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Dyspnea Management inEarly-Stage Lung Cancer

A Palliative Perspective

Anna Cathy Williams, BSN, PHN, RN Marcia Grant, DNSc, FAAN, RN Brian Tiep, MD Jae Y. Kim, MD Jennifer Hayter, MA, OTR/L, SWC, CLT-LANA

A new cohort of lung cancer patient is on the horizon.With rapidly evolving diagnostics and treatmentmethodology, early-stage nonsmall cell lung cancerpatients are increasing in numbers. Although stage I-IIpatients are deemed curable, there linger threats ofrecurrence, new primaries, and existing or imposedcomorbidities due to the treatment itself. Consequently,the outlook remains tenuous for this population. Withimproving survival rates, it is imperative that patientswith early-stage nonsmall cell lung cancer be fullyassessed, aggressively managed, and followed up longterm, according to the National Comprehensive CancerNetwork guidelines. Dyspnea is one of the mostfrightening of all symptoms, regardless of diagnosisand stage of any disease. It accompanies feelings ofsuffocating and even impending death. Given thesubjectivity of dyspnea, it is critical to assess the impact

it imposes on quality of life for each patient and theirloved ones. Cognizant of the abundance of careinvolved in such cases, it is the palliative care nursewho is the core advocate and coordinator of services.Through a comprehensive care plan and interdisciplinaryeffort, healthcare professionals may be able to offerearly-stage nonsmall cell lung cancer patients withdyspnea stellar evidence-based intervention andhopefully a greater chance of possessing a senseof normalcy in their lifestyles.

KEY WORDS

dyspnea, early-stage lung cancer, quality of life

Virtually unheard of before the last decade, early-stage nonsmall cell lung cancer (ES-NSCLC) survi-vors have become part of a growing population.

Currently comprising 15% of the 221,000 newly diagnosedlung cancers in 2011, the National Cancer Institute citesimproved screening and increased public consciousnessin allowing the medical community to offer this group achance of curative intervention, something practically non-existent in lung cancer.1,2 Approximately 32% of these in-dividuals have a stage I or II disease, the focus populationfor this article. Amounting to an approximately 50% 5-yearsurvival rate at stage IA-B, and averaging 30% for stages

IIA-B,3-5 patients with newly diagnosed ES-NSCLC warranttreatment methods that use an interdisciplinary approach.It is only through comprehensive assessment, interdisci-plinary management, and surveillance that the palliative

care team will demonstrate sound clinical strategies, en-hancing the quality of life (QOL) for these patients andtheir families.6

Often referred to as the sixth vital sign by leadingauthorities, dyspnea is defined as respiratory demand ex-ceeding the bodys ability to meet that need.2,3,7 It is asubjective or perceived, sensory, varied, and yet com-mon experience in lung cancer patients. It is associatedwith a conscious sensation of uncomfortable breathing,smothering or suffocating, difficult, or labored breathing;inability to get enough air; or tightness in the chest.7,8 Itdiffers from tachypnea (increased respirations) or breath-

lessness, which can be a normal physiological responseas seen in exercise or a state of excitement.7 Dyspneavaries in intensity, consisting of an interface among phys-iological, psychological, social, and environmental fac-tors, inducing secondary responses.7,9 In the clinical

Anna Cathy Williams, BSN, PHN, RN, is Senior Research Specialist,Division of Nursing Research & Education, Department of Cancer Con-trol & Population Sciences, City of Hope, Duarte, California.

Marcia Grant, DNSc, FAAN, RN, is Director and Professor, Division ofNursing Research & Education, Department of Cancer Control & Popu-

lation Sciences, City of Hope, Duarte, California.

Brian Tiep, MD,is Staff Physician, Critical Care Medicine, Departmentof Medical Specialists, City of Hope, Duarte, California.

Jae Y. Kim, MD,is Staff Surgeon, Division of Thoracic Surgery, Depart-ment of Surgery, City of Hope, Duarte, California.

Jennifer Hayter, MA, OTR/L, SWC, CLT-LANA, is Director, ExpenseRehabilitation Services, City of Hope, Duarte, California.

