.
True treatment points were chosen on the basis of
traditionally used points for breathlessness. Placebo
points were allocated in body areas away from true
acupressure points. Following the single acupuncture
session, participants were requested to apply pressure
to semipermanent acupressure studs by making small
circular movements with fingers – the study protocol
recommended 2 or 3 cycles per second for 1 or 2 min
per point. The subjective sensation of breathlessness
was assessed with a NRS (0–10) imme- diately before
and after acupuncture treatment and daily for a week
thereafter. In this study, 47 partici- pants were
randomized and 45 provided follow-up data.
Participants in the acupuncture/acupressure and control
group improved, but there were no differences between
the groups at 7 days.
In the second acupuncture study, 20 patients whose
breathlessness was directly related to primary or sec-
ondary malignancy underwent a single acupuncture
session using sternal and L14 acupressure points. 32
Breathlessness and anxiety were rated by patients
using pre and post VADS (- 10) treatment. There was a
significant improvement in VAS scores for breath-
lessness and anxiety at least up to 6-h postacupunc-
ture, which were maximal at 90 min. A reduction in
respiratory rate was also reported, which was sus-
tained for 90 min postacupuncture.
Cough
There was no study identified that reported cough as
the primary outcome measure. Only one study reported
a specific cough outcome. In an RCT, Moore et al. 35
applied the EORTC-LC13 which41 includes one item
that refers to the frequency of cough in the past week.
Responses for this single item were reported 3, 6 and
12 months following either nurse- led follow-up or
conventional medical follow-up. There was no
significant improvement in the single cough item in the
nurse-led follow-up group com- pared to conventional
group at any of the three post- randomisation follow-
up points.
Haemoptysis
There was no study identified that reported haemopty-
sis as the primary outcome measure. As with cough,
Moore et al.35 provided the only measure of haemop-
tysis. The EORTC-L13 contains41 one item that
assesses how often participants coughed up blood in
the past week. In that study, the scores for haemopty-
sis at each data collection point were zero.
There was no study that identified the reported
outcome measures for less common respiratory
symp- toms in lung cancer, such as wheeze and
hoarseness.
Trials with combined/overall symptom
scores
Four studies applied an instrument that assessed a
range of symptoms and associated distress and
reported total scores only, that is, no specific symp-
tom either measured by a single item or subscale
was provided.34,36–38 In this section, we present
these stud- ies because each of the instruments
used contain at least one item that represents the
experience of breath- lessness, cough, or
haemoptysis. None of these instru- ments record
experience of less common respiratory symptoms
of hoarseness and wheeze.
The SDS25 was used in an RCT to test the effects
of three home care treatment regimens on the
psycholo- gical well-being of patients with lung
cancer.34 The three treatment groups included
standard home care; specialised oncology home
care; and an office care group who received
standard care by the physician. The specialised
oncology intervention was delivered by specialised
cancer nurses. The SDS measures the patients'
perceived level of distress in response to 13
symptoms, including breathlessness, cough and
hae- moptysis.25 A total of 166 patients were
randomised and 78 completed 4 interview points
and were included in the final analysis at 12 weeks.
There was a significant improvement in symptom
distress in the two nursing home programmes
compared to the office care group.
Sarna37 tested the effectiveness of structured nur-
sing assessment of symptom distress in patients
with advanced lung cancer compared to usual care.
Both groups (N 48) completed the SDS25 every
month for a 6-month period. In a multivariate
model, che- motherapy and systematic nursing
assessment were associated with less symptom
distress over time. Skrutkowski et al. 38 conducted
an RCT to test the impact of a 'pivot' nurse in
oncology on symptom dis- tress experienced by
patients with lung cancer (n 113) or breast cancer
(n 77). The intervention consisted of an
experienced palliative care nurse who had received
additional training in symptom manage- ment. The
pivot nurse conducted an in-depth assess- ment of
the patient's symptom burden, family and support
situation, provided training for symptom
management, additional support and initiated
follow-up telephone calls. No significant difference
in SDS scores between the two groups was found.
 The efficacy of a caregiver-assisted coping skills
training was tested in an RCT involving 233 patients
with lung cancer and their caregivers. 36 Two condi-
tions were tested in this study: caregiver-assisted
cop- ing skills training and an education/support
condition. The caregiver training condition included
training on symptom management where the
caregiver's role was described as that of a 'coach,'
with the goal of helping the patient learn and apply
coping skills. The second condition included the
provision of information regarding lung cancer and
its treatment. Both patients and caregivers were
involved in session for both condi- tions. The FACT-
LC13 was used to assess symptoms 40 from the
patients' perspective. The FACT-LC13 con- sists of
items assessing shortness of breath and cough- ing.
Patients in both treatment conditions showed
improvements in the FACT-LC13 scores.
Exploratory analyses suggested that the caregiving-
coping inter- vention was more beneficial to patients
with stage II and III cancers/caregivers, whereas the
education/ support intervention was more beneficial
to patients with stage I cancer/caregivers.
