: The European Organisation for Research and Treatment of Cancer; FACT-L: Functional Assessment of Cancer Treatment – Lung cancer; MCD: Minimal clinical difference; NRS: Numer- ical Rating Scale; QOL: quality of life; RCT: randomised controlled trial; SDS: Symptom Distress Scale; VAS: Visual Analogue Scale.

Significant improvement (within sample) in all VAS scores, Rotterdam scores

Significant improvement in symptom cluster and specific symptoms – breathlessness High attrition, breathlessness improved but

Significant improvement in breathlessness best; b/ness distress; depression; physical symptoms

No effectiveness data: ‘worst’ and ‘average’ past 24 h most useful assessment

Within group significant improvement in all symptoms at least up to 6 h post tx; maximal at 90 min

MCD of a 20% greater improvement in acupuncture group

not statistically


Symptom Distress Scale – no specific symptoms Breathlessness – NRS

EORTC QOL score and lung cancer module – breathlessness, cough,

Rotterdam Symptom Checklist

worst and best; and associated distress Breathlessness and associated distress on VAS

Breathlessness NRS; brief COPE; breathlessness distress; HADS

‘Symptom cluster’ and separate breathlessness scores on VAS Breathlessness scores on VAS at

haemoptysis FACT-L with breathlessness and cough subscales

Breathlessness and associated distress Rotterdam Symptom Checklist Symptom Distress Scale

Breathlessness VAS – best and worse, and related distress

Symptoms/outcomes assessed relevant to this review

Breathlessness, anxiety, and relaxation on VAS

Symptom Distress Scale

Lung cancer (n ¼ 48), newly diagnosed, need paper

Lung cancer (n ¼ 169), only 15 completed protocol

Lung cancer (n ¼ 113) and breast cancer (n ¼ 77) Lung cancer 80%; breast 20% (n ¼ 47)

Primary or secondary lung cancer (n ¼ 20)

Lung cancer (n ¼ 166)

Lung cancer (n ¼ 140)

Lung cancer (n ¼ 119)

Lung cancer (n ¼ 239)

Lung cancer (n ¼ 20)

Lung cancer (n ¼ 30)

Lung cancer (n ¼ 22)

Advanced lung cancer (n ¼ 203)

Diagnostic groups

Physiotherapy – teaching breathing control, relaxation, energy conservation Nurse intervention – counselling, breathing retraining, relaxation, coping strategies vs. control (speak freely about breathlessness but no training or counselling) Sternal and L14 acupuncture points

Specialist home nursing care vs. standard home care vs. clinic care Nurse-led follow-up vs. conventional medical follow-up

breathing Nurse intervention – breathlessness focus, muscle relaxation, psychosocial support vs. standard care Psychoeducational vs. usual care

Specialist physiotherapy sessions

Caregiver-assisted coping skills training vs. education/support including caregiver

High ( 3 sessions) vs. low ( 1 session) intensity training in

Structured nursing assessment

Acupuncture vs. placebo

Pivot nurse in oncology


Table 1. Characteristics of included studies


Multicentre RCT


Feasibility RCT

Reference and country Type of study

Cohort study

Open pilot









McCorkle et al. 34 USA

Chan et al. 29 Hong Kong Connors et al. 30 UK

Skrutkowski et al. 38 Canada Vickers et al. 39 USA

Porter et al. 36 USA

Corner et al. 31 UK

Barton et al. 27 UK

Moore et al. 35 UK

Bredin et al. 28 UK

Hately et al. 33 UK

Filshie et al. 32 UK

Sarna 37 USA


CI: confidence interval; FACT-L: Functional Assessment of Cancer Treatment – Lung cancer; HADS: Hospital Anxiety and Depression Scale; MCD: Minimal clinical difference; QOL: quality of life; NRS: Numerical Rating Scale; VAS: Visual Analogue Scale.

