ONS Connect - August 2008 - (Page 19)

Figure 1. interventions for Cancer-Related Dyspnea Recommended for Practice Immediate-release oral or parenteral opioids Likely to Be Effective If the patient has weeks, months, or years to live • Temporary ventilator support • Oxygen therapy • Benzodiazepines for anxiety • Nonpharmacologic therapies – Increase ambient air flow to the face and nose. – Provide cooler temperatures. – Promote relaxation and stress reduction. – Provide education and support to patients and caregivers, referring them to other disciplines as appropriate. If the patient is dying • Scopolamine, hyoscyamine, or atropine to reduce secretions • Oxygen therapy • Sedation as needed • Discontinue fluid support and consider low-dose diuretics. Effectiveness Not Established Pharmacologic • Extended-release morphine • Midazolam plus morphine • Nebulized fentanyl, furosemide, lignocaine, or opioids • Supplemental oxygen Nonpharmacologic • Acupuncture • Cognitive-behavioral approach Note. Based on information from DiSalvo et al., 2008. Figure 2. interventions Supported by expert Opinion Low-risk interventions that are consistent with sound clinical practice and are suggested by experts in peer-reviewed publications can be recommended, although limited evidence exists for their use. • Use treatments that previously have been effective in an individual patient. • Position patients upright so they can achieve optimal lung capacity. • Teach patients breathing exercises, such as diaphragmatic breathing, altering breathing rhythm, and pursed-lip breathing. • If dyspnea occurs with physical activity, patients should use assistive devices and portable oxygen. • Expert opinion regarding the use of benzodiazepines is conflicting. Note. Based on information from DiSalvo et al., 2008. the respiratory tract minimizes systemic toxicity. However, a meta-analysis and an integrated review both lacked scientific data about their use, and several lowerlevel studies had limited sample sizes or inadequate study design. Therefore, the ONS PEP team concluded that current evidence is insufficient for nebulized opioid therapy for cancer-related dyspnea and effectiveness is not established. Oxygen therapy: The ONS PEP team evaluated three studies, two of which that used oxygen therapy or supplemental oxygen and a third that compared Heliox 28 (72% helium and 28% oxygen) to oxygenenriched air (72% nitrogen and 28% oxygen) or medical air (78.9% nitrogen and 21.1% oxygen). Because helium has a low density, it is thought to make breathing easier. The team found evidence to support the use of supplemental oxygen in only one small study of hypoxic patients with dyspnea at rest. Insufficient data exist to recommend supplemental oxygen or Heliox 28 in nonhypoxic patients; the team concluded that for both therapies, effectiveness is not established. Cognitive-Behavioral Approach The ONS PEP team reviewed the literature related to one nonpharmacologic ap- proach, cognitive-behavioral therapy. The approach is often used for patients with anxiety or similar disorders, and because patients with dyspnea often experience anxiety, the therapy has been explored as a treatment option for dyspnea. Four studies were reviewed, three that examined breathing retraining combined with psychosocial support interventions from a trained nurse and one that looked at the use of acupuncture. Because of study design or sample size, all were assigned a lower level of evidence, and effectiveness was not established. Refer to DiSalvo et al. (2008) for additional information on treatments for cancer-related dyspnea. The ONS PEP card on dyspnea is in volume 2 of the ONS PEP cards, which also contains cards on caregiver strain and burden, mucositis, depression, constipation, and peripheral neuropathy. To order the pocket cards, visit http://esource .ons.org/Publications or e-mail customer service@ons.org. ✱ DiSalvo, W.M., Joyce, M.M., Tyson, L.B., Culkin, A.E., & Mackay, K. (2008). Putting Evidence Into Practice®: Evidence-based interventions for cancer-related dyspnea. Clinical Journal of Oncology Nursing, 12(2), 341–352. Retrieved July 17, 2008, from http://ons.metapress.com/ content/c21324512r838824/fulltext.pdf August 2008 ONS CONNECT 19 http://esourceons.org/Publications http://esourceons.org/Publications http://ons.metapress.com/content/c21324512r838824/fulltext.pdf http://ons.metapress.com/content/c21324512r838824/fulltext.pdf

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ONS Connect - August 2008 Contents Editor's Note Just In Safe Handling of Chemotherapy A Year in the Life—Month Eight Put Evidence Into Practice to Manage Dyspnea Web Connect Capitol Connection Notice Nursing Now Caregiver Care KRAS Status Predicts Response to Cetuximab for Metastatic Colorectal Cancer Calendar of Events Working for You Staying on Top

ONS Connect - August 2008

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