Address correspondence to Anna Cathy Williams, BSN, PHN, RN, Divi-sion of Nursing Research & Education, Department of Cancer Control& Population Sciences, City of Hope, 1500 E Duarte Rd, Duarte, CA91010 ([email protected]).

The authors have no conflict of interest to disclose.

This work is supported by a grant from the National Cancer Institute (PO1

CA136396Palliative Care for Quality of Life and Symptom Concerns inLung Cancer; B. Ferrell, PI).

DOI: 10.1097/NJH.0b013e318258043a

332 www.jhpn.com Volume 14 & Number 5 & July 2012

Symptom Management Series

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presentation chronic, labored breathing is one of the mostdifficult symptoms to identify or manage, and once ac-quired, it promises to remain an ever-present condition.Dyspnea possesses unique characteristics in that acuteepisodes, such as asthma or bronchitis, are manageable

and tend to subside and resolve with uncomplicated orminimal intervention of the underlying cause. Chroniccases are persistent, linger, and have varied intensity, re-gardless of intervention. In chronic dyspnea, 85% of theetiologies stem from cardiopulmonary and psycho-genic causes.10 The American Thoracic Society suggeststhe prevalence ranges from 55% to 87% in all stages oflung cancer.

The sensation of breathlessness is frightening to pa-tients and their caregivers (CGs), leading to a feeling ofsuffocation and possible death. Not only is dyspnea analarming, multidimensional symptom, the impact on apatients QOL is undeniable and often incessant.7,11,12

Cognizant of the needs of these individuals, it is the pal-liative care nurse, possessing a specialized skill set, whois poised as the point person in coordinating care andis a critical component of the interdisciplinary health-care team.

Along with the diagnosis of ES-NSCLC, 60% of thesepatients suffer comorbid conditions and symptoms, suchas chronic obstructive pulmonary disease (COPD) anddyspnea.13 The plan of care should encompass pharmaco-logical and nonpharmacological interventions for preexist-

ing medical concerns, along with those issues imposedby lung cancer or cancer treatments. Supportive and pal-liative care is an essential ingredient in ES-NSCLC patientswith dyspnea. The following discussion addresses theetiology, assessment, management, and follow-up for thesymptom of dyspnea in ES-NSCLC patients.

CLINICAL CHARACTERISTICS ANDETIOLOGY OF DYSPNEA INEARLY-STAGE LUNG CANCER

The most common symptom in all lung cancers, dyspneais one of the most unpleasant and is described subjectivelyand according to the underlying cause. The etiology ofdyspnea can be direct or indirect (as seen in Table 1). Adirect cause of dyspnea involves cancer, or its effects,such as tumor or lymphatic invasion, effusion, obstructionof pulmonary tissue, or the complication of pulmonaryembolism.12,15,21 Indirect causes are numerous, such asanemia, underlying cardiac or pulmonary disease, tho-racic surgery, or cancer treatments such as chemotherapy,biotherapy, and radiation.15,21

Dyspnea often displays similar characteristics but isunique because of the underlying etiology and body sys-tem involved (ie, pulmonary or cardiac). It is frequently

classified by the severity, symptoms, type, duration, dis-tress to the patient, and interference with activities of dailyliving (ADLs).16,23 The pathophysiology is certainly poorlyunderstood,21,22 and etiologies are varied, as shown inTable 1. Dyspnea stems from the mechanisms of in-

creased ventilatory demand, impaired mechanical re-sponses, or a blending of both.11 Variations exist in theextent of dyspnea due to various afferent causes from thebrains autonomic center or the receptors in the airway,lungs, and chest wall. Further contributors to the variabilityof dyspnea are the type of provocation such as situation,behavioral influence, and the patients ability to depictthe sensation.10,23

Breathlessness is unique in the sense that there are nospecialized dyspnea receptors, although more recently,magnetic resonance imaging (MRI) studies have revealedmidbrain arenas exhibiting a perception of dyspnea.21