Symptom-specific items reported separately

Symptom-specific items not reported separately, only total scores measured Symptom-specific items not reported separately, only total scores measured Symptom-specific items not reported separately

worst scores most sensitive Symptom-specific items not reported separately, only total scores measured

Breathlessness item scored but recorded: total scores reported only Breathlessness item scored but recorded: total scores reported only Dyspnoea subscale reported separately

Current: before and after 1 h treatment; average daily level Past 24 h; not specified Feasibility study – average and

General comments

Past 24 hours

Not specified

Not specified

Recall period

Feeling lately

Extent of experience 0–4: 0 (not at all) to 4 (very Two breathlessness items Past week

Past week

Past week

As above

As above

As above

Past 24 h

Past 24 h


Related to breathlessness Current

Best, worst, average Related to breathlessness

Not specified Best, worst Not specified Best, worst, average Related to breathlessness Not clear

ease of breathing Extent of experience 1–4: 1 (not at all) to 4 (very Three breathless items –

1–5: 1 (breathe normally or One breathlessness item

climbing stairs; one cough item; one haemoptysis item 0–4: 0 (not very much) to 4 One shortness of breath

Average, worst distress

– sort of breath and

and one cough item

Dyspnoea subscale

Best, worst Not specified Average for 7 days

at rest, walking,

As above

As above

As above



seldom cough) to 5 (almost always have severe trouble breathing

or persistence severe cough) As above

(very much)

Not specified

Not specified

Scaling range

As above

As above














Degrees of distress

Multiple symptom

QOL experience


As above

As above

As above















Table 2. Instruments used to assess respiratory symptoms

15-Item symptom list, provides a total score

Multidimensional symptom distress includes 23 items As above



QOL measure















Skrutkowski et al. 38 As above

As above

McCorkle et al. 34

Connors et al. 30

Chan et al. 29 Connors et al. 30

Vickers et al. 39

Corner et al. 31

Barton et al. 27

Moore et al. 35

Bredin et al. 28

Bredin et al. 28

Porter et al. 36

Hately et al. 33

Hately et al. 33

Filshie et al. 32

Review study

Sarna 37

Visual Analogue Scale for breathlessness and distress 23

Rotterdam Symptom Check List 26

Chronic Respiratory

Questionnaire 42

Symptom Distress

Numerical Rating Scale for breathlessness and distress 24



Scale 25



Chronic Respiratory Disease 9(2)

and reported separate scores for breathlessness. Like- wise, the Chronic Respiratory Questionnaire, 42 a QOL instrument for use in chronic respiratory diseases, was applied in Corner et al.’s 31 study, and a separate score for the dyspnoea subscale was reported in that study. Multisymptom scales, including the Functional Assessment of Cancer Treatment–Lung cancer

at ‘worst,’ and distress caused by breathlessness were reduced over time in the intervention group but not in the control group. 31 The feasibility study was stopped early since the intervention group showed a clear benefit. The subsequent adequately powered trial 28 included 119 participants of which 103 were included

(FACT-L), 40 SDS, 25 and the Rotterdam Symptom in the final analysis. The intervention was similar

Checklist, 26 were also used in studies included in this review but separate scores for breathlessness were not provided (see Table 2). Breathlessness is a multidi- mensional experience and consists of different sensa- tions with different intensities, 10 yet no study included in this review applied a measure to reflect the entirety of this symptom.

Description of interventions with breathlessness as a

discrete symptom. A variety of interventions aimed at improving the patient’s experience of breathlessness were included in this review. Interventions for breath- lessness were difficult to categorise as many of the interventions included more than one component, provided by various professionals and in different settings. Therefore, categ ories were grouped accord- ing to the main mode of treatment delivery and included (a) multimodal interventions with a nursing focus; (b) multimodal interventions with a phy- siotherapy or multiprofessional focus; and (c) acu- puncture/acupressure.

