Dyspnea management in advanced cancer: ASCO Guideline

Recommendations

Screening and Assessment

• Clinicians should perform systematic assessment of dyspnea at every inpatient and outpatient encounter in patients with advanced cancer using validated patient-reported outcome measures.
• For patients who are unable to self-report, clinicians should use a validated observation measure.
• Whenever possible, patients with dyspnea should undergo a comprehensive evaluation for the severity, chronicity, potential causes, triggers, and associated symptoms, as well as emotional and functional impact.

Treatment of Underlying Causes

• Patients with potentially reversible, common etiologies of dyspnea such as pleural effusion, pneumonia, airway obstruction, anemia, asthma, chronic obstructive pulmonary disease (COPD) exacerbation, pulmonary embolism, or treatment-induced pneumonitis should be given goal-concordant treatment(s) consistent with their wishes, prognosis, and overall health status.
• Patients with dyspnea because of underlying malignancy (eg, lymphangitic carcinomatosis, atelectasis because of large pulmonary mass, malignant pleural effusion) may benefit from cancer-directed treatments if consistent with their wishes, prognosis, and overall health status.
• Patients with underlying comorbidities such as COPD or heart failure should have the management of these conditions optimized.

Referral to Palliative Care

• Patients with advanced cancer and dyspnea should be referred to an interprofessional palliative care team where available.

Nonpharmacologic Interventions

• Airflow interventions such as directing a fan at the cheek (trigeminal nerve distribution) should be offered.
• Standard supplemental oxygen should be available for patients with hypoxemia who are experiencing dyspnea (ie, SpO₂ ≤ 90% on room air).
• Supplemental oxygen is not recommended when SpO₂ > 90%.
• A time-limited therapeutic trial of high-flow nasal cannula oxygen therapy, if available, may be offered to patients who have significant dyspnea and hypoxemia despite standard supplemental oxygen.
• A time-limited therapeutic trial of noninvasive ventilation, if available, may be offered to patients who have significant dyspnea despite standard measures and do not have contraindications.
• Other nonpharmacologic measures such as breathing techniques, posture, relaxation, distraction, meditation, self-management, physical therapy, and music therapy may be offered.
• Acupressure or reflexology, if available, may be offered.
• Evidence remains insufficient for a recommendation for or against pulmonary rehabilitation in patients with advanced cancer and dyspnea.