To evaluate/compare three treatments for oral mucositis: (1) Plantago major extract mouthwash, (2) chlorhexidine 0.12%, and (3) aqueous solution of 5% sodium bicarbonate for  the treatment of oral mucositis in patients with solid tumors. Evaluation points included healing time, pain, oral intake, and quality of life.

Randomized controlled trial (phase 3)

• Group A: Control group, received standard of care which included sodium bicarbonate 5% aqueous solution with an additional dose of sodium bicarbonate 5% aqueous solution. 
• Group B: Experimental group, received sodium bicarbonate 5% aqueous solution plus Plantago major extract
• Group C: Experimental group, received sodium bicarbonate 5% aqueous solution plus chlorhexidine 0.12%

The treatment was 14 days for all groups. All groups received education regarding the management of mucositis, a set of instructions, a diary to record signs and symptoms of mucositis, and instruction for proper storing of the mouthwashes. All participants were instructed to rinse with 8 ml of solution for two minutes every six hours. They were instructed to leave 15 minutes between the two mouthwashes.

• N = 50 (evaluable)   
• AGE: Mean age = 59.5 years (SD = 14.3)
• MALES: 48%  
• FEMALES: 52%
• CURRENT TREATMENT: Chemotherapy
• KEY DISEASE CHARACTERISTICS: Tumor types: breast (30.6%), colorectal (32.7%), lung (14.3%), gastric (8.2%) and other (14.2%)
• OTHER KEY SAMPLE CHARACTERISTICS: Patients had a mean of 3.6 (SD = 3.2) chemotherapy cycles prior to oral mucositis outbreak. Patients received many different chemotherapy drugs. No participants developed neutropenia.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Spain

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Elder care, palliative care

Randomized controlled trial; investigators, participants, care providers, and statistician were all blinded.

• WHO mucositis scale
• Visual analogue scale (VAS) for pain intensity
• Intake capacity was captured by asking the participants if they could tolerated liquids only or liquids and solids. 
• European Organizsation for Research and Treatment of Cancer Quality of Life Core 30 Questionnaire (EORTC QLQ-C30)
• CBC (evaluation of neutropenia)
• Patient diary

• Healing time: No statistical difference between groups. The group that used the double 5% sodium bicarbonate solution did have a shorter time to heal by two days, which may be clinically significant. 
• Pain intensity: No significant difference
• Oral intake capacity: No significant difference
• Quality of life: No significant difference

In this small group, there is no advantage in using a chlorhexidine or Plantago major extract mouthwash in comparison to a double sodium bicarbonate solution. The latter is likely less expensive and more readily available

• Small sample (< 100)
• Findings not generalizable
• Subject withdrawals ≥ 10%
• Other limitations/explanation: Not generalizable to those patients who become neutropenic or patients with non-solid tumors. Potentially some bias as there was self-reporting of oral intake versus an objective measure. Attrition rate 16% (failure to follow through with monitoring, interruption of the intervention)

This study does not support the use of Plantago major or chlorhexidine mouthwashes over double doses of sodium bicarbonate 5% aqueous solution.

Primary: To evaluate the use of Zataria multiflora (ZM) extract mouthwash to reduce the incidence and severity of oral mucositis (OM) in adult patients with head and neck cancer undergoing radiation therapy alone or combined radiation and chemotherapy. 

Secondary: The impact of ZM extract mouthwash on the amount of opioid used, the use of anti-inflammatory drug use, antibiotic use, and body weight over the course of therapy

• Double blinded, randomized
• Intervention group: Used a mouthwash containing ZM extract
• Control group: Used a placebo mouthwash with no ZM extract
• Both groups: Oral examination prior to initiation of therapy and then weekly until completion of the last radiation dose. Participants encouraged to use the mouthwash three times daily (after breakfast and lunch and at bedtime) in addition to one half hour prior to each radiation session. Maintained for seven weeks after therapy (data collected only until the end of therapy). Participants instructed to not rinse mouth with water up to one hour after gargling with mouthwash. Participants were also instructed not to smoke or eat hot, spicy, or very cold foods. Oral analgesics and anti-inflammatory medications were given as needed and per standard of care.