The reaction is likely a consequence of a complex inter-action between chemoreceptor stimulation, mechanicalabnormalities in breathing, and the perception of the ab-normalities by the central nervous system or neuromecha-nical uncoupling.21 Essentially, dyspnea results from thecortex dominating the respiratory center, rousing chemo-receptors in the lung and respiratory muscles. Respiratoryeffort intensifies, and there is a boost in the use of respira-tory muscles. This amplifies ventilatory requirements andcan occur acutely, as in exercise or exertion, or chroni-cally, as with COPD.2,24

QUALITY OF LIFE RELATED TODYSPNEA IN EARLY-STAGELUNG CANCER

A rapidly growing population of survivors brings with itexpectations of an enhanced QOL, along with a greateremphasis on patient-centered issues. The goal of pallia-tion is to improve patient care by managing symptoms inthe physical, psychological, social, and spiritual realmsassociated with lung cancer and/or its treatment.17,25 Pal-

liative intervention should be received concurrently withtreatment and continue as long as needed.

Current literature clearly demonstrates the impact ofdyspnea on surgical patients and their loved ones, before,during, and after treatment,13,26 citing dyspnea as a com-mon symptom in the years following surgical resection.Additionally, the article reports that 65% of these patientsoffered no complaint of preoperative dyspnea. In anotherlongitudinal study exploring QOL in patients with re-sected ES-NSCLC 2 years postoperatively, surgery wasfound to have substantially reduced QOL across all do-mains except emotional functioning.13 The impact of dys-pnea on QOL is undeniable. Physically, this symptom isregarded as one of the most distressing, as the phenomenon

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of decreased oxygen lends to increased fatigue and breath-

lessness, and may be accompanied by discomfort, burning,numbness, or a feeling of impending death.27,28 It impactsability to sleep, work, exercise, and experience intimacy.29

There is a multitude of psychological responses to dys-pnea, that of fear, anxiety, and possibly guilt and depres-sion, often exacerbating the dyspnea. From a socialstandpoint, patients suffer all manner of upset. There isobservable role reversal, CG burden, loss of leisure activ-ity, isolation, compromised sexuality, and frequently fi-nancial burden.27,30 Often overlooked is the spiritualsuffering involved, along with existential questions whenpatients are faced with life-altering symptoms such as lungcancer and dyspnea. Living often takes on new meaningand purpose, even when patients are diagnosed at an

TABLE 1 Etiology of Dyspnea

Known Cause

Possible Signs/Symptoms

AccompanyingDyspnea Intervention

Direct cause

Tumor Cough Surgical

Lymph invasion Difficultyswallowing

Chemotherapy

Radiation

Obstruction/restriction

Decreased oxygensaturation

Controlled oxygen

COPD Fremitus Bronchodilators

Pulmonaryembolism Clubbed fingers/toes Corticosteroids

Asthma Cyanosis Antibiotics

Confusion Opioids

Blood gases

Sputum cytology

Pulmonaryrehabilitation

Effusion Diminished breath

sounds

Thoracentesis

PleurX/pleurodesis

Tunneled catheter

Indirect cause

Cancertreatments

Postoperative pain Treat underlyingcause

Thoracic surgery Loss of lung tissue Pulmonaryrehabilitation

Chemotherapy/biotherapy Chemotherapy-induced nauseaand vomiting

(See Table 2)

Radiation Cough

Anemia Pallor Transfusion

Erythropoietin

Nutritionalconsult

Cardiacpathology

Chest pain ECG

CHF Congestion Echo

TABLE 1 Continued

Known Cause

Possible Signs/Symptoms

AccompanyingDyspnea Intervention

MI Cardiac enzymes

Cardiomyopathy Diuretics andmonitor fluidbalance

Sepsis Febrile Cytology

Chills Antibiotics

Pain Patient reported Treat underlyingcause

Grimace Pain medications

as directed

Distractiontechnique

Anxiety Tachypnea Anxiolytics

Panic Tachycardia Teach copingtechniques

Diaphoresis Psychology/CSWreferral

Remain withpt duringexacerbation

Sedentarylifestyle

Activity intolerance Exercise program

Nutritional consult

Abbreviations: CHF, congestive heart failure; COPD, chronic obstructivepulmonary disease; CSW, clinical social work; ECG, electrocardiogram;MI, myocardial infarction.

