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Catching Your Breath

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Shortness of breath, air hunger, breathlessness, or the medical term dyspnea—all terms trying to capture one of the most unsettling feelings that a person can have.  That feeling that you are under water and need a snorkel.  The sensation of tightness in the chest and anxiety all wrapped up together.  That feeling of being “too aware” of your own breathing.  Dyspnea is the medical term for this symptom, and for simplicity’s sake, I will use that word to encompass all the different terms.  For patients with cancer, this symptom occurs commonly but is difficult to treat and has gotten far too little attention than cancer-related pain.  It has been estimated to occur in 80% of patients who have an advanced cancer and in up to 20% of all cancer patients regardless of the stage of their disease. 

What causes shortness of breath? 

Ultimately, this sensation is a complicated one and still not completely understood. Dyspnea happens because of a mismatch of breathing effort with the body’s signals for breath.  There are several different types of signals that are at play in dyspnea—chemical, such as levels of carbon dioxide and oxygen in the blood; mechanical, such as the stretch of chest muscles; and neural or vagal, related to the nervous system of the lungs.  On a more operational level, there are three major mechanisms for dyspnea that create a mismatch: 1) an increased workload requiring more effort; 2) an increase in the amount of lung muscle needed to achieve a normal workload; and 3) an increase in the need to ventilate unrelated to the lungs.  While it is not entirely understood, anxiety and depression both are associated with higher frequency of dyspnea as well, presumably through mechanisms in the brain related to mood.

 

In patients with lung cancer, there are multiple reasons dyspnea occurs:

  1. Increased workload: Lung cancer can block airways making the lungs work harder to breathe.  Fluid inside the lung can do the same thing—this fluid can come from the back pressure from a weak heart or from inflammation.  Fluid around the lung in the pleural space (between the chest wall and the lung) also does this.
  2. Decreased lung muscle function: Muscle weakness of the chest wall, for example.
  3. Increased ventilation needs: Cancer and cancer treatments such as chemotherapy can cause anemia which signals a need for more ventilation to make up for the low blood levels, even while the lungs themselves are otherwise working properly.  Fever (from infection or from the cancer) can also cause this as well; there is an increased metabolic rate driving this.

 

Treatment

Treatment should start with a thorough evaluation for the underlying cause; this could mean imaging (chest X-ray, CT scan, etc) and laboratory tests (blood counts, chemistries, etc) in addition to a doctor’s visit.  The primary approach should be as follows:

 

  1. Treat the underlying cause.
  2. Treat the underlying cause.
  3. Treat the underlying cause.

 

This could mean blood transfusion in the case of symptomatic anemia or drainage of pleural fluid, for example.  Then, if that is not working, there are some additional approaches to take. 

 

Non-drug therapy

Exercise

Pulmonary rehabilitation and exercise have therapeutic benefit by decreasing dyspnea for patients with lung cancer but most of the studies have demonstrated this effect in patients who are functioning well and have disease that can be controlled with surgery.  This does make some intuitive sense in that you are training the respiratory muscles to do more work through aerobic exercise. 

 

Oxygen therapy

There has been some evidence to suggest that oxygen therapy can help treat dyspnea in patients with cancer.  However, the effectiveness of oxygen for dyspnea is proportional to how low the blood oxygen levels are and tend to be most helpful when the oxygen levels are very low.  In general, to qualify for coverage of home oxygen, a patient’s oxygen levels have to go below a certain number.  There was a recent study out of Duke that compared oxygen therapy versus regular air for patients who had dyspnea but whose oxygen levels were not low enough to qualify for oxygen.  This study found no difference in the effect of oxygen versus air, but interestingly, patients had the same improvement in their dyspnea whether they had oxygen or air.  

 

Medications

Opioids: Opioids have long been used in the treatment of dyspnea.  Why do they work?  Chemical opioid receptors, when triggered, dampen the feeling of dyspnea.  There is a fear that opioids will cause someone to stop breathing.  However, given in moderate doses for dyspnea, they have proven to be efficacious and safe to the point that the American College of Chest Physicians came out with a consensus statement in 2010 on dyspnea in patients with advanced lung or heart disease, recommending that physicians “titrate opioids…for the relief of dyspnea.”  Sometimes, treating the underlying cause does not resolve the dyspnea, so usage of opioids can be certainly used alongside other treatments targeting the cause. 

