jurnal respirasi.pdf

Review Series: Palliation of dyspnea

Nonpharmacological interventionsfor managing respiratory symptomsin lung cancer

Janelle Yorke1, Alison Brettle1 and Alex Molassiotis2

AbstractPatients with lung cancer experience significant symptom burden, particularly symptoms of a respiratorynature. Such symptom burden can be distressing for patients and negatively impact their functional statusand quality of life. The aim of this review is to evaluate studies of nonpharmacological and noninvasiveinterventions for the management of respiratory symptoms experienced by patients with lung cancer. Intotal, 13 studies met the inclusion criteria for this review and included 1383 participants of which 1296were 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 measurementtools were used and a broad range of intervention strategies evaluated. Lack of consistency betweenstudies impinged on the ability to combine studies. It is not possible to draw any firm conclusion as tothe effectiveness of nonpharmacological interventions for the management of respiratory symptoms inlung cancer. Nonpharmacological interventions may well have an important role to play in themanagement of some of the respiratory symptoms (or combinations of respiratory symptoms), but morework of higher quality is necessary in the future.

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

Introduction

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).3–5

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 ofSalford, Manchester, UK2 School of Nursing, Midwifery and Social Work, University ofManchester, Manchester, UK

Corresponding author:Alex Molassiotis, School of Nursing, Midwifery and Social Work,Jean McFarlane Building, University of Manchester, Oxford Road,Manchester M13 9LPEmail: [email protected]

Chronic Respiratory Disease9(2) 117–129ª The Author(s) 2012Reprints and permission:sagepub.co.uk/journalsPermissions.navDOI: 10.1177/1479972312441632crd.sagepub.com

period.4 Optimal management of breathlessness

requires a combination of pharmacological and non-

pharmacological interventions.10 The evidence base

for pharmacological interventions has been reported

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

cate a limited evidence base for the use of opioids for

symptom relief; benzodiazepines to relieve anxiety;

and the use of oxygen. Pharmacological interventions

alone often do not relieve breathlessness adequately

and the use of drugs to treat breathlessness is some-

times limited as they can cause adverse effects and

require careful titrating.10,12 As breathlessness is a sub-

jective experience, nonpharmacological interventions

as an adjunct to drug treatments offer promise for the

management of this distressing symptom.

Cough presents a significant burden for people

with lung cancer and is reported to be present in

40% to 70% of patients with lung cancer at initial pre-

sentation and as the disease progresses.2 Cough may

exacerbate breathlessness13,14 and has a profound

effect on QOL, particularly its psychosocial aspects.5,15

In lung cancer, the aetiology for cough is multifactorial

and can be the result of direct anatomic effects of the

cancer (obstruction), indirect effects of cancer (pleural

effusion or pneumonitis secondary to radiation or che-

motherapy), or underlying chronic conditions (asthma,

COPD and postnasal drip).16,17 There are few manage-

ment options for cough in lung cancer that are evidence

based.18,19 One of the oldest medications for the con-

trol of cough is codeine that suppresses the central ner-

vous symptoms responsible for triggering cough.20

Other pharmacological treatments are largely based

on the use of antitussive drugs (cough suppressants) –

opioids or nonopioids – for which the evidence base is

minimal or conflicting. A Cochrane review of interven-

tions (pharmacological and nonpharmacological) for

cough in cancer concluded that research in this area

was limited with poor quality and significant methodo-

logical problems.18 The Cochrane review reported that

a range of pharmacological treatments (e.g. codeine,

morphine, dihydrocodeine, sodiumcromoglycate and

butamirate citrate linctus – cough syrup) showed some

improvements in cough, although all studies had sig-

nificant risk of bias. Molassiotis et al.18 also included

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

noninvasive interventions for the management of

cough in cancer were included in the review as no stud-

ies were identified.18 Interventions that encompass a

broad range of psychosocial, behavioural, educational

and environmental strategies may provide a more com-

prehensive approach to ameliorating the effects of this

distressing symptom.