Adapted from References 6, 7, 10, 13, and 19-22.



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early stage. There appears to be an abundance of uncer-tainty and loss of ones belief systems. It is imperativethat the nurses clinical assessment incorporates not onlydiagnostic manifestations, but also provides a compre-hensive examination into these all-encompassing QOLdimensions.6

ASSESSMENT OF DYSPNEA INEARLY-STAGE LUNG CANCER

As dyspnea is a highly subjective symptom, evaluatingan individuals shortness of breath is an obscure circum-stance at best, and severity may be associated with thepatients perception of what the dyspnea means.15Along

TABLE 2 Methods of Pulmonary Rehabilitation

Prevention Gas exchange/oxygen transport

(1) Smoking cessation (1) Oxygen therapy

(2) Ensure immunizations (2) Bronchial hygiene

(3) Prevent exacerbation (3) Exercise program

(4) Optimize medical management Exercise training

Self-management (1) Ambulation training

(1) Medication training (2) Upper-extremity training

(a) Metered dose inhaler (3) Ventilatory muscle training

(b) Nebulizer Functional training (ADLs)

(2) Bronchial hygiene (1) Self-care

(3) Breathing retraining (2) Care of the home

(4) Oxygen therapy (3) Leisure pursuits

(5) Adequate nutrition (4) Work (as appropriate)

(6) Family training (5) Active lifestyle

(7) Reporting to physician (6) Shopping

(8) Exacerbation protocol (7) Sexual counseling

(a) Self-assessment Team support

(b) Self-intervention (1) Acceptance of disease

(c) Access physician (2) Coping skills

Dyspnea relief (3) Encouragement

(1) Exercise program (4) Positive thinking

(2) Breathing retraining (5) Self-esteem

(3) Bronchodilators (6) QOL focus

(4) Bronchial hygiene Advance directives

(5) Reduce anxiety, depression (1) Advance directives

(6) Reduce fear, apprehension (2) Continuing directives

(7) Improve confidence

Abbreviation: ADLs, activities of daily living.Adapted from Tiep,14 Table 3.



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TABLE 3 Assessment of Dyspnea in Early-Stage NonSmall Cell Lung Cancer Patients

Subjective Objective

Self-reporting scales such as History and physical examination

&

Numeric rating scale & Vital signs

0 = no problem, 10 = the worst & Systems review

& Baseline Dyspnea Scale & Respiratory assessment

Functional Auscultation/percussion

Magnitude of task Quality of breaths (pursed lip, puffing, blowing, flared nostrils)

Magnitude of effort Dry or productive cough

& Respiratory Distress Observational Scale Sputum quantity and character

Observational documentation Use of accessory muscles

Ability to complete full sentence

Identify stable or unstable dyspnea and acute respiratory failure

& Skin color and temperature

& Dependent edema and abdominal girth

& Smoking and COPD screening

Symptoms and interference with ADLs Pulmonary function testing

& Baseline, during treatment and exacerbations & Pulse oximetry

& Onset (sudden or gradual), intensity, duration & Spirometry

& What alleviates or aggravates dyspnea

Impact of symptoms on QOL Laboratory testing

& Physical: difficulty breathing, decreased oxygen, compromisedactivity, fatigue

& Complete blood count (anemia)

& Psychological: fear, depression, anxiety & Chemistry

& Social: financial burden, isolation & ABGs (blood gases)

& Spiritual: meaning and purpose in life, which is breathing

Assess Imaging

& Inhaler/oxygen techniques & Chest x-ray

& Medication administration and compliance & CT

& Strategy for secretion clearance & Echo

& Shuttle walking test

Education/evaluation as needed: (maintain symptoms diary) Consultations and surveillance

& Alter perception of breathlessness & Nutrition (healthy diet and maintenance)

