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Dyspnea and Coughing in Patients With Advanced Cancer

    Introduction

    Dyspnea is defined as an uncomfortable awareness of breathing. It is a subjective experience involving many factors that modulate the quality and intensity of its perception. Patients with comparable degrees of functional lung impairment and disease burden may describe varying intensities of dyspnea. Patients use a host of different words and phrases to describe the sensation of breathlessness. Terms such as tightness and suffocating are sometimes used.[1]

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    Reports on the frequency of dyspnea also vary, depending on the setting and the extent of disease.[2] In one study, 49% of a general cancer population reported breathlessness, and 20% rated their breathlessness as moderate to severe.[3] Patients with advanced cancer experience this symptom more frequently and more intensely than do patients with limited disease. One study found that 75 of 135 patients with advanced cancer reporting to an outpatient palliative care clinic were experiencing moderate-to-severe dyspnea.[4] Breathlessness was a complaint at presentation in 60% of 289 patients with lung cancer.[5] Results of a large study showed that 70% of patients suffered from dyspnea in the last 6 weeks of life.[6] About one third of patients who could report the intensity of their dyspnea rated it as moderate to severe. Another study revealed that half of patients with advanced cancer scored their dyspnea as moderate to severe.[7]

    Etiology

    The pathophysiological mechanisms of breathlessness are numerous and complex.[8] Peripheral and central mechanisms as well as mechanical and chemical pathways are involved.

    The direct causes of dyspnea in patients with advanced cancer are numerous; categorizing them can assist in the etiologic work-up. One approach is to divide direct causes into the following four groups:

    1. Direct tumor effects such as intrinsic or extrinsic airway obstruction, pleural involvement, parenchymal involvement either by primary or metastatic disease, superior vena cava syndrome, lymphangitic carcinomatosis, and pericardial effusion.
    2. Indirect tumor effects such as pneumonia, a pulmonary embolus, paralysis of a hemidiaphragm, or weakening of the respiratory muscles from sarcopenia.
    3. Treatment-related causes such as pulmonary fibrosis secondary to radiation therapy or chemotherapy or chemotherapy-induced cardiomyopathy.
    4. Causes unrelated to the cancer. These include chronic obstructive airway disease, congestive heart failure, anemia, certain acidotic states, and bronchospasm.
    5. Functional causes (e.g., anxiety).
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