Other respiratory symptoms such as haemoptysis,

hoarseness and wheeze are much less common than

breathlessness and cough. At presentation, up to

20% of patients report mild haemoptysis,21 and

approximately 9% of patients have reported haemop-

tysis in the last 8 weeks of life.22 While much less pre-

valent than breathlessness and cough, haemoptysis

can be alarming for both patients and their families.

Intrusive interventions target bronchial vessels since

these vessels supply the airways and are under higher

pressure than pulmonary arteries. At present, there are

no clinical trials specifically evaluating the efficacy of

these invasive interventions to treat haemoptysis in

patients with lung cancer. Other, less common symp-

toms are also likely to cause distress, such as hoarse-

ness and wheeze, and may also occur as a result of the

cancer or underlying comorbidity such as asthma and

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

whether nonpharmacological interventions have a

role to play in ameliorating the distressing effects of

these symptoms.

Given the multitude of respiratory symptoms

patients can experience, alleviating discomfort and

symptom distress often requires several treatment

modalities to reach an acceptable outcome. In addition,

symptom incidence and distress levels may vary over

time and lung cancer treatment, making their manage-

ment challenging. Usually managed as isolated symp-

toms, they often occur simultaneously. It may be that

interventions that include behavioural, psychosocial

and/or educational strategies assist patients to better

cope with distressing symptomology.

The aim of this review is to evaluate studies of

nonpharmacological and noninvasive interventions

for the management of respiratory symptoms experi-

enced by patients with lung cancer. We aimed to

include studies that incorporated a broad range of

interventions including psychosocial, behavioural,

educational, complementary therapies and environ-

mental/service delivery strategies.

Methods

Searches were conducted on a range of electronic

databases, covering a range of perspectives. These

included Medline (Ovid interface; biomedical), Psy-

chinfo (Ovid interface; psychological), Amed (Ovid

118 Chronic Respiratory Disease 9(2)

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 include studies that reported

combined/overall symptom scores – this included

studies that only reported, for example, a total score

for the SDS and Rotterdam Symptom Checklist.26

Results

Searches resulted in 1289 records that were uploaded

onto endnote, de-duplicated and filtered for relevance

to the review question. A additional three studies were

located by checking reference lists of relevant systema-

tic reviews. This process resulted in 54 articles that

were further scrutinised for relevance to this review.

Studies were further excluded because they were

reviews or opinion articles (n ¼ 15), case studies or

descriptive studies (n ¼ 11). Other studies were

excluded because the sample was heterogenous or

respiratory symptoms were not grouped. Noncancer

participants or cancer patients with mixed aetiology

or respiratory symptoms were not included as an out-

come measure (n ¼ 10). Further five studies were

excluded because the intervention was not classified

as nonpharmacological.

Description of included studies

In total, 13 studies27–39 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).27–34,39 Cough was included

as a single outcome measure in one study35 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

Breathlessness was the primary outcome for six

studies27,28,30–32,39 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.

Methods of breathlessness assessment. A variety of

methods were used to assess breathlessness (see

Table 2 for a description of the instruments used). Six

studies used VAS23 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

and Connors et al. who did not specify a scaling range.

The majority of studies measured breathlessness

intensity on a VAS or NRS at ‘best’ or ‘worst’ breath-

lessness over the preceding 24-h period. In a feasibility

RCT, Barton et al.27 used area under the curve analysis

and concluded that the NRS measures of ‘worst’ and

‘average’ breathlessness over the past 24 h were the

most useful assessments. The majority of studies that

applied the VAS and NRS to assess the intensity of

breathlessness also used the same scaling method to

assess distress associated with breathlessness.27,28,30–33

The European Organisation for Research and

Treatment of Cancer–lung cancer quality of life ques-

tionnaire (EORTC-LC13)41 is a multidimensional

QOL instrument that contains three items relating to

breathlessness. Moore et al. used the EORTC-LC13

Yorke et al. 119

Tab

le1.