• N: 63 patients randomized, 25 in treatment group (16% attrition) and 27 in placebo group (20% attrition)   
• AGE: 57.48 years (SD = 17.98) in treatment group, 64.62 years (SD = 12.75) in placebo group
• MALES: 71%  
• FEMALES: 29%
• CURRENT TREATMENT: Radiation, combination radiation and chemotherapy
• KEY DISEASE CHARACTERISTICS: Head and neck cancer (radiation [at least 6000 cGy] planned for the entire oropharynx, nasopharynx, and/or greater than one-third of the oral cavity, a KPS > 70, with or without chemotherapy)
• OTHER KEY SAMPLE CHARACTERISTICS: No prior history of head and neck radiation, no current poor oral hygiene, no active infections of the mouth, no liver or kidney disease, no diabetes, no autoimmune disease or disease that might alter healing

• SITE: Multi-site   
• SETTING TYPE: Not specified    
• LOCATION: Iran

• PHASE OF CARE: Active anti-tumor treatment
• APPLICATIONS: Elder care

Double blinded, randomized, placebo controlled study

• World Health Organization (WHO) mucositis scale
• Oral Mucositis Assessment Scale (OMAS)
• Visual analogue score (VAS) for pain
• Required opioid analgesia (weekly)
• Required anti-inflammatory drugs (weekly)
• Required antibiotics (weekly)
• Weekly body weights

Primary outcomes: 

• The presence and intensity of OM the groups was significantly different using the OMAS for all six weeks of assessment (p < 0.05 [range = 0.002-0.016]) and for weeks 3, 4, and 6 using the WHO OM scale (p < 0.05 [range = 0.009-0.045]) favoring the ZM group. There was a decrease in the incidence of grades 3-4 OM in the ZM group in comparison to the placebo group (24% versus 55.5%).

Secondary outcomes: 

• Pain: The ZM group demonstrated a lower pain score in weeks 2-6
• Weight loss: Less in the ZM group (p = 0.000)
• Required analgesia: Less in the ZM group (p = 0.010)
• Antibiotic use: Less in the ZM group (p = 0.037)

The use of ZM mouthwash positively impacted the incidence and severity of OM in patients with head and neck cancer undergoing head and neck radiation with or without concurrent chemotherapy. In addition, the ZM mouthwash contributed to less use of opioid analgesia, less antibiotic use, and decreased weight loss.

• Small sample (< 100)
• Subject withdrawals ≥ 10%  
• Other limitations/explanation: It is hard to discern how analgesic and anti-inflammatory use was ascertained.

ZM may offer an option for decreasing OM in patients undergoing radiation with or without concurrent chemotherapy in the head and neck cancer population.

PURPOSE: To use sub-antimicrobial doxycycline 50 mg per day on patients with leukemia to reduce the onset and severity of OM

TYPES OF PATIENTS ADDRESSED: Patients with ML or LL

RESOURCE TYPE: Evidence-based guideline

PROCESS OF DEVELOPMENT: Patients aged 15 years and older with specific leukemia (N = 47). Patients had basic oral examination and were taught oral care protocol. A baseline oral examination was done three times per week for three weeks. The strategy of development was to prevent the devastating consequences of OM in patients with leukemia. 

INCLUSION CRITERIA: Aged 15 years or older, male or female

EXCLUSION CRITERIA: Patients using the following medications: acitretin, isotretinoin, or tretinin

• PHASE OF CARE: Diagnostic    
• APPLICATIONS: Palliative care

The low-dose use of doxycycline proved ineffective in the management of OM in patients with acute leukemia during chemotherapy.

Effectiveness unlikely. The intervention with doxycycline lacks effectiveness in the reduction of the severity or onset of OM in patients with leukemia.

The findings are not generalizable; limited to one disease group.

The nursing implication is that continued attention to OM is needed to manage and treat the dose interruption and debilitating nutritional problems associated in patients receiving treatment for cancer.

PURPOSE: Prevention of combination drug therapy-induced OM (stomatitis) This is the second clinical trial supported by Novartis in patients taking combination drug therapy (everolimus and exemestane).