Sit upright supported by pillow & Pulmonary rehabilitation

Continued



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with assessing dyspnea quality, specific descriptions

should be elicited according to the onset, duration, inten-sity, activity level, and psychological response before,during, and after dyspnea experience.9,31,32 Upon the in-itial assessment, the nurse begins with the patients sub-jective (self-report) of dyspnea, which can involve aquantitative scale (Table 3). Examples of scales availableare the Numeric Rating Scale (where 0 = the least pro-blem and 10 = the worst), or visual analog scale, whichmeasures symptom intensity with a 100-mm line (verticalor horizontal). Other commonly used measurements areBaseline Dyspnea Index (which grades severity of dys-pnea in 3 different categories; functional status, magni-

tude of task, and magnitude of effort, 0 = severe, 4 =unimpaired) or Respiratory Distress Observational Scale,which is survey-like with observational documenta-tion.18,19,32 Collectively, all scales ask the patient to ratedyspnea related to shortness of breath and impact onADLs and/or QOL.

Objective assessment involves a thorough history andphysical examination, providing invaluable information viathe actual interview, assessment scales, auscultation, andpercussion, and is diagnostic in at least one-half of patients.The use of imaging yields discovery of common cardiopul-monary diseases, along with the diagnostics listed below.

Nursing assessment of dyspnea may assist in locatingthe cause, in addition to establishing the most appropri-

ate interventions regarding symptom prevention, man-

agement, and follow-up. Table 3 presents an overviewof nursing appraisal components. Along with the one-to-one assessment, imaging, a complete blood count,metabolic profile, arterial blood gases, echocardiogram/electrocardiogram (echo/ECG), pulmonary function, andsputum cytology should be completed. Considerationshould also be given to the possible adverse effects andoutcomes of the patient undergoing treatment interven-tion for their lung cancer, such as thoracic surgery, che-motherapy, or radiation.2,7,33

NURSING MANAGEMENT OF DYSPNEAIN EARLY-STAGE LUNG CANCER

The goal of nursing in dyspnea is to obtain a full pictureof the patients experience and impact on ADLs and QOLfor both the patient and family. Nurses must also acknowl-edge and accept the patients self-report of dyspnea.32,33

Following a full assessment of all four domains in QOL(physical, psychological, social, spiritual), as seen inTable 3 it is of the utmost importance to achieve a thoroughunderstanding of the perceptions, fears, and uncertaintiessurrounding the symptom of dyspnea. Nurses must be ex-ceptionally skilled in assessing dyspnea in the ER-NSCLCpatient, along with implementing effectual interventions,and improving outcomes for this population.

TABLE 3 Continued

Subjective Objective

Provide ambient air flow in environment (fan) & CT every 6-12 mo, then annually

&

Reduce respiratory demand & Annual influence and pneumococcal vaccinations

Plan important activities first (energy conservation) & Routine vital signs, pulse oximetry, and laboratory work

Teach pursed lip/diaphragmatic breathing & Bone density as appropriate

Rest periods/relaxation and coping techniques & Routine dental exams

Keep frequently used items within reach & Regular physical activity

Walker or wheelchair as needed

Perform grooming sitting down

Wear clothing that is easy to put on

Avoid environmental irritants

Call medical doctor/nurse practitioner if

Febrile 9 100.5

Change in breathing, cough or sputum

Abbreviations: ABGs, arterial blood gases; ADLs, activities of daily living; COPD, chronic obstructive pulmonary disease; CT, computed tomography; QOL,quality of life.

Adapted from references 6, 7, 10, 13, and 15-20.



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Once the medical and nursing assessment has takenplace, the underlying cause is addressed. Depending onthe chronicity of dyspnea, the nurse is able to provide sup-port for disease management including the interdisciplinaryplan of care, promoting energy conservation, strict medica-

tion adherence, relaxation and coping techniques, nutri-tional evaluation, and pulmonary rehabilitation.34,35

Working collaboratively, the nurse ensures the high-est QOL possible for the patient and family, renderingeducation and referrals as needed. As an integral partof follow-up, the nurse should advocate for chronic re-view of outcome and institute intervention refinement,endorse organizational and policy strategies, and assessprogram needs concerning services to facilitate adequatesurveillance, always embracing the patients QOL.36,37