  • 1. Multimodal interventions with a nursing focus

Three studies were included that evaluated interven- tions that consisted of a broad range of psychosocial, educational and behavioural strategies, included a specific measure of breathlessness, and were led by nurses. 28,31,35 The intervention strategies used across these studies were reasonably similar, with each study including elements of relaxation techniques, counsel- ling and anxiety management. The seminal studies by Corner et al. 31 and Bredin et al. 28 tested the combination of a nurse-led multimo- dal intervention that combined breathing and relaxa- tion training, counselling and teaching coping and adaptive strategies. Both studies included the inten- sity of breathlessness as the primary outcome mea- sured on a VAS, 0–10 scaling range. In Corner’s feasibility study, 34 participants with lung cancer were included of which 19 were randomized to the intervention and 15 to the control group. 31 The inter- vention group attended weekly sessions with a nurse practitioner over 3–6 weeks. Breathlessness at ‘rest,’

between the two studies; however, in Bredin’s study the intervention strategy was tailored to individual patient’s needs. 28 This included detailed assessment of the meaning of breathlessness and factors that con- tribute or help to relief it. The intervention strategy also incorporated supportive measures for patients’ family members. After 8 weeks, the intervention group showed significant improvement in breathless- ness at ‘best’ but there was no significant improve- ment in breathlessness at ‘worst’ or distress caused by breathlessness. Moore et al. 35 examined the effects of a nurse-led follow-up service compared to conventional medical follow-up. The nurse-led intervention consisted of clinical assessment, access to the nursing clinics and communication with the general practitioner and pri- mary care team. Participants randomized to the inter- vention were allocated to one of two clinical nurse specialists and were assessed monthly to identify signs of disease progression, symptoms warranting intervention, or serious complications. The nurse spe- cialists provided information and support and coordi- nated input from other services. Breathlessness was measured 41 using EORTC-LC13 and separate breath- lessness scores were provided. Three months after study commencement, participants rated their breath- lessness severity significantly less severe than partici- pants in the conventional follow-up. There was no difference in breathlessness after 6 months but again there was a significant difference after 12 months. In addition, participants in the intervention group had significantly improved scores for emotional function- ing and treatment satisfaction was significantly higher in the intervention group for both patients and carers. A nurse-delivered psychoeducational intervention was tested by Chan et al. 29 in Hong Kong. The inter- vention group received a 40-min education session on symptom management and coaching in the use of pro- gressive muscle relaxation delivered 1 week prior to commencing radiotherapy, and repeated after 3 weeks. The intervention was delivered by registered nurses who had attended a 2-day training session focusing on the educational package and practice of

Yorke et al.


progressive muscle relaxation. Symptom data were The sessions involved a broad range of strategies collected prior to the intervention, 3 weeks, 6 weeks including breathing control, relaxation, anxiety man- and 12 weeks postintervention. A total of 140 patients agement, energy conservation, goal setting and life- consented to participate in the study and the overall style readaption. This programme suffered high attrition rate at week 12 was 27%, with the sole reason attrition – 160 patients were recruited at baseline, but being attributed to death. Breathlessness was one of only 14 completed the programme. The investigators the primary outcomes and was measured on a acknowledged that patient selection was the likely 100 mm VAS. The study aimed to assess the efficacy reason for the high dropout, since the sample was of the psychoeducational intervention on symptom selected from the entire lung cancer population which clusters in lung disease – breathlessness, fatigue and included the frail and patients receiving cancer treat- anxiety. We discuss the specific outcomes for breath- ments. In contrast, similar studies included patients lessness intensity measured on the VAS here. There who had completed active cancer treatments. 28,31 was a significant improvement in breathlessness Connors et al. 30 reported nonsignificant changes in intensity scores between the 2 study groups at week breathlessness measured on a VAS for breathless- 6 and week 12, although the effect sizes were small ness at best and at worst, distress caused by breath-

(partial Z 2 ¼ 0.04 and 0.043, respectively). 43

  • 2. Multimodal interventions with a physiotherapy or multiprofessional focus

lessness, and the dyspnoea subscale of Chronic Respiratory Questionnaire. 42 The feasibility of high- versus low-intensity train- ing in breathing techniques for breathless patients