TYPES OF PATIENTS ADDRESSED: Patients with hormone receptor-positive, HER2-negative metastatic breast cancer 

RESOURCE TYPE: Evidence-based guideline

DATABASES USED: PubMed   

INCLUSION CRITERIA: Metastatic breast cancer with hormone receptor-positive, HER2-negative

EXCLUSION CRITERIA: All other types of cancer

PHASE OF CARE: Late effects and survivorship

This is the second clinical trial performed by Novartis to eliminate dose interruption of everolimus tablets in combination therapy for women with hormone receptor-positive, HER2-negative metastatic breast cancer. Twenty-three investigational sites based in the United States participated. The average age of the 92/86 female participants was 61 years. It was a single-arm phase 2 study. The primary endpoint was the incidence of grade 2 or worse OM was significantly reduced by proactive oral care use of alcohol-free dexamethasone oral solution (SWISH).

This is the first and largest OM prevention study completed that combines therapeutic management with proactive patient engagement to reduce the incidence of OM in patients who are postmenopausal and receiving combination pill therapy(everolimus and exemestane) as treatment for hormone receptor-positive, HER2-negative metastatic breast cancer. The use of dexamethasone oral solution for two minutes, four times a day, will stop OM from occurring or reduce the severity. It is used for eight weeks or longer if results are positive.

The primary limitation is it is for only one targeted group and for one target drug. The clinical trial is high strength and high quality. There could not be a control group due to the fact that the investigators did not find it ethical for patients to suffer with OM. Novartis is the manufacture of dexamethasone oral rinse and gives free eight-week supplies.

The nursing implication is to teach an oral care protocol to all patients with cancer and ask for more clinical trials for patients with other types of cancer or receiving other treatments. The SWISH trial found that a commercially available, inexpensive, well tolerated dexamethasone oral rinse is an effective intervention in the prevention of OM in women with HER2-negative metastatic breast cancer treated with everolimus.

• To determine the impact of music therapy sessions on outcomes of pain, depression, anxiety, shortness of breath, and mood
• To understand which patient characteristics and goals and music therapist interventions had an effect on study outcomes

Data was collected on admitted palliative medicine patients receiving music therapy from September 2000 to May 2012. A board-certified music therapist (MT-BC) on the unit conducted music therapy sessions with individual palliative medicine patients and family members present. Multiple goals may have been addressed at a single session, using a variety of live patient-preferred musical interventions. Interventions included six main categories—music listening, verbal/cognitive participation, vocal participation, physical participation, verbal/emotional participation, and music-assisted relaxation. Symptom evaluations from patients included pre- and post-session severity of pain, depression, anxiety and shortness of breath. Data collected on patients included standardized music therapy assessment, elements of standardized music therapy, clinical note, patient related information, patient goals for the session, interventions used by the music therapist, symptom evaluations from patients, behavioral evaluations from the therapist, music used, patient and family member reactions, and narratives.

• N = 239   
• AGE: Average = 60 years; median = 61 years; range = 20-89 years
• MALES: 33.1%  
• FEMALES: 66.9%
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: All palliative patients; diagnoses include lung cancer, hematologic cancer, breast cancer, gastrointestinal cancer, gynecologic cancer, ASL, sickle cell disease, cardiovascular, chronic pain/RSD/fibromyalgia, liver disease/cirrhosis, ESRD, AIDS, bowel obstruction, multiple sclerosis 
• OTHER KEY SAMPLE CHARACTERISTICS: Patients were included if they were 18 years or older, having at least one patient-reported rating of pain, depression, anxiety, shortness of breath, or mood before and after the music therapy session.

• SITE: Single site   
• SETTING TYPE: Inpatient    
• LOCATION: The Cleveland Clinic (Ohio)

• PHASE OF CARE: Multiple phases of care
• APPLICATIONS: Palliative care

This is a retrospective study of data collected on palliative medicine patients admitted from September 2000 to May 2012 who participated in music therapy sessions.