MEDICAL MANAGEMENT OF PRIMARYDISEASE EARLY-STAGE LUNG CANCER

Early-stage NSCLC patients with dyspnea undergo all na-ture of complex treatment, including, but not limited to,surgery, radiotherapy, and chemotherapy or a combina-tion thereof. Even with current, cutting-edge technolo-gies, long-term survival remains somewhat elusive. Afterinitial, potentially curative treatment, long-term survivalwithout recurrence remains elusive, as many patients de-velop new primary lung malignancies. In addition, 21%of ES-NSCLC patients enter into therapy with minimal or

no dyspnea, yet any number of curative interventionsmay actually provoke dyspnea.38,39 After their potentiallyrestorative treatment, ES-NSCLC patients with dyspnearequire continued surveillance and follow-up care for dys-pnea, other medical issues, and QOL concerns.

Clinical assessment and pretreatment evaluation forstage IA may consist of pulmonary function, cardiopul-monary exercise testing, bronchoscopy, mediastinoscopyand/or endobronchial ultrasound, and a positron emissiontomography (PET)/computed tomography (CT) scan. Forstage I-IIB, an MRI of the brain should also be performed.1,2,8

For early-stage disease, surgical resection is the stan-

dard of care, providing the best chance for cure. Surgicalprocedures range from limited resections of wedge orsegmentectomy, to more extensive resections of a lobec-tomy, bilobectomy, or pneumonectomy. The surgery, ifoffered as an intervention, is largely dependent on his-tology, the extent of disease, and comorbidities suchas cardiopulmonary status. Procedurally, surgery is per-formed with a posterolateral thoracotomy incision or thatof robotic or video-assisted thoracoscopic surgery (VATS).The lesser invasive procedures may reduce pain and re-covery time and perhaps lower morbidity.

For patients with wholly resected with stage I disease,adjuvant chemotherapy or radiotherapy is not recom-mended. For stage I-IIB disease, chemotherapy and

radiotherapy are most often instituted, according to his-tology, biomarkers, the tumor margins and location, andlymph node sampling.2,4,7

At times, unique services may be available to the pa-tient, such as pulmonary prerehabilitation/rehabilitation.

The definition of pulmonary rehabilitation is that it shouldbe evidence-based, multidisciplinary, and comprehen-sive intervention for patients with acute and chronic re-spiratory disease who are symptomatic and often havedecreased daily life activities.7 It is designed to reducesymptoms, optimize function, increase participation, andreduce healthcare costs through stabilizing or reversingsystemic manifestations of the disease.13,40,41 Indicationsfor referrals include dyspnea and comorbid lung diseasessuch as COPD, asthma, and pulmonary fibrosis. Expecta-tions would include a reduction in dyspnea, improved ex-ercise capacity, sense of control regarding disease process,and overall enhanced QOL.

In considering the potential for interdisciplinary roles, itis best to consider who should be involved, the relevancy,what the interventions might consist of, and how QOL out-comes are achieved. Most assuredly, thoracic surgeons ormedical oncologists perform important functions, provid-ing appropriate treatment regimens, according to the pa-tients medical requirements. Pulmonary rehabilitationshould be enlisted early on, pretreatment if possible. Thiswould help to establish a baseline, enhance pulmonaryfunction, and open the way for planning care during and

after therapy.12,39,40

Nutritional services should be pro-vided to enhance the complex dietary needs of cancerpatients. Lastly, clinical social work and/or chaplaincy arean indispensable support for any individual with a malig-nant process. Social work can also coordinate psychologi-cal, financial, or legal resources. It is only through such atruly collaborative team that healing and progress can beachieved throughout the lung cancer trajectory.1,2,5,12

Medical surveillance should consist of a regular historyand physical examination, along with a chest CT every6 to 12 months for 2 years, then annually. The patientshould receive an annual influenza and pneumococcal

vaccination as appropriate, routine pulse oximetry, bloodpressure, cholesterol, and glucose monitoring. Additionalworkup might consist of a bone density, routine dental ex-aminations, and evaluation of diet and nutritional needs.Regular physical activity should be encouraged.2,3