 

Anti-anxiety medications such as the benzodiazepines (Ativan (lorazepam) or Xanax (alprazolam)), as well as selective serotonin reuptake inhibitors (SSRIs) like Paxil (paroxetine) have been used in the treatment of dyspnea.  This is based on the fact that patients who have anxiety report more dyspnea than other patients.  In light of the “brain component” modulating the sensation of dyspnea, it makes sense that treating the anxiety would reduce the amount of dyspnea experienced, though this has not played out consistently in studies. 

 

 

Integrative medicine therapies

Heliox: This is a mixture of oxygen and helium and has demonstrated some modest benefit in patients with lung cancer to decrease dyspnea.  It’s expensive and relatively limited in its availability, so it has not been used very much yet.  More trials are definitely needed to see if this is worth pursuing further. 

Acupuncture has been shown in a few small trials to improve dyspnea in patients with lung cancer as well as patients with emphysema, but not much further than that.  Recent reviews have not demonstrated evidence to recommend it routinely. 

 

 

I hope this summary provides a helpful summary of this common and challenging symptom, along with some useful treatment ideas. Your questions and comments are always very welcome.

 


12 Responses to Catching Your Breath

  • Follansbee says:

    My husband also has COPD, which increases his tendency toward dyspnea. I imagine this is not unusual for ex-smokers with lung cancer.

  • certain spring says:

    Really helpful, Dr Harman. Thank you so much. I have a couple of questions if I may. I have a closed-off left lower lobe; a tumour poised to block the left bronchus; and a bronchial stent with granulation tissue growing around it. So I’ve had some episodes of acute shortness of breath (during lung collapses); but also much milder, day–to-day sensations of being blocked, which mainly involve getting wheezy and incredibly tired.
    I am conscious that my breathing is very shallow in everyday life. Is there any evidence that patients can be trained to breathe more deeply, and does it help? I have a wonderful physiotherapist who is always reminding me to try and get some air circulating in my lungs, but I constantly forget.
    The other question is about exercise – it is more of a dilemma really. I swim three times a week and skate occasionally, and I feel it helps. The scans suggest that my good lung has expanded to make up some of the deficit. But I find that when I am blocked, I get totally exhausted, to the point where I will sleep for two hours when I get home. It’s not “fatigue”, it’s “must go to bed right now this minute”. I struggle to find a balance between working my lungs and losing big chunks of time because I get so tired. Is this normal for someone in my situation? I would be glad to hear the experiences of others.
    I also wanted to add that my physiotherapist helped me a great deal – she is the only person who has ever taken a real interest in my breathing and how to improve it.

  • Blue skies says:

    This is a very timelty post for me and I am glad to know more about this problem and how to address it in the future.

    I also had a recent episode (over the last weekend) of acute shortness of breath related to the effects of a progressing tumor closing off a branch in my right lung and pressing against my bronchus. This was compounded by increasing levels of mucous and congestion and a choking cough, wheezing, and change in my voice…very disturbing as I was holding on to begin radiation treatment this past Tuesday. These conditions had been incrementally progressing over the last 3 to 4 weeks to the point where I considered going to urgent care this past Saturday morning to make sure I wasn’t in danger of more serious consequences.

    I had noticed after my first low dose chemo session that ended up with me getting two doses of decadron to address a reaction to the taxol, that the symptoms dramatically improved the following day (but then developed again). The next chemo session resulted in a similar improvement the next day (though not as dramatic as with the double doxe of steroids). My oncologist agreed that it made sense to continue with a low daily dose of steroids for the time being to reduce the inflammation and address the symptoms until the combination chemo/radiation can get things back to a manageable level.

    I am feeling much better day by day and hope to be able to taper off the steroids and spend less time cleaning the house and other middle of the night projects (like trying to ge tmy profile reposted on GRACE!)….. :-)

  • certain spring says:

    Dear Blue Skies – I have been rummaging around the site trying to get back here as I am so sorry you had a rough weekend of it. I am glad the steroids seem to be working but no heroics please. Follow your instinct. Just read about Milz’s mother having a lung collapse and wrote a note about what helped me at the time:
    http://cancergrace.org/lung/topic/shortness-of-breath-not-improved-after-pleurx/#post-6336
    Look after yourself.

  • Blue skies says:

    Certain Spring – I have been thinking of our recent conversations as I have been struggling with this and knew I would likely hear back from you after my posted comment. I have been frustrated by my inability to initially even access the site, send private messages or navigate the site these first few days (especially as this has been one of the most challenging periods over my two years of treatment) but remain patient as this is such a massive redeploy of the website and its structure.