Char

acte

rist

ics

ofin

cluded

studie

s

Ref

eren

cean

dco

untr

yT

ype

ofst

udy

Inte

rven

tion

Dia

gnost

icgr

oups

Sym

pto

ms/

outc

om

esas

sess

edre

leva

nt

toth

isre

view

Res

ults

Bar

ton

etal

.27

UK

Feas

ibili

tyR

CT

Hig

h(�

3se

ssio

ns)

vs.lo

w(�

1se

ssio

n)

inte

nsi

tytr

ainin

gin

bre

athin

g

Lung

cance

r(n¼

22)

Bre

athle

ssnes

sN

RS;

bri

efC

OPE;

bre

athle

ssnes

sdis

tres

s;H

AD

SN

oef

fect

iven

ess

dat

a:‘w

ors

t’an

d‘a

vera

ge’

pas

t24

hm

ost

use

fulas

sess

men

t

Bre

din

etal

.28

UK

Multic

entr

eR

CT

Nurs

ein

terv

ention

–bre

athle

ssnes

sfo

cus,

musc

lere

laxat

ion,

psy

choso

cial

support

vs.st

andar

dca

re

Lung

cance

r(n¼

119)

Bre

athle

ssnes

sV

AS

–bes

tan

dw

ors

e,an

dre

late

ddis

tres

sR

ott

erdam

Sym

pto

mC

hec

klis

t

Sign

ifica

nt

impro

vem

ent

inbre

athle

ssnes

sbes

t;b/n

ess

dis

tres

s;dep

ress

ion;phys

ical

sym

pto

ms

Chan

etal

.29

Hong

Kong

RC

TPsy

choed

uca

tional

vs.usu

alca

reLu

ng

cance

r(n¼

140)

‘Sym

pto

mcl

ust

er’an

dse

par

ate

bre

athle

ssnes

ssc

ore

son

VA

SSi

gnifi

cant

impro

vem

ent

insy

mpto

mcl

ust

eran

dsp

ecifi

csy

mpto

ms

–bre

athle

ssnes

sC

onnors

etal

.30

UK

Cohort

study

Phys

ioth

erap

y–

teac

hin

gbre

athin

gco

ntr

ol,

rela

xat

ion,en

ergy

conse

rvat

ion

Lung

cance

r(n¼

169),

only

15

com

ple

ted

pro

toco

lBre

athle

ssnes

ssc

ore

son

VA

Sat

wors

tan

dbes

t;an

das

soci

ated

dis

tres

s

Hig

hat

tritio

n,bre

athle

ssnes

sim

pro

ved

but

not

stat

istica

lly

Corn

eret

al.3

1U

KR

CT

Nurs

ein

terv

ention

–co

unse

lling,

bre

athin

gre

trai

nin

g,re

laxat

ion,

copin

gst

rate

gies

vs.co

ntr

ol

(spea

kfr

eely

about

bre

athle

ssnes

sbut

no

trai

nin

gor

counse

lling)

Lung

cance

r(n¼

20)

Bre

athle

ssnes

san

das

soci

ated

dis

tres

son

VA

SSi

gnifi

cant

impro

vem

ents

com

par

edw

ith

the

contr

oli

nbre

athle

ssnes

sat

bes

t(p

<0.0

2)

and

wors

t(p

<0.0

5),

dis

tres

sca

use

dby

bre

athle

ssnes

s(p

<0.0

1)

Fils

hie

etal

.32

UK

Open

pilo

tpre

test

–post

test

Ster

nal

and

L14

acupunct

ure

poin

tsPri

mar

yor

seco

ndar

ylu

ng

cance

r(n¼

20)