with lung cancer delivered by a specialist phy- Two nonrandomised studies 30,33 assessed siotherapists or lung cancer specialist nurse was tested physiotherapy-led multimodal interventions for by Barton et al. 27 This was a single-centre, non- patients with lung cancer. In a single-centre study, blinded RCT designed to assess recruitment and Hately et al. 33 evaluated an intervention strategy for retention, best end point and variability of breathless- patients with lung cancer including physiotherapist- ness scores to inform a subsequent powered study. led reviews in a specialist outpatient breathlessness The intervention consisted of training in diaphrag- clinic. Patients were monitored by the senior phy- matic breathing, pacing, anxiety management and siotherapists at 3 sessions, each lasted a maximum relaxation during an hour-long clinic session. The of 90 min, over a period of 4–6 weeks. The interven- control group (low intensity) received the session tion consisted of a range of strategies, including once and the intervention group (high intensity) breathing retraining, relaxation techniques, activity received subsequent sessions at weeks 2 and 3. Both pacing and psychosocial support. Compared to other groups also received written and DVD reinforcement studies included in this review, the inclusion of a material and a telephone call from their therapist a specific-activity pacing component was a unique week after the last training session. Because this was feature of this intervention. Forty-five patients partici- a feasibility study, no primary or secondary outcome pated in the pretest–posttest study, of whom 15 (33%) measures were assigned. Breathlessness was deteriorated or died before completion – results refer recorded on a NRS for worst, average and now, dis- to the 30 patients who were able to complete the entire tress caused by breathlessness and coping with study period. Patient-reported outcomes included a breathlessness. Over a 12-month period, 22 patients VAS for breathing at worst and at best in the preced- were randomised with a 40 % dropout rate by week ing 24 h as well as the distress caused by breathless- 4. From this study, it was concluded that the most ness. There was a statistically significant useful NRS scores for breathlessness severity were improvement in all VAS breathlessness outcomes for worst and average over past 24 h. from pre- to postintervention. These results should be interpreted with caution due to the small and non- 3. Acupuncture/Acupressure randomised sample. Over a 4-year period, Connors et al. 30 evaluated a In this category, two studies were included – one was physiotherapist-led breathlessness programme for an RCT 39 and the other was an open pilot study with patients with intrathoracic malignancies. The pro- no randomisation exploring the safety and efficacy of gramme consisted of an individual 1-h session on 4 acupuncture. 32 Vickers et al. 39 used a single session of consecutive weeks and a review session 1 month later. acupuncture or placebo followed by true or placebo


Chronic Respiratory Disease 9(2)

acupressure. True treatment points were chosen on the

There was no study that identified the reported

basis of traditionally used points for breathlessness. outcome measures for less common respiratory symp-

Placebo points were allocated in body areas away toms in lung cancer, such as wheeze and hoarseness. from true acupressure points. Following the single acupuncture session, participants were requested to

apply pressure to semipermanent acupressure studs

Trials with combined/overall symptom scores

by making small circular movements with fingers – the Four studies applied an instrument that assessed a study protocol recommended 2 or 3 cycles per second range of symptoms and associated distress and

for 1 or 2 min per point. The subjective sensation of reported total scores only, that is, no specific symp-

breathlessness was assessed with a NRS (0–10) imme-

tom either measured by a single item or subscale was

diately before and after acupuncture treatment and provided. 34,3638 In this section, we present these stud- daily for a week thereafter. In this study, 47 partici- ies because each of the instruments used contain at

pants were randomized and 45 provided follow-up least one item that represents the experience of breath- data. Participants in the acupuncture/acupressure and lessness, cough, or haemoptysis. None of these instru- control group improved, but there were no differences ments record experience of less common respiratory

between the groups at 7 days. In the second acupuncture study, 20 patients whose

symptoms of hoarseness and wheeze. The SDS 25 was used in an RCT to test the effects of

breathlessness was directly related to primary or sec- three home care treatment regimens on the psycholo- ondary malignancy underwent a single acupuncture gical well-being of patients with lung cancer. 34 The session using sternal and L14 acupressure points. 32 three treatment groups included standard home care; Breathlessness and anxiety were rated by patients specialised oncology home care; and an office care using pre and post VADS (- 10) treatment. There was group who received standard care by the physician. a significant improvement in VAS scores for breath- The specialised oncology intervention was delivered lessness and anxiety at least up to 6-h postacupunc- by specialised cancer nurses. The SDS measures the

ture, which were maximal at 90 min. A reduction in patients’ perceived level of distress in response to 13 respiratory rate was also reported, which was sus- symptoms, including breathlessness, cough and hae-

tained for 90 min postacupuncture.