CASE PRESENTATION

Mr B. is a 67-year-old Asian American former athlete,with a former 50-pack-year history of smoking. He pre-sented with abnormal imaging, with presumed stage IIB(ES-NSCLC). A PET/CT revealed uptake of a 5-cm massin the left upper lobe. There was also a small, slightlyspiculated density in the left lower lobe, along with an



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enlarged mediastinal lymph node. The patients comorbid-ities consisted of COPD, hypertension, and depression.Along with a complete history and physical examination,Mr B. underwent a preoperative education by the nurse.Workup consisted of complete blood count and chemis-

try profile, pulmonary function, a brain MRI, bone scan,and an echo/ECG. After it was noted that the brain MRIand bone scan were negative, discussions related to treat-ment alternatives were conducted at a chest conference.Upon dialog with the thoracic surgeon, Mr B. opted to un-dergo VATS consisting of a pneumonectomy and medias-tinal lymph node sampling. He was cleared for surgeryand was later advised that the surgery went very well, andtumor margins were clear. His case was presented at the in-terdisciplinary thoracic tumor board; since his biomark-ers were positive for excision repair cross-complementinggroup 1 and ribonucleotide reductase M1, the patientdecided on treatment defined by the National Comprehen-sive Cancer Network (NCCN) for stage IIB ES-NSCLC, perthe physicians recommendation. This consisted of adju-vant chemotherapy of taxotere and gemcitabine, givinghim the greatest chance for a curative effect. No radiationwas intended. The plan of care was thoroughly discussedamong the oncology team, the oncologist, and with thefamily present.

Prior to his initial treatment, Mr B. was seen in pul-monary rehabilitation and nutrition and had a peripher-ally inserted central catheter line placed for ease of

obtaining blood specimens and chemotherapy adminis-tration. At his first chemotherapy appointment, with hisspouse present, he met with the oncologist and thenthe chemo nurse. Teaching began with the patientand CG concerning the treatment schedule and adverseeffects of the chemotherapy drugs, in concert with theroutine ancillary medications needed to complete regi-men. Information was also provided on whom, when,and where to call should issues arise. Symptom andmedication diaries were provided. They were to be filledout and brought to clinic upon each return visit to eval-uate for adverse events.

Mr B. did well postoperatively and with his chemotreatment, yet suffered a great deal of dyspnea, due tothe surgical intervention. He was compliant in the pul-monary rehabilitation program, yet continued to becomemore depressed over time at the loss of his athletic andsocial capacities. He also admitted to fear of intimacyand not being able to keep up with his spouse. Hewas referred back to his local psychologist, who con-tinues to work with Mr B. and his spouse on communi-cation, role change, and intimacy concerns. At his lastclinic visit, 1 year after treatment, his spirits were up,and he reported that his respiratory status had much im-proved. He cited his overall QOL as good. It was de-termined that he was in remission and would return for

follow-up according to guidelines established by theNCCN (Table 3).

IMPLICATIONS FOR DYSPNEA IN

PALLIATIVE CAREThe intricacies of dyspnea are multifaceted and complex,and challenges facing health professionals remain rigor-ous and challenging. Nursing management and educationof dyspnea in the ES-NSCLC patient are directed towardprevention, expedient recognition, all-inclusive assess-ment, genuine interdisciplinary methodology, and thor-ough follow-up surveillance. Nurses must be aware ofthe frequent and widespread etiologies of such cases andinstitute chronic evaluation, coordination, and manage-ment of dyspnea, as these are all integral components inthe care of ES-NSCLC. Equipped with an understandingof patients and families equating shortness of breath withfeelings of suffocation, helplessness, and isolation, thenurse is cognizant that all aspects of care must be attendedto meticulously, from ADLs to the impact on QOL and re-habilitative referrals.

There is a continued need for further clinical researchin this arena. Although there are preliminary fundamentalguidelines and personalized care in place, clinicians andnurse researchers must develop an empirical endeavor tobetter understand the experience of dyspnea in ES-NSCLCpatients and their loved ones. With the increased numbers

of cancer survivors, healthcare must acknowledge the im-plications for establishing survivorship programs as an in-tegral part of the cancer care trajectory.42

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For more than 57 additional continuing education articles related to cancer, go to NursingCenter.com\CE.



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