Bre

athle

ssnes

s,an

xie

ty,an

dre

laxat

ion

on

VA

SW

ithin

group

sign

ifica

nt

impro

vem

ent

inal

lsy

mpto

ms

atle

ast

up

to6

hpost

tx;

max

imal

at90

min

Hat

ely

etal

.33

UK

Pre

test

–post

test

Spec

ialis

tphys

ioth

erap

yse

ssio

ns

Lung

cance

r(n¼

30)

Bre

athle

ssnes

san

das

soci

ated

dis

tres

sR

ott

erdam

Sym

pto

mC

hec

klis

t

Sign

ifica

ntim

pro

vem

ent(w

ithin

sam

ple

)in

all

VA

Ssc

ore

s,R

ott

erdam

score

s

McC

ork

leet

al.3

4U

SAR

CT

Spec

ialis

thom

enurs

ing

care

vs.

stan

dar

dhom

eca

revs

.cl

inic

care

Lung

cance

r(n¼

166)

Sym

pto

mD

istr

ess

Scal

eSi

gnifi

cant

diff

eren

cein

Sym

pto

mD

istr

ess

Score

Moore

etal

.35

UK

RC

TN

urs

e-le

dfo

llow

-up

vs.co

nve

ntional

med

ical

follo

w-u

pA

dva

nce

dlu

ng

cance

r(n¼

203)

EO

RT

CQ

OL

score

and

lung

cance

rm

odule

–bre

athle

ssnes

s,co

ugh

,hae

mopty

sis

Sign

ifica

ntly

impro

ved

bre

athle

ssnes

sbutnot

cough

and

hae

mopty

sis

at3

month

s,none

at6

month

sPort

eret

al.3

6U

SAR

CT

Car

egiv

er-a

ssis

ted

copin

gsk

ills

trai

nin

gvs

.ed

uca

tion/s

upport

incl

udin

gca

regi

ver

Lung

cance

r(n¼

239)

FAC

T-L

with

bre

athle

ssnes

san

dco

ugh

subsc

ales

Pat

ient:

sign

ifica

nt

impro

vem

ents

infu

nct

ional

wel

l-bei

ng,

sym

pto

ms;

Car

e-gi

ver:

sign

ifica

nt

impro

vem

ents

inan

xie

tyan

dse

lf-ef

ficac

ySa

rna3

7U

SAR

CT

Stru

cture

dnurs

ing

asse

ssm

ent

Lung

cance

r(n¼

48),

new

lydia

gnose

d,nee

dpap

erSy

mpto

mD

istr

ess

Scal

eFa

tigu

ew

asth

em

ost

seve

rely

dis

tres

sing

sym

pto

m;m

ultiv

aria

tem

odel¼

chem

oth

erap

yan

dsy

stem

atic

nurs

ing

asse

ssm

ent

wer

eas

soci

ated

with

less

sym

pto

mdis

tres

sove

rtim

eSk

rutk

ow

skiet

al.3

8

Can

ada

RC

TPiv

ot

nurs

ein

onco

logy

Lung

cance

r(n¼

113)

and

bre

ast

cance

r(n¼

77)

Sym

pto

mD

istr

ess

Scal

e–

no

spec

ific

sym

pto

ms

SDS

–no

sign

ifica

nt

diff

eren

cebet

wee

ngr

oups

Vic

kers

etal

.39

USA

RC

TA

cupunct

ure

vs.pla

cebo

Lung

cance

r80%

;bre

ast

20%

(n¼

47)

Bre

athle

ssnes

s–

NR

SN

oef

fect

–95%

CIe

xcl

udes

the

pre

spec

ified

MC

Dofa

20%

grea

ter

impro

vem

ent

inac

upunct

ure

group

EO

RT

C:T

he

Euro

pea

nO

rgan

isat

ion

for

Res

earc

han

dT

reat

men

tofC

ance

r;FA

CT

-L:F

unct

ional

Ass

essm

entofC

ance

rT

reat

men

t–

Lung

cance

r;M

CD

:Min

imal

clin

ical

diff

eren

ce;N

RS:

Num

er-

ical

Rat

ing

Scal

e;Q

OL:

qual

ity

oflif

e;R

CT

:ra

ndom

ised

contr

olle

dtr

ial;

SDS:

Sym

pto

mD

istr

ess

Scal

e;V

AS:

Vis

ual

Anal

ogu

eSc

ale.