There was no study identified that reported cough as the primary outcome measure. Only one study reported a specific cough outcome. In an RCT, Moore et al. 35 applied the EORTC-LC13 which 41 includes one item that refers to the frequency of cough in the past week. Responses for this single item were reported 3, 6 and 12 months following either nurse- led follow-up or conventional medical follow-up. There was no significant improvement in the single cough item in the nurse-led follow-up group com- pared to conventional group at any of the three post- randomisation follow-up points.


moptysis. 25 A total of 166 patients were randomised and 78 completed 4 interview points and were included in the final analysis at 12 weeks. There was a significant improvement in symptom distress in the two nursing home programmes compared to the office care group. Sarna 37 tested the effectiveness of structured nur- sing assessment of symptom distress in patients with advanced lung cancer compared to usual care. Both groups (N ¼ 48) completed the SDS 25 every month for a 6-month period. In a multivariate model, che- motherapy and systematic nursing assessment were associated with less symptom distress over time. Skrutkowski et al. 38 conducted an RCT to test the impact of a ‘pivot’ nurse in oncology on symptom dis- tress experienced by patients with lung cancer (n ¼ 113) or breast cancer (n ¼ 77). The intervention consisted of an experienced palliative care nurse who

There was no study identified that reported haemopty- had received additional training in symptom manage- sis as the primary outcome measure. As with cough, ment. The pivot nurse conducted an in-depth assess- Moore et al. 35 provided the only measure of haemop- ment of the patient’s symptom burden, family and tysis. The EORTC-L13 contains 41 one item that support situation, provided training for symptom assesses how often participants coughed up blood in management, additional support and initiated

the past week. In that study, the scores for haemopty- follow-up telephone calls. No significant difference

sis at each data collection point were zero.

in SDS scores between the two groups was found.

Yorke et al.


The efficacy of a caregiver-assisted coping skills between people difficult. 10,45 There are no apparent training was tested in an RCT involving 233 patients standard principles to regulate their consistent use:

with lung cancer and their caregivers. 36 Two condi- they have been adapted to measure different aspects tions were tested in this study: caregiver-assisted cop- of breathlessness, such as ‘uncomfortable breathing,’ ing skills training and an education/support condition. ‘severity of breathlessness,’ ‘intensity of breathless- The caregiver training condition included training on ness,’ ‘best,’ ‘worst,’ ‘average’ and so on as well as

symptom management where the caregiver’s role was difference in scaling ranges (e.g. 0–10 or 0–100), and described as that of a ‘coach,’ with the goal of helping different recall period (e.g. now, today, or past the patient learn and apply coping skills. The second 24-hours). This makes comparisons between studies


included the provision of information problematic. In our review, it was not possible to

regarding lung cancer and its treatment. Both patients combine the results from individual studies in any

and caregivers were involved in session for both condi- meaningful way to obtain an overall effect size for tions. The FACT-LC13 was used to assess symptoms 40 studies that evaluated similar interventions and from the patients’ perspective. The FACT-LC13 con- included a VAS or NRS for breathlessness assessment.

sists of items assessing shortness of breath and cough-

Because breathlessness is highly correlated with anxi-

ing. Patients

in both treatment conditions showed ety and distress, some authors applied a VAS to capture

improvements in the FACT-LC13 scores. Exploratory ‘distress’ associated with breathlessness. 27,28,3033

analyses suggested that the caregiving-coping inter- Studies that reported breathlessness as a single item vention was more beneficial to patients with stage II extracted from of a list of symptoms (e.g. SDS 25 ) are and III cancers/caregivers, whereas the education/ also limited to the quantification of symptom fre- support intervention was more beneficial to patients quency and intensity only.

with stage I cancer/caregivers.


This review of the effectiveness of nonpharmacologi- cal interventions for improving the experience of respiratory symptoms in patients with lung cancer found that interventions have largely focused on breathlessness and reflect a broad range of strategies. Given the multitude of respiratory symptoms patients with lung cancer can experience, alleviating symp- tom burden often requires several treatment modal- ities. Thirteen studies were included in this review although only one of these assessed cough and hae- moptysis as distinct symptoms.

