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1. Definition

1.1. The term generally applied to sensations experienced by individuals who complain of unpleasant or uncomfortable respiratory sensations

2. Etiology

2.1. Cancer related

2.1.1. • Lung cancer primary or metastatic • Superior vena cava syndrome (SVCS) • Malignant pleural effusion, atelectasis • Pericardial effusion • Pulmonary embolus • Ascites • Pathologic chest wall fractures • Tracheal esophageal fistula • Electrolyte imbalance • Low hemaglobin

2.2. Cancer treatment related

2.2.1. • Surgery (e.g. lobectomy, pneumonectomy) • Radiation therapy to lung or chest (e.g. radiation - induced pneumonitis, pulmonary fibrosis, pericardial disease) • Chemotherapy (e.g. chemotherapy induced pneumonitis, pulmonary toxicity, cardiomyopathy, anemia) • Immunosuppression with respiratory infection • Immunotherapy- Checkpoint inhibitors

2.3. Pscychosocial

2.3.1. Anxiety, fear

2.4. Relevant medical history

2.4.1. • Airway obstruction, aspiration • Chronic obstructive pulmonary disease (COPD), asthma, chronic bronchitis, emphysema • Cardiac disease (e.g. congestive heart failure, cardiac ischemia, atrial fibrillation) • Neuromuscular disorders • Chest wall deformity • Atelectasis • Pneumonia, bronchitis • Pneumothorax • Systemic infection

2.5. Other

2.5.1. • Deconditioning – overall decline in functional status resulting in exercise intolerance • Environmental factors (e.g. exposure to second hand smoke or other irritants, air pollution) • Obesity, malnutrition • Smoking history • Fatigue • Pain

3. Focused health assessment

3.1. General Assessment

3.1.1. Contact & General Information

3.1.2. Consider Contributing Factors

3.2. Symptom Assessment

3.2.1. Normal

3.2.2. Onset

3.2.3. Provoking/Palliating

3.2.4. Quality (in last 24 hours)

3.2.5. Region

3.2.6. Severity/other symptom

3.2.7. Understanding/impact on patient

3.2.8. Value

3.3. Physical Assessment

3.3.1. Vital signs

3.3.2. Observe general appearance

3.3.3. Chest assessment

3.3.4. Assess mental status

3.3.5. Weight, fluid balance

4. Grading scale

4.1. Grade 1 (mild)

4.1.1. Shortness of breath with moderate exertion

4.2. Grade 2 (moderate)

4.2.1. Shortness of breath with minimal exertion; limiting instrumental ADL (e.g. preparing meals, shopping, managing money)

4.3. Grade 3 (severe)

4.3.1. Shortness of breath at rest; limiting self-care ADLs (e.g. bathing, dressing, feeding self, using the toilet, taking medication)

4.4. Grade 4 (life-threatening)

4.4.1. Life-threatening consequences; urgent intervention required

4.5. Grade 5

4.5.1. Death

5. Management

5.1. Grade 1 (non-urgent)

5.1.1. Potential care and assessment • Assessment and management of underlying causes of dyspnea • For patients receiving Immunotherapy, collaborate with physician

5.1.2. General supportive measures • Assess emotional response to shortness of breath • Reassure that shortness of breath can be managed • Environmental considerations: - Maintain calm atmosphere - Promote cooler temperatures - Promote ambient air flow directed at nose or mouth - stimulates trigeminal nerve, providing sense of relief from dyspnea - Use of hand fan - Humidify air - Avoid smoke/smoking • Stress management and relaxation techniques (e.g. controlled breathing, visualization, music therapy, complete muscle relaxation, massage, therapeutic touch, yoga or Tai Chi) • Consider assistive devices (e.g. wheelchair) to decrease physical activity that may exacerbate dyspnea