120

Tab

le2.

Inst

rum

ents

use

dto

asse

ssre

spir

atory

sym

pto

ms

Mea

sure

Rev

iew

study

Const

ruct

Var

iable

Scal

ing

range

Conte

nt

Rec

allper

iod

Gen

eral

com

men

ts

Vis

ual

Anal

ogu

eSc

ale

for

bre

athle

ssnes

san

ddis

tres

s23

Bre

din

etal

.28

Unid

imen

sional

Inte

nsi

ty0–10

Bes

t,w

ors

t,av

erag

ePas

t24

hD

istr

ess

0–10

Rel

ated

tobre

athle

ssnes

sC

han

etal

.29

Unid

imen

sional

Inte

nsi

ty0–100

Not

spec

ified

Not

spec

ified

Connors

etal

.30

Unid

imen

sional

Inte

nsi

tyN

ot

spec

ified

Bes

t,w

ors

tN

ot

spec

ified

Dis

tres

sN

ot

spec

ified

Not

spec

ified

Corn

eret

al.3

1U

nid

imen

sional

Inte

nsi

ty0–10

Bes

t,w

ors

t,av

erag

ePas

t24

hD

istr

ess

0–10

Rel

ated

tobre

athle

ssnes

sFi

lshie

etal

.32

Unid

imen

sional

Inte

nsi

ty0–10

Not

clea

rC

urr

ent

Dis

tres

s0–10

Rel

ated

tobre

athle

ssnes

sC

urr

ent

Hat

ely

etal

.33

Unid

imen

sional

Inte

nsi

ty0–10

Bes

t,w

ors

tPas

t24

hours

Dis

tres

s0–10

Not

spec

ified

Num

eric

alR

atin

gSc

ale

for

bre

athle

ssnes

san

ddis

tres

s24

Vic

kers

etal

.39

Unid

imen

sional

Inte

nsi

ty0–10

Ave

rage

for

7day

sC

urr

ent:

bef

ore

and

afte

r1

htr

eatm

ent;

aver

age

dai

lyle

vel

Bar

ton

etal

.27

Unid

imen

sional

Seve

rity

0–10

Ave

rage

,w

ors

tdis

tres

sPas

t24

h;not

spec

ified

Feas

ibili

tyst

udy

–av

erag

ean

dw

ors

tsc

ore

sm

ost

sensi

tive

Sym

pto

mD

istr

ess

Scal

e25

McC

ork

leet

al.3

415-I

tem

sym

pto

mlis

t,pro

vides

ato

tal

score

Deg

rees

ofdis

tres

s1–5:1

(bre

athe

norm

ally

orse

ldom

coug

h)to

5(a

lmos

tal

way

sha

vese

vere

trou

ble

brea

thin

gor

pers

iste

nce

seve

reco

ugh)

One

bre

athle

ssnes

sitem

and

one

cough

item

Feel

ing

late

lySy

mpto

m-s

pec

ific

item

snot

report

edse

par

atel

y,only

tota

lsc

ore

sm

easu

red

Sarn

a37

As

above

As

above

As

above

As

above

As

above

Sym

pto

m-s

pec

ific

item

snot

report

edse

par

atel

y,only

tota

lsc

ore

sm

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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.’s31 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

(FACT-L),40 SDS,25 and the Rotterdam Symptom

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 adiscrete 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, categories 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,’