Measurement issues

There is evidence that breathless patients use a variety of descriptors to describe the experience of breathlessness and that these descriptors represent sensory quality and affective dimensions of breath- lessness. In this review, no study included a unified measure of breathlessness that reflects its multidimen- sionality. The Dyspnoea-12 is a recently developed instrument 46 that captures the sensory quality ‘physi- cal’ and emotional dimensions of breathlessness. It consists of 12 items, each ranging from 0 ‘none’ to 3 ‘severe’, 7 items measure the patient’s physical per- ceptions of breathlessness and 5 items measure affect. It has been reported as a valid and reliable measure of breathlessness in patients with cardiac 46 and respira- tory conditions, 4749 but it is yet to be validated for use in lung cancer.

In this review, no study included a specific instru- Breathlessness is the most commonly reported ment to measure cough, haemoptysis and other less respiratory symptom in patients with lung cancer. 7 common respiratory symptoms. Since cough is fre- There is no gold standard measure currently available quently reported in the lung cancer population, 7 its that has been validated to capture this multifaceted inclusion as a specific outcome measure in studies construct. 44 In this review, the VAS and NRS were designed to assist patients to better cope with distres- mostly used to measure breathlessness. It has been sing symptomology warrants greater attention. suggested that, in the absence of a gold standard Recently, a cough scale has been developed for use all-encompassing measure for breathlessness, these with lung cancer patients and could be used as an out- unidimensional, single-item scales be used for the come for such trials, focusing on cough. 50 Given the assessment of breathlessness in palliative care 44 and broad range of strategies applied in the interventions advanced disease. 10 There are limitations to their use. included in this review, it is likely that any resilience Both VAS and NRS scales have two anchors that are and coping mechanisms adopted by study participants unique to each individual, making comparison are likely to influence patients’ perceptions of the


Chronic Respiratory Disease 9(2)

burden of multiple symptoms and not just breathless- ness. One study 35 did report a separate score for cough

nonpharmacological interventions for respiratory symptoms in lung cancer, we categorised studies

and haemoptysis extracted 40 from the EORTC-LC13. according to symptoms: breathlessness, cough and

This practice is not ideal because the instrument was not designed to provide individual symptom scores but a combined score for the lung cancer module. Other studies reported total scores that incorporate a variety of symptoms including the SDS 25 and Rotter- dam Symptom Checklist. 26 Such lists are useful for providing overall scores of symptom burden, although it is difficult to discern the full experience and impact of prominent symptomatology, notably breathlessness and cough, with such lists. Studies involving patients with lung cancer suffer from high attrition. Limiting participant research bur-

haemoptysis. As evidenced in this review, to date breathlessness has been the area of focus for research in the area of nonpharmacological interventions. We elected to further categorise these studies according to the mode of delivery. The majority of these studies included a multimodal intervention that was delivered by nurses. 28,29,31,35 Taking account of sample size, dropout rate, outcome measures and repeatability of interventions, feasible interventions emerge from a few nurse-led therapies. 28,29,35 The interventions evaluated in these three studies had some common foundations including a focus on breathlessness man-

den plays a key role in successful study recruitment agement, psychological support and an element of

and retention. Introducing a battery of questionnaires for every possible symptom, both respiratory and oth- erwise, is not a viable option. This presents a chal- lenge for lung cancer researchers to strike a balance between adequately capturing patient-related out- comes and patient burden. The choice of the most

patient education. However, key difference also exists in relation to the extent that interventions were tai- lored to the needs of individual patients, context of comparison groups and functional state of patients at recruitment. Additionally, Bredin et al. 28 and Chan et al. 29 measured breathlessness on a VAS but used

appropriate symptoms to include as specific study different anchor descriptors and different scaling

outcomes and the instruments used to capture these depend on the focus on the intervention and desired outcomes. It would appear that at the least, breathless- ness and cough warrant inclusion as specific outcome measures, but it is equally important that the multidi- mensionality of these symptoms is captured. It is likely that the broad range of strategies used in the interventions included in this review will have great- est impact on affect and ability to cope with distres- sing symptoms rather than severity only. As noted by Bausewein et al., 10 studies to date have largely focused on the management of symptoms rather their assessment. To gauge the benefits of interventions that require significant health care resources and com- mitment from patients and their families, measure- ment tools that reflect the experience of symptoms