5.1.3. Energy conservation • Pacing – Balance activities with rest – Slow and steady pace uses less energy • Planning – Organize your time, methods, and space – Encourage activities which are most enjoyed on days when feeling best – Develop a routine for rest and activity • Priority setting – Eliminate unnecessary tasks, delegate responsibilities and ask for help • Posture – Change positions frequently – Keep activities/work within easy range using correct body alignment – Avoid bending and lifting • Proficiency - Use labour saving devices (e.g. elevator) to maximize efficiency and minimize workload

5.1.4. Positioning Goal: Avoid compression of chest and abdomen when positioning • Positions that allow for optimal lung expansion and gas exchange are: – Sitting: Sit upright with back against chair, with feet wide apart, leaning forward with arms on bedside table or on knees – allows more space for lung expansion – Standing: Lean back against wall with feet slightly apart and head and shoulders relaxed – In Bed: Elevate head of the bed, support and elevate arms with pillows – Other: Lean forward on banister when climbing stairs or shopping cart when shopping

5.1.5. Techniques to Retrain and Control Breathing Goal: Decrease dyspnea and help patient regain control over their breathing. Techniques to prevent /reduce trapped air in lungs and help to inhale more fresh air: Pursed Lip Breathing, Shortness of Breath, Diaphragmatic Breathing

5.1.6. Physical Activity • Encourage activity to tolerance, increasing intensity to prevent deconditioning • Upper and lower extremity exercises help improve endurance • Upper – extremity exercise improves respiratory muscle strength

5.1.7. Pharmacological Management • Opioids • Bronchodilators • Corticosteroids (Refer to protocol specific algorithm if patient is on Immunotherapy)

5.1.8. Patient Education and Follow-Up • If indicated, discuss smoking cessation strategies • Reinforce with patients when to seek immediate medical attention: - Temperature greater than or equal to 38° C - Acute onset of respiratory distress and/or chest pain • If breathing does not improve or begins to deteriorate: - Instruct patient/family to call back - If indicated, arrange for nurse initiated or physician follow – up for further assessment - If patient on Immunotherapy, follow up should be within 2 – 3 days

5.2. Grade 2-3 (urgent)

5.2.1. Patient care and assessment • Collaborate with physician re: need for further patient assessment at clinic or with GP •Assessment and management of underlying causes of dyspnea *If breathing does not improve or worsens, consider urgency of symptom and calling 911 • Lab tests that may be ordered: - Complete blood count (CBC), serum electrolytes, pulse oximetry, arterial blood gases, Chest X – Ray. If above not adequate, further evaluation might include: Pulmonary function tests, CT scan, ventilation – perfusion scans.

5.2.2. Pharmacological management • Oxygen therapy • Smooth muscle relaxants • Bronchodilators • Anti-inflammatories • Diuretics • Corticosteroids (Refer to protocol specific algorithm if patient is on Immunotherapy • Opioids • Anxiolytics/sedatives • Antibiotics, antifungals, antivirals

5.2.3. Patient educational and follow up • Develop plan to address patterns of shortness of breath and patients way of coping • Explain concept of multiple triggers of dyspnea • If patient on Immunotherapy, follow up should be daily

5.3. Grade 4 (emergent)

5.3.1. Patient care and assessment • If patient at home, instruct to call 911 • Notify physician of assessment and need for hospital admission; facilitate arrangements as necessary • If patient on Immunotherapy, remind patient to present Immunotherapy alert card. •Lab tests that may be ordered: - Complete blood count (CBC), serum electrolytes, pulse oximetry, arterial blood gases, Chest X – Ray. If above not adequate, further evaluation might include: Pulmonary function tests, CT scan, ventilation – perfusion scans. • Suctioning might be indicated • If dyspnea severe, may need to open airways (e.g. endobronchial stents, radiation therapy)

5.3.2. Pharmacological management • As severity of dyspnea increases, consider higher doses of opioids or switch to another route • Consider anticholinergics (e.g. scopolamine, atropine) to help control secretion production • Refer to protocol specific algorithm if patient is on Immunotherapy