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 trial28

included 119 participants of which 103 were included

in the final analysis. The intervention was similar

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

measured41 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


progressive muscle relaxation. Symptom data were

collected prior to the intervention, 3 weeks, 6 weeks

and 12 weeks postintervention. A total of 140 patients

consented to participate in the study and the overall

attrition rate at week 12 was 27%, with the sole reason

being attributed to death. Breathlessness was one of

the primary outcomes and was measured on a

100 mm VAS. The study aimed to assess the efficacy

of the psychoeducational intervention on symptom

clusters in lung disease – breathlessness, fatigue and

anxiety. We discuss the specific outcomes for breath-

lessness intensity measured on the VAS here. There

was a significant improvement in breathlessness

intensity scores between the 2 study groups at week

6 and week 12, although the effect sizes were small

(partial Z2 ¼ 0.04 and 0.043, respectively).43

2. Multimodal interventions with a physiotherapy

or multiprofessional focus

Two nonrandomised studies30,33 assessed

physiotherapy-led multimodal interventions for

patients with lung cancer. In a single-centre study,

Hately et al.33 evaluated an intervention strategy for

patients with lung cancer including physiotherapist-

led reviews in a specialist outpatient breathlessness

clinic. Patients were monitored by the senior phy-

siotherapists at 3 sessions, each lasted a maximum

of 90 min, over a period of 4–6 weeks. The interven-

tion consisted of a range of strategies, including

breathing retraining, relaxation techniques, activity

pacing and psychosocial support. Compared to other

studies included in this review, the inclusion of a

specific-activity pacing component was a unique

feature of this intervention. Forty-five patients partici-

pated in the pretest–posttest study, of whom 15 (33%)

deteriorated or died before completion – results refer

to the 30 patients who were able to complete the entire

study period. Patient-reported outcomes included a

VAS for breathing at worst and at best in the preced-

ing 24 h as well as the distress caused by breathless-

ness. There was a statistically significant

improvement in all VAS breathlessness outcomes

from pre- to postintervention. These results should

be interpreted with caution due to the small and non-

randomised sample.

Over a 4-year period, Connors et al.30 evaluated a

physiotherapist-led breathlessness programme for

patients with intrathoracic malignancies. The pro-

gramme consisted of an individual 1-h session on 4

consecutive weeks and a review session 1 month later.

The sessions involved a broad range of strategies

including breathing control, relaxation, anxiety man-

agement, energy conservation, goal setting and life-

style readaption. This programme suffered high

attrition – 160 patients were recruited at baseline, but

only 14 completed the programme. The investigators

acknowledged that patient selection was the likely

reason for the high dropout, since the sample was

selected from the entire lung cancer population which

included the frail and patients receiving cancer treat-

ments. In contrast, similar studies included patients

who had completed active cancer treatments.28,31

Connors et al.30 reported nonsignificant changes in

breathlessness measured on a VAS for breathless-

ness at best and at worst, distress caused by breath-

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-

siotherapists or lung cancer specialist nurse was tested

by Barton et al.27 This was a single-centre, non-

blinded RCT designed to assess recruitment and

retention, best end point and variability of breathless-

ness scores to inform a subsequent powered study.

The intervention consisted of training in diaphrag-

matic breathing, pacing, anxiety management and

relaxation during an hour-long clinic session. The

control group (low intensity) received the session

once and the intervention group (high intensity)

received subsequent sessions at weeks 2 and 3. Both

groups also received written and DVD reinforcement

material and a telephone call from their therapist a

week after the last training session. Because this was

a feasibility study, no primary or secondary outcome

measures were assigned. Breathlessness was

recorded on a NRS for worst, average and now, dis-

tress caused by breathlessness and coping with

breathlessness. Over a 12-month period, 22 patients

were randomised with a 40% dropout rate by week

4. From this study, it was concluded that the most

useful NRS scores for breathlessness severity were

for worst and average over past 24 h.

3. Acupuncture/Acupressure

In this category, two studies were included – one was

an RCT39 and the other was an open pilot study with

no randomisation exploring the safety and efficacy of

acupuncture.32 Vickers et al.39 used a single session of

acupuncture or placebo followed by true or placebo

Yorke et al. 123

acupressure. True treatment points were chosen on the

basis of traditionally used points for breathlessness.