• Patient-reported severity of pain, depression, anxiety, and shortness of breath were all rated on a scale from 0 to 10 that was obtained pre- and post-music session.
• Patient-reported mood rated on a scale from 0 to 4 based on the Rogers Happy/Sad Faces Assessment Tool that was obtained pre- and post-music session.
• Music therapist-reported scores on facial expression, body movement, and vocalization based on a three-point scale before, during, and after the music therapy session based on the Nursing Assessment of Pain Intensity and Riley Infant Pain Scale.

Statistically significant reduction improvement in pre- and post-session mean scores were reported for all measurements (p < 0.001) except body movement (p = 0.16). However, the percentage of patients who achieved the clinical significant threshold ranged from 0.7% to 66.2%. Outcomes with the highest percentage of patients with clinically relevant improvement were mood (66.2%), vocalization (58.7%), and facial expression (55.6%). Only 12.3% of patients experienced any clinically relevant improvement. 96% of participants had an overall positive verbal response to the session versus 4% of participants that experienced an ambivalent or no verbal response. Patients who listed pain, depression, anxiety, shortness of breath, or mood as a goal for music therapy achieved the most improvement in these symptoms. Vocalization seemed to have significantly improved when verbal/emotional intervention was used and when distraction was a goal of music therapy. There was no impact on patient demographic or cancer diagnosis on outcomes.

Music therapy does appear to have a positive effect on symptoms of dyspnea and should be considered as an adjunct to current standard interventions. However, more research is needed to determine the degree of clinical benefit of music therapy in the improvement of dyspnea, as well as its cost-effectiveness and duration effect.

• Risk of bias (no control group)
• Risk of bias (no random assignment)
• Risk of bias (no appropriate attentional control condition)
• Unintended interventions or applicable interventions not described that would influence results
• Measurement validity/reliability questionable
• Other limitations/explanation: Use of observational behavioral data (such as the music therapist-reported outcomes) could be biased as it relies on the therapist’s opinion. Therefore, inter-rater reliability of the rating scales was not assessed to account for multiple interpretations of various patient behaviors. Authors “arbitrarily” decided that a change of 2 points on a 10-point rating scale and a change in 1 point on a 4-point rating scale would be considered clinically relevant improvement of symptoms. The study results do not take into consideration the effects of session interruptions, patients with severe pain or high anxiety, actively dying, or those who had fallen asleep. Study also does not capture cost-effectiveness or duration effect of music therapy.

Music therapy should be considered as an adjunct to current standard interventions for dyspnea.

To determine time to onset, efficacy, feasibility, and safety of transmucosal fentanyl (FBT) in comparison to immediate-release morphine (IRM) for the relief of episodic breathlessness.

Fentanyl buccal tablets 100 mcg and 2% immediate release morphine are titrated to 1/6th dosing based on their daily oral morphine equivalent (DOME) to start and increase up to 400 mcg fentanyl or 1/6th + 100% of DOME. Patients were to keep a diary of when dyspnea episode started and when medication taken, with various times to record effectiveness and oxygen saturation over one hour. Patients had twice-a-day safety checks by researchers. Actual doses used were 100-200 mcg of fentanyl and 6-36 mg morphine. Patients crossed over after five days (of a 10-day study).

• N = 6 patients completed the study
• AGE: Mean = 58 years old
• MALES: 60%
• FEMALES: 40%
• CURRENT TREATMENT: Palliative care
• KEY DISEASE CHARACTERISTICS: Patients with incurable cancer who had at least one month to live and SOB scores greater than 3 of 10.
• OTHER KEY SAMPLE CHARACTERISTICS: Older than age 18 years and opiate tolerant.

• SITE: Multi-site   
• SETTING TYPE: Outpatient    
• LOCATION: Germany

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Elder care, palliative care

This is an open-label, randomized, active-controlled (morphine), crossover, phase II trial with an open label dose titration phase.

Oxygen saturation testing was done, stop watch, and a breathlessness scale of 0-10, with 10 being the worst score. Respiratory rate, Glasgow Coma Scale, and Karnofsky level.

The Breathlessness Index Difference (BID) was calculated.  At 10 minutes, the difference was p = 0.051, with mean time to onset of meaningful breathlessness relief was for FBT 12.7 minutes (plus or minus 10 minutes), and, for IRM, 23.6 minutes (plus or minus 15.1 minutes), with a mean difference of 10.9 minutes (95% CI [-24.5, 2.7], p = 0.094) in favor for FBT (FBT-IRM). Time of onset between morphine and fentanyl was a mean difference of 8.4 (95% CI [-18.8, 2.1], p = 0.085), which was not statistically significant.