Discussion
This review of the effectiveness of
nonpharmacologi- cal interventions for improving
the experience of respiratory symptoms in patients
with lung cancer found that interventions have
largely focused on breathlessness and reflect a broad
range of strategies. Given the multitude of
respiratory symptoms patients with lung cancer can
experience, alleviating symp- tom burden often
requires several treatment modal- ities. Thirteen
studies were included in this review although only
one of these assessed cough and hae- moptysis as
distinct symptoms.
Measurement issues
Breathlessness is the most commonly reported
respiratory symptom in patients with lung cancer. 7
There is no gold standard measure currently
available that has been validated to capture this
multifaceted construct.44 In this review, the VAS and
NRS were mostly used to measure breathlessness. It
has been suggested that, in the absence of a gold
standard all-encompassing measure for
breathlessness, these unidimensional, single-item
scales be used for the assessment of breathlessness
in palliative care44 and advanced disease. 10 There are
limitations to their use. Both VAS and NRS scales
have two anchors that are unique to each individual,
making comparison
between people difficult.10,45 There are no apparent
standard principles to regulate their consistent use:
they have been adapted to measure different aspects
of breathlessness, such as 'uncomfortable breathing,'
'severity of breathlessness,' 'intensity of breathless-
ness,' 'best,' 'worst,' 'average' and so on as well as
difference in scaling ranges (eg 0–10 or 0–100), and
different recall period (eg now, today, or past 24-
hours). This makes comparisons between studies
problematic. In our review, it was not possible to
combine the results from individual studies in any
meaningful way to obtain an overall effect size for
studies that evaluated similar interventions and
included a VAS or NRS for breathlessness
assessment. Because breathlessness is highly
correlated with anxi- ety and distress, some authors
applied a VAS to capture 'distress' associated with
breathlessness.27,28,30–33 Studies that reported
breathlessness as a single item extracted from of a list
of symptoms (eg SDS25) are also limited to the
quantification of symptom fre- quency and intensity
only.
There is evidence that breathless patients use a
variety of descriptors to describe the experience of
breathlessness and that these descriptors represent
sensory quality and affective dimensions of breath-
lessness. In this review, no study included a unified
measure of breathlessness that reflects its
multidimen- sionality. The Dyspnoea-12 is a recently
developed instrument46 that captures the sensory
quality 'physi- cal' and emotional dimensions of
breathlessness. It consists of 12 items, each ranging
from 0 'none' to 3 'severe', 7 items measure the
patient's physical per- ceptions of breathlessness and
5 items measure affect. It has been reported as a valid
and reliable measure of breathlessness in patients
with cardiac46 and respira- tory conditions, 47–49 but it
is yet to be validated for use in lung cancer.
In this review, no study included a specific instru-
ment to measure cough, haemoptysis and other less
common respiratory symptoms. Since cough is fre-
quently reported in the lung cancer population, 7 its
inclusion as a specific outcome measure in studies
designed to assist patients to better cope with distres-
sing symptomology warrants greater attention.
Recently, a cough scale has been developed for use
with lung cancer patients and could be used as an
out- come for such trials, focusing on cough. 50 Given
the broad range of strategies applied in the
interventions included in this review, it is likely that
any resilience and coping mechanisms adopted by
study participants are likely to influence patients'
perceptions of the
burden of multiple symptoms and not just breathless-
ness. One study35 did report a separate score for cough
and haemoptysis extracted40 from the EORTC-LC13.
This practice is not ideal because the instrument was
not designed to provide individual symptom scores but
a combined score for the lung cancer module. Other
studies reported total scores that incorporate a variety
of symptoms including the SDS25 and Rotter- dam
Symptom Checklist.26 Such lists are useful for
providing overall scores of symptom burden, although
it is difficult to discern the full experience and impact
of prominent symptomatology, notably breathlessness
and cough, with such lists.
Studies involving patients with lung cancer suffer
from high attrition. Limiting participant research bur-
den plays a key role in successful study recruitment
and retention. Introducing a battery of questionnaires
for every possible symptom, both respiratory and oth-
erwise, is not a viable option. This presents a chal-
lenge for lung cancer researchers to strike a balance
between adequately capturing patient-related out-
comes and patient burden. The choice of the most
appropriate symptoms to include as specific study
outcomes and the instruments used to capture these
depend on the focus on the intervention and desired
outcomes. It would appear that at the least, breathless-
ness and cough warrant inclusion as specific outcome
measures, but it is equally important that the multidi-
mensionality of these symptoms is captured. It is likely
that the broad range of strategies used in the
interventions included in this review will have great-
est impact on affect and ability to cope with distres-
sing symptoms rather than severity only. As noted by
Bausewein et al.,10 studies to date have largely focused
on the management of symptoms rather their
assessment. To gauge the benefits of interventions that
require significant health care resources and com-
mitment from patients and their families, measure-
ment tools that reflect the experience of symptoms in
lung cancer, and are sensitive enough to detect change
in response to interventions need to be applied.