Placebo points were allocated in body areas away

from true acupressure points. Following the single

acupuncture session, participants were requested to

apply pressure to semipermanent acupressure studs

by making small circular movements with fingers – the

study protocol recommended 2 or 3 cycles per second

for 1 or 2 min per point. The subjective sensation of

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

diately before and after acupuncture treatment and

daily for a week thereafter. In this study, 47 partici-

pants were randomized and 45 provided follow-up

data. Participants in the acupuncture/acupressure and

control group improved, but there were no differences

between the groups at 7 days.

In the second acupuncture study, 20 patients whose

breathlessness was directly related to primary or sec-

ondary malignancy underwent a single acupuncture

session using sternal and L14 acupressure points.32

Breathlessness and anxiety were rated by patients

using pre and post VADS (- 10) treatment. There was

a significant improvement in VAS scores for breath-

lessness and anxiety at least up to 6-h postacupunc-

ture, which were maximal at 90 min. A reduction in

respiratory rate was also reported, which was sus-

tained for 90 min postacupuncture.

Cough

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 which41 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.

Haemoptysis

There was no study identified that reported haemopty-

sis as the primary outcome measure. As with cough,

Moore et al.35 provided the only measure of haemop-

tysis. The EORTC-L13 contains41 one item that

assesses how often participants coughed up blood in

the past week. In that study, the scores for haemopty-

sis at each data collection point were zero.

There was no study that identified the reported

outcome measures for less common respiratory symp-

toms in lung cancer, such as wheeze and hoarseness.

Trials with combined/overall symptom scores

Four studies applied an instrument that assessed a

range of symptoms and associated distress and

reported total scores only, that is, no specific symp-

tom either measured by a single item or subscale was

provided.34,36–38 In this section, we present these stud-

ies because each of the instruments used contain at

least one item that represents the experience of breath-

lessness, cough, or haemoptysis. None of these instru-

ments record experience of less common respiratory

symptoms of hoarseness and wheeze.

The SDS25 was used in an RCT to test the effects of

three home care treatment regimens on the psycholo-

gical well-being of patients with lung cancer.34 The

three treatment groups included standard home care;

specialised oncology home care; and an office care

group who received standard care by the physician.

The specialised oncology intervention was delivered

by specialised cancer nurses. The SDS measures the

patients’ perceived level of distress in response to 13

symptoms, including breathlessness, cough and hae-

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.

Sarna37 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 SDS25 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

had received additional training in symptom manage-

ment. The pivot nurse conducted an in-depth assess-

ment of the patient’s symptom burden, family and

support situation, provided training for symptom

management, additional support and initiated

follow-up telephone calls. No significant difference

in SDS scores between the two groups was found.


The efficacy of a caregiver-assisted coping skills

training was tested in an RCT involving 233 patients

with lung cancer and their caregivers.36 Two condi-

tions were tested in this study: caregiver-assisted cop-

ing skills training and an education/support condition.

The caregiver training condition included training on

symptom management where the caregiver’s role was

described as that of a ‘coach,’ with the goal of helping

the patient learn and apply coping skills. The second

condition included the provision of information

regarding lung cancer and its treatment. Both patients

and caregivers were involved in session for both condi-

tions. The FACT-LC13 was used to assess symptoms40

from the patients’ perspective. The FACT-LC13 con-

sists of items assessing shortness of breath and cough-

ing. Patients in both treatment conditions showed

improvements in the FACT-LC13 scores. Exploratory

analyses suggested that the caregiving-coping inter-

vention was more beneficial to patients with stage II

and III cancers/caregivers, whereas the education/

support intervention was more beneficial to patients

with stage I cancer/caregivers.