Fentanyl was found to work quicker then MS, without any difference in side effects or satisfaction with the medications.

• Small sample (< 30)

For many patients, once SOB has started, time to relief can be an important factor in keeping the anxiety factor down. For some, the price of fentanyl outweighs the benefit against morphine as both have tolerated side effects for opiate-tolerant patients.

To study the effect of fentanyl in preventing dyspnea before exertion.

Opiate-tolerant patients were given a six-minute walk test for baseline, then later given fentanyl or a placebo, waited 30 minutes, then repeated the six-minute walk test. Study measures were then taken between the two arms.

• N = 20 
• AGE: Average age = 55 years
• MALES: 40%  
• FEMALES: 60%
• CURRENT TREATMENT: Supportive care
• KEY DISEASE CHARACTERISTICS: 90% had metastatic disease. All had some concurrent scheduled medications for SOB besides opiates; 0% were used to taking 66-130 mg of morphine a day. SOB of 3-7 on a scale of 10 at rest.
• OTHER KEY SAMPLE CHARACTERISTICS: Karnofsky level mean was 71. Average fvc = 2.4 L, and fev1 = 1.7 L.

• SITE: Single site   
• SETTING TYPE: Outpatient    
• LOCATION: Supportive care clinics

• PHASE OF CARE: End-of-life care
• APPLICATIONS: Palliative care

Double blind randomized placebo controlled trial comparing baseline six-minute walk test and then a second six-minute walk test (6MWT) effects of placebo versus single dose of fentanyl buccal tablet 30 minutes prior to second walk.

Dyspnea was measured using a modified BORG scale from 0-10, with 10 indicating the worst score. Vital signs of BP: O₂ saturation, heart rate, respiratory rate taken before and after the six-minute walk test. Distance walked per minute was recorded. Lung function was only done at baseline. Neurocognitive testing was done before medication and after the second six-minute walk.

No difference with either arm seen for distance walked or fatigue, or vital signs other then respiratory rate between the first and second 6MWTs (mean change = 2.6, 95% CI [0.4, 4.7]) with a trend toward greater level of dyspnea relief compared with placebo (estimate = 0.25, p = 0.068).

Buccal fentanyl had a significant effect in reducing dyspnea then placebo after 30 minutes, when patients exerted themselves.

• Small sample (< 30)

Nurses caring for patients with dyspnea recognize the need to provide interventions that minimize dyspnea during daily activities, particularly when dyspnea interferes with ADLs and impacts patients' quality of life. Interventions such as prophylactic FBT may enable patients to participate in activities, regain independence, and improve their quality of life without experiencing adverse events such as dizziness, drowsiness, and nausea.

To determine the effect of fan therapy on dyspnea in patients with terminally ill cancer.

Fan therapy consisted of directing a fan to blow air for five minutes across the region innervated by the second/third trigeminal nerve branches. Control was directing a fan to blow air for five minutes to legs. Intervention delivered after a washout period for opioids.

• N = 40   
• AGE: Average age = 69 years
• MALES: 55%  
• FEMALES: 45%
• CURRENT TREATMENT: Had to be getting no cancer treatment
• KEY DISEASE CHARACTERISTICS: Metastatic or locally advanced cancer, ECOG score of 3 or 4
• OTHER KEY SAMPLE CHARACTERISTICS: Dyspnea while sitting or laying at rest, O₂ saturation of 90% or greater

• SITE: Single site
• SETTING TYPE: Inpatient palliative care unit    
• LOCATION: Hospital in Chiba, Japan

• PHASE OF CARE: End of life
• APPLICATIONS: Palliative care

Randomized controlled trial

ESAS-r (ESAS-revised): used NRS for dyspnea (0-10 scale) (primary measure),  facial temperature, respiratory rate, peripheral O₂ saturation, and heart rate (secondary measures)