    I was very worried about lung collapse and possible infection. The mucous remained thin and clear and the coughing and shortness of breath improved over the course of Saturday morning with continued upright activity and walking around…which made me more confident…but I was ready to ask for professional assessment and assistance. I had a scheduled chemo session (steroid opportunity!) and appointment with my oncologist on Monday and things improved from there. Mitzi’s post and your response today also contain helpfu information and advice. Fortunately, things are going in a much better direction for me now.

    Thanks for your continued concern and support. You continue to be in my thoughts as well.

  • Dr Harman says:

    Thank you all for your comments.

    Follansbee, you are right about patients who have both COPD and lung cancer experience more issues with dyspnea. A lot of the research into dyspnea has been done in patients with COPD and not lung cancer.

    Certain spring, there is evidence that pulmonary rehabilitation improves dyspnea, but this has primarily been in patients with COPD, not lung cancer. There is good evidence that in patients with lung cancer who have had or about to have lung resections, aerobic exercise can improve dyspnea. It is great that you are exercising as well as you are with your left lower lobe collapsed and partial blockage at any given time of the remainder of your left lung. I think your experience of being exhausted is not surprising, given that small changes in the diameter of your blockage can make a huge difference in air going in and out of your left lung. You have a great ally in your physiotherapist–sometimes it takes some experimentation to balance how much to exercise with how tired you are.

    Blue skies, I’m glad that the steroids have helped and that things are heading in a much better direction for you.

  • certain spring says:

    Thank you, Dr Harman. I know I am lucky to be able to swim, and I love how it makes me feel at the time (healthy!), but it is a hard calculation as to whether it is worth forfeiting most of the rest of the working day. I can absolutely testify that what you say is true – a very small change in the aperture is greatly amplified in my breathing. Another problem is that mucus gets stuck in the stent, which serves me very well in other respects. I just spent half an hour this morning lying on the floor at an angle to get it to drain. Gravity is a good friend!
    You can see that this is a subject of consuming interest and relevance to me. Thanks again for the post.

  • Follansbee says:

    Certain spring, I had trouble finding this post to get back to it, too. I finally resorted to the link on my email.

    Dr Harman, you mentioned pulmonary rehabililtation for COPD. My husband was scheduled to start it last year but that was superceeded by his lung cancer diagnosis and treatment. Now that he is on maintenance chemo and not progressing (hopefully) he is scheduled to start rehab. In the meantime he has been staying fairly active, water aerobics and a little “land” aerobics. Hopefully this will help maintain his performance status. He is seventy four but has no other underlying conditions and wants to continue treatment as long as his quality of life is good.

  • laya d. says:

    Hi Everyone:

    Just wanted to add my two-cents here. . .

    About 6 months after my Mom underwent her right pneumonectomy, she did pulmonary rehab for 6 wks. It was great for her – – especially with regard to stamina, learning how to breathe differently (from what my Mom reported, more akin to the way they teach you to breath with yoga) and the importance of clearing mucous from the airways (another exercise that they taught her). She walked away with a lot of valuable information and considered it having been a really worthwhile endeavor. But, as Dr. Harman mentioned, she was the only lung cancer patient in her class of 8.

    certain spring – – I was wondering if you have a pulmonologist and what his/her opinion is on your breathing issues?

    Laya

  • Follansbee says:

    I guess we were thinking only of the lungs as being the potential cause of my husband’s shortnes of breath. His pulmonologist thought outside the box and ordered an echocardiogram, which identified significant heart failure, probably the primary cause of his shortness of breath

  • Dr Harman says:

    Duly noted, Follansbee. I failed to include other non-lung causes of shortness of breath like heart failure, and depending on the chemotherapy agent, certain cancer treatments can contribute to or cause heart failure.

  • jonscat says:

    Only just spotted this post Dr Harman.

    I was surprised you did not mention breathing exercises to help deal with dyspnea. I mentioned some time ago to Dr West I do a full range of breathing exercises each and every day and also some breathing exercises including balloons. My thinking was that the lungs themselves need exercise. I am Stage 4 NSCLC Adenocarcinoma and today I have cut a lawn, lifted 9stone gas boiler off and on a wall as well as carried the older heavier one to a car some 70 yards away. When I was first diagnosed i could barely hold my breath for forty seconds, it is now a comfortable 2 minutes. My problem is I overdo it with training but I recover from any breathlessness within twenty to thirty seconds. I hardly take any inhalers either.

    I started these exercises on diagnosis and reckon they saved my life as I had two pulmonary emboli form after my second chemotherapy. I still take Fragmin because of the risk and because my onc believes it helps stop my form of disease. If I had not been able to control my breathing it would have been easy to panic and suffer the consequences and believe I owe my life to these exercises..

    Regards

    jon

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