Online version of table
Mechanism of dyspnea
Increased ventilatory
demand
Respiratory muscle
weakness/abnormalities
there is an imbalance
between the force which the
body requires to be
generated by the muscle
and its capacity to do this,
the difference between the
central command given and
the force generated is
perceived as dyspnoea.
NB In all conditions
associated with resp muscle
weakness it may be
appropriate on occasion to
use non-invasive ventilation.
Causes in cancer patient
Infection/pneumonia
Co-morbid conditions assoc.
with increased dead space e.g.
pulmonary vascular disease,
COPD
De-conditioning (lack of
exercise)
Anemia
Cachexia possibly leading to
breathlessness by an unknown
mechanism
Co-morbidities assoc with resp
muscle weakness e.g.
myasthenia gravis
Resp muscle syndromes assoc
with cancer e.g. Lambert Eaton
syndrome
COPD assoc with lung (&
therefore thoracic)
hyperinflation leading to
inefficiency of resp. muscles.
Specific management
Antibiotics and other
standard therapies when
appropriate
Optimize medical
management of pre-
existing/co-incident
conditions.
Rehabilitation, see text
EPO, blood transfusion
where appropriate
Prevention of cachexia,
activity plus possibly some
dietary supplements
Optimal treatment of all co-
morbid conditions
Treatment of underlying
disease most effective
treatment
Optimal treatment &
palliation of COPD
Abnormal ventilatory
impedance leading