Improvement in dyspnea for the treatment arm was seen with mean NRS scores that changed by -1.35 in the treatment arm versus a change of -0.1 in the control arm (p < 0.001) and the number of patients who experienced a greater than one or two-point reduction on their NRS was greater (80%) when compared to the control group (25%). There was also a reduction noted in drowsiness in the treatment group. Significant secondary outcomes included that the mean change in drowsiness on NRS was 0.4 for the treatment group versus -0.45 for control (p = 0.01) and facial temperature was significantly lower after the intervention for the treatment group (reduction of 1.43 degrees C) versus control (reduction of 0.01) (p = 0.003)

The authors conclude that the study presents evidence that fan therapy is effective for the treatment of dyspnea in terminally ill patients with cancer.

• Small sample (< 100)

This study has significant implications for nursing as it provides an intervention for dyspnea that could be wholly within the ability of nurses to deliver and could be taught to families. It is also an intervention with little risk and could offer patients some control.

STUDY PURPOSE: Evaluate the four most commonly used pharmacologic therapy options for the management of breathlessness in patients with advanced cancer and non-cancerous diagnosis

TYPE OF STUDY: Meta-analysis and systematic review

DATABASES USED: Ovid, PubMed, Medline, Cochrane

YEARS INCLUDED: (Overall for all databases) 1950 to 2012

INCLUSION CRITERIA: Randomized controlled trials, controlled clinical trials, and systematic literature reviews and meta-analyses that were published in German or English of patients who experienced continued breathlessness despite treatment for the underlying disease including cancer, COPD, chronic heart failure, ALS, MS, and HIV/AIDS, and received pharmacologic treatment with opioids, benzodiazepines, corticosteroids, or oxygen which the intensity of breathlessness could be measured. 

EXCLUSION CRITERIA: Studies with the use of nebulized or oral steroids as a basic treatment for COPD and studies including oxygen for patients with hypoxic COPD.

TOTAL REFERENCES RETRIEVED: 2,029

EVALUATION METHOD AND COMMENTS ON LITERATURE USED: Database search yielded 2,559 reviews; after review for duplicates, the references were 2,029. Two reviewers independently searched and analyzed the title, abstract, and study for inclusion criteria, which left 65 references. The reviewers then conducted a full-text review, leaving seven references which made up the final inclusion along with eight references from experts. The final number of studies included 5 systematic reviews and 10 randomized controlled trials.

FINAL NUMBER STUDIES INCLUDED: 15

TOTAL PATIENTS INCLUDED IN REVIEW: 2,125

SAMPLE RANGE ACROSS STUDIES: Patients with advanced cancer, cancer, CHF, COPD

KEY SAMPLE CHARACTERISTICS: Included nine studies, one systematic review and eight RCT/CCT, on efficacy of opioids. Two studies, one systematic review, and one RCT/CCT on efficacy of benzodiazepines. Four studies (three systematic reviews and one RCT) on efficacy of oxygen.

PHASE OF CARE: Multiple phases of care     

APPLICATIONS: Elder care, palliative care

Results are categorized in three medication groups and oxygen. No results are available for corticosteroids because there were no studies identified. Two reviews for benzodiazepines were conducted. A systematic review of seven studies, including 200 patients in which 6 of the 7 studies did not show efficacy for the use of benzodiazepines for breathlessness (effect size = -0.32 with 95% CI [-0.89, -0.24]). The second review was a RCT comparing temazepam to placebo with no difference in relief of breathlessness between the two groups. The strongest evidence is from the nine reviews (one systematic literature review and eight RCT) for studies using opioids. Significant efficacy was reported from the systematic literature review of 18 RCT and 293 patients with oral/parenteral morphine (effect size = -0.4 with 95%CI [-0.63, 0.17], p = 0.0006). All eight reviews of RCT were positive, with three showing morphine significantly better than placebo and five showing relief of breathlessness. There were four reviews (three systematic reviews and one RCT) for the efficacy of oxygen identified. The three systematic reviews all compared oxygen to room air. Two did not show significant improvement, however, in one study of 702 non-hypoxemic COPD patients, oxygen showed significant improvement of breathlessness (effect size = -0.37 with 95% CI [-0.5, -0.24]). The RCT compared oxygen to room air in 239 patients. Breathlessness was improved in both the morning and evening by 0.9 and 0.7 points, however, there was no significant difference between the two groups.