Discussion

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

Breathlessness is the most commonly reported

respiratory symptom in patients with lung cancer.7

There is no gold standard measure currently available

that has been validated to capture this multifaceted

construct.44 In this review, the VAS and NRS were

mostly used to measure breathlessness. It has been

suggested that, in the absence of a gold standard

all-encompassing measure for breathlessness, these

unidimensional, single-item scales be used for the

assessment of breathlessness in palliative care44 and

advanced disease.10 There are limitations to their use.

Both VAS and NRS scales have two anchors that are

unique to each individual, making comparison

between people difficult.10,45 There are no apparent

standard principles to regulate their consistent use:

they have been adapted to measure different aspects

of breathlessness, such as ‘uncomfortable breathing,’

‘severity of breathlessness,’ ‘intensity of breathless-

ness,’ ‘best,’ ‘worst,’ ‘average’ and so on as well as

difference in scaling ranges (e.g. 0–10 or 0–100), and

different recall period (e.g. now, today, or past

24-hours). This makes comparisons between studies

problematic. In our review, it was not possible to

combine the results from individual studies in any

meaningful way to obtain an overall effect size for

studies that evaluated similar interventions and

included a VAS or NRS for breathlessness assessment.

Because breathlessness is highly correlated with anxi-

ety and distress, some authors applied a VAS to capture

‘distress’ associated with breathlessness.27,28,30–33

Studies that reported breathlessness as a single item

extracted from of a list of symptoms (e.g. SDS25) are

also limited to the quantification of symptom fre-

quency and intensity only.

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

instrument46 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 cardiac46 and respira-

tory conditions,47–49 but it is yet to be validated for

use in lung cancer.

In this review, no study included a specific instru-

ment to measure cough, haemoptysis and other less

common respiratory symptoms. Since cough is fre-

quently reported in the lung cancer population,7 its

inclusion as a specific outcome measure in studies

designed to assist patients to better cope with distres-

sing symptomology warrants greater attention.

Recently, a cough scale has been developed for use

with lung cancer patients and could be used as an out-

come for such trials, focusing on cough.50 Given the

broad range of strategies applied in the interventions

included in this review, it is likely that any resilience

and coping mechanisms adopted by study participants

are likely to influence patients’ perceptions of the

Yorke et al. 125

burden of multiple symptoms and not just breathless-

ness. One study35 did report a separate score for cough

and haemoptysis extracted40 from the EORTC-LC13.

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 SDS25 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-

den plays a key role in successful study recruitment

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

appropriate symptoms to include as specific study

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

in lung cancer, and are sensitive enough to detect

change in response to interventions need to be

applied.

Interventions

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

nonpharmacological interventions for respiratory

symptoms in lung cancer, we categorised studies

according to symptoms: breathlessness, cough and

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-

agement, psychological support and an element of

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

different anchor descriptors and different scaling

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,

including broad inclusion criteria and subsequent fragi-

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


medical care.52 We located two small studies that

evaluated the effect of acupuncture in a nonrando-

mised study32 and a single acupuncture session fol-

lowed by acupressure in an RCT.39 Although Filshie

et al.32 describe a significant within-group improve-

ment in breathlessness up to 6 h postintervention,

the lack of a control group limits the applicability of

the results. Vickers et al.39 found no difference in

reported breathlessness between acupuncture and pla-

cebo groups. The timing of assessment was also dif-

ferent in the two approaches described, and it may

be that acupuncture has only short-lived effects. In the

context of management of respiratory symptoms for

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 EORTC41 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-LC41 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.

Conclusions

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

nonpharmacological interventions to help address this

need has been reviewed in this article. The majority of

studies refer to breathlessness or a list of multiple

symptoms. The interventions included in this review

mostly included a broad range of strategies. Based

on these facts, it is not possible to draw any firm con-

clusion as to the effectiveness of nonpharmacological

interventions for the management of respiratory

symptoms in lung cancer. Nonpharmacological inter-

ventions 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.

Funding

This research received no specific grant from any funding

agency in the public, commercial, or not-for-profit sectors.

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