Interventions
The interventions evaluated in this review covered a
broad range of strategies. The variability and incon-
sistent use of interventions for respiratory symptoms
are also evident in clinical practice, as shown in a UK
survey of respiratory management practices. 51 Since
the focus of this review was to evaluate
nonpharmacological interventions for respiratory
symptoms in lung cancer, we categorised studies
according to symptoms: breathlessness, cough and
haemoptysis. As evidenced in this review, to date
breathlessness has been the area of focus for
research in the area of nonpharmacological
interventions. We elected to further categorise
these studies according to the mode of delivery.
The majority of these studies included a
multimodal intervention that was delivered by
nurses.28,29,31,35 Taking account of sample size,
dropout rate, outcome measures and repeatability
of interventions, feasible interventions emerge
from a few nurse-led therapies.28,29,35 The
interventions evaluated in these three studies had
some common foundations including a focus on
breathlessness man- agement, psychological
support and an element of patient education.
However, key difference also exists in relation to
the extent that interventions were tai- lored to the
needs of individual patients, context of comparison
groups and functional state of patients at
recruitment. Additionally, Bredin et al.28 and Chan
et al.29 measured breathlessness on a VAS but used
different anchor descriptors and different scaling
ranges, and Moore et al. extracted single scores for
breathlessness, cough and haemoptysis from items
located on the FACT-LC.42 Based on these results,
no definitive conclusion for the effect of nurse-led
multimodal interventions could be made.
Two studies reflected the interventions led by
phy- siotherapist but these were nonrandomised. 30,33
Simi- lar to the nurse-led studies, these
interventions included a broad range of strategies.
It is not possible to draw any firm conclusions from
these studies due to the weak methodological
approaches used, the small sample size included in
Hately et al.33 study, and the remarkably high
dropout rate experienced by Connors et al. 30 where
160 patients were recruited at baseline yet only 14
completed the programme. Explanations for the
high dropout rate are provided by the authors,
including broad inclusion criteria and subsequent
fragi- lity of participants and many were receiving
cancer treatments. This study is important because
it high- lights important considerations when
developing study protocols for interventional
studies including patients with lung cancer. The
nonstatistical result drawn from these studies is
likely to reflect inherent methodologi- cal flaws as
opposed to the mechanism of intervention delivery
by physiotherapists.
Complementary and alternative medicine use
has become increasingly popular throughout the
Western world, as patients seek supplemental
strategies to
medical care.52 We located two small studies that
evaluated the effect of acupuncture in a nonrando-
mised study32 and a single acupuncture session fol-
lowed by acupressure in an RCT. 39 Although Filshie
et al.32 describe a significant within-group improve-
ment in breathlessness up to 6 h postintervention, the
lack of a control group limits the applicability of the
results. Vickers et al.39 found no difference in
reported breathlessness between acupuncture and
pla- cebo groups. The timing of assessment was also
dif- ferent in the two approaches described, and it
may be that acupuncture has only short-lived effects.
In the context of management of respiratory
symptoms for people with lung cancer, no
recommendations for acupuncture can be made.
To our surprise, only one study,35 a nurse-led mul-
timodal intervention, assessed cough and haemopty-
sis. No difference in cough experience was found
between the intervention and control groups. Hae-
moptysis was the single symptom in that study,
which no patients reported and the pre- and
postintervention scores were zero. It is difficult to
gauge the true mean- ing of these results since the
symptoms were assessed as part of the EORTC 41
instrument.
Due to the lack of studies that included specific
respiratory symptoms, we elected to review studies
that only included a total score from symptom lists.
Three studies measured symptoms on the SDS to
eval- uate the efficacy of a nurse-led
intervention.34,37,38 Although the same outcome
measure was used in these studies, the intervention
strategies and comparison groups were varied.
Positive results were reported in two of these
studies,34,37 but it was not possible to com- bine
studies due to the differences between the studies.
The FACT-LC41 was used to assess the effect of pro-
viding caregivers of people with lung cancer specific
training in coping skills. The positive outcomes
reported for the caregiver-assisted coping skills
train- ing group provide promise for the involvement
of care- givers in nonpharmacological interventions.
Because these studies did not include any outcome
measures for single symptoms, it is not possible to
assess the relative effect of these interventions.
Conclusions
Lung cancer carries significant mortality and
morbid- ity. Management of distressing respiratory
symptoms is complex. There is a need to provide
patients with viable options to help them better cope
with lung cancer symptomatology. The evidence
related to
nonpharmacological interventions to help address
this need has been reviewed in this article. The
majority of studies refer to breathlessness or a list of
multiple symptoms. The interventions included in
this review mostly included a broad range of
strategies. Based on these facts, it is not possible to
draw any firm con- clusion as to the effectiveness of
nonpharmacological interventions for the
management of respiratory symptoms in lung cancer.
Nonpharmacological inter- ventions may well have
an important role to play in the management of some
of the respiratory symptoms (or combinations of
respiratory symptoms), but more work of higher
quality is necessary in the future.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
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