The review emphasizes the treatment of breathlessness is still a challenge with evidence varying and partly limited. However, opioids are recommended as a first choice for the treatment of breathlessness for patients with cancerous and non-cancerous advanced diseases. Benzodiazepines are recommended as a second choice for the co-existing management of panic symptoms, anxiety, and breathlessness. Oxygen is not proven to be effective in the non-hypoxic patient with cancer and the use of hand-held fans should be offered.

• Limited search
• Limited number of studies included
• The search strategy was not specific, including only studies written in English or German, excluding studies in other languages. Studies with uncontrolled study designs were also excluded.

Findings show that only opioids offer benefit to patients experiencing breathlessness and should be considered as first-line therapy. However, there are several other nursing implications provided by this review. A smaller dose of opioid is effective in relieving breathlessness and, whenever possible, should be started low and go slow. The fear of respiratory depression with the use of opioids is not warranted based on results of several studies. This finding should be communicated to nurses with education provided to patients and families. Although benzodiazepines are commonly used for breathlessness, efficacy has not been established. However, nurses must recognize the benefit of reducing anxiety and possibly allowing for lower doses of opioids. Lastly, the use of hand-held fans producing an air stream across the patient’s midface and over the nasal mucosa is an intervention nurses may easily use to reduce breathlessness.

To evaluate the effects of auricular acupressure on dyspnea intensity, distress, and oxygen saturation in patients with lung cancer with advanced disease.

Patients were randomly assigned to one of three groups: either standard of care, standard of care with auricular acupressure appropriately placed, or standard of care with placebo placement of auricular acupressure (placed on alternate site on ear not associated with lung function). Acupressure was applied with vaccaria segetalis seed taped to portion of ear associated with lung function, according to traditional Chinese medicine by a licensed accupuncturist. Data was collected twice per day for all participants, each time oxygen saturation was measured with pulse oximeter and the participants completed the Cancer Dyspnea Scale tool. Baseline data was collected on day 1, treatment intervention began on day 2, and data was collected on days 2, 3, and 4.

• N = 11   
• AGE: Adults, specific age not stated
• MALES (%): Unknown  
• FEMALES (%): Unknown
• CURRENT TREATMENT: Not applicable
• KEY DISEASE CHARACTERISTICS: Diagnosis of lung cancer, 36% inpatient and 64% outpatient hospice/palliative care center

• SITE: Single site   
• SETTING TYPE: Multiple settings    
• LOCATION: Southern California

• PHASE OF CARE: End-of-life care
• APPLICATIONS:  Elder care, palliative care

Randomized controlled trial; participants randomly assigned to three conditions

Cancer Dyspnea Scale, 12-items assessing three dimensions of dyspnea: effort, anxiety, and discomfort using a five-point Likert-type scale. Level of oxygen saturation was measured via pulse oximeter.

Statistical analysis were used as basis for planning for future research design as true analysis was limited by small sample size. No significant relationship was identified for oxygen saturation between the three groups, statistical analysis suggests that the treatment arm had an effect on the measure of dyspnea effort. Data were also analyzed using non-parametric statistic Friedman two-way ANOVA by ranks; running test once for each of the three groups. The only condition that resulted in statistically significant change over time was the auricular acupressure experimental group (chi-squared = 7 and p = 0.43).

Experiment was conducted as a feasibility study showing that the intervention was well-tolerated, with low subject burden and, therefore, auricular acupressure seems to be a feasible intervention with no negative impact. Since subscale of dyspnea effort showed significant change, larger studies are indicated to validate usefulness of intervention to positively affect symptom of dyspnea in end-stage patients with lung cancer.

• Small sample (< 30)
• Findings not generalizable
• Other limitations/explanation: Feasibility study

Use of auricular acupressure to mitigate sensation of dyspnea in patients with advanced lung cancer needs to be studied further with appropriately sized patient populations to accurately measure effect. Use of auricular acupressure did not appear to have negative effects for this small sample size.