ranges, and Moore et al. extracted single scores for breathlessness, cough and haemoptysis from items located on the FACT-LC. 42 Based on these results, no definitive conclusion for the effect of nurse-led multimodal interventions could be made. Two studies reflected the interventions led by phy- siotherapist but these were nonrandomised. 30,33 Simi- lar to the nurse-led studies, these interventions included a broad range of strategies. It is not possible to draw any firm conclusions from these studies due to the weak methodological approaches used, the small sample size included in Hately et al. 33 study, and the remarkably high dropout rate experienced by Connors et al. 30 where 160 patients were recruited at baseline yet only 14 completed the programme. Explanations for the high dropout rate are provided by the authors,

in lung cancer, and are sensitive enough to detect including broad inclusion criteria and subsequent fragi-

change in response to interventions need to be applied.


The interventions evaluated in this review covered a broad range of strategies. The variability and incon- sistent use of interventions for respiratory symptoms are also evident in clinical practice, as shown in a UK survey of respiratory management practices. 51 Since the focus of this review was to evaluate

lity of participants and many were receiving cancer treatments. This study is important because it high- lights important considerations when developing study protocols for interventional studies including patients with lung cancer. The nonstatistical result drawn from these studies is likely to reflect inherent methodologi- cal flaws as opposed to the mechanism of intervention delivery by physiotherapists. Complementary and alternative medicine use has become increasingly popular throughout the Western world, as patients seek supplemental strategies to

Yorke et al.


medical care. 52 We located two small studies that nonpharmacological interventions to help address this evaluated the effect of acupuncture in a nonrando- need has been reviewed in this article. The majority of mised study 32 and a single acupuncture session fol- studies refer to breathlessness or a list of multiple lowed by acupressure in an RCT. 39 Although Filshie symptoms. The interventions included in this review et al. 32 describe a significant within-group improve- mostly included a broad range of strategies. Based ment in breathlessness up to 6 h postintervention, on these facts, it is not possible to draw any firm con- the lack of a control group limits the applicability of clusion as to the effectiveness of nonpharmacological the results. Vickers et al. 39 found no difference in interventions for the management of respiratory reported breathlessness between acupuncture and pla- symptoms in lung cancer. Nonpharmacological inter- cebo groups. The timing of assessment was also dif- ventions may well have an important role to play in ferent in the two approaches described, and it may the management of some of the respiratory symptoms be that acupuncture has only short-lived effects. In the (or combinations of respiratory symptoms), but more context of management of respiratory symptoms for work of higher quality is necessary in the future. people with lung cancer, no recommendations for

acupuncture can be made. To our surprise, only one study, 35 a nurse-led mul- timodal intervention, assessed cough and haemopty- sis. No difference in cough experience was found between the intervention and control groups. Hae- moptysis was the single symptom in that study, which no patients reported and the pre- and postintervention scores were zero. It is difficult to gauge the true mean- ing of these results since the symptoms were assessed as part of the EORTC 41 instrument. Due to the lack of studies that included specific respiratory symptoms, we elected to review studies that only included a total score from symptom lists. Three studies measured symptoms on the SDS to eval- uate the efficacy of a nurse-led intervention. 34,37,38 Although the same outcome measure was used in these studies, the intervention strategies and comparison groups were varied. Positive results were reported in two of these studies, 34,37 but it was not possible to com- bine studies due to the differences between the studies. The FACT-LC 41 was used to assess the effect of pro- viding caregivers of people with lung cancer specific training in coping skills. The positive outcomes reported for the caregiver-assisted coping skills train- ing group provide promise for the involvement of care- givers in nonpharmacological interventions. Because these studies did not include any outcome measures for single symptoms, it is not possible to assess the relative effect of these interventions.


Lung cancer carries significant mortality and morbid- ity. Management of distressing respiratory symptoms is complex. There is a need to provide patients with viable options to help them better cope with lung cancer symptomatology. The evidence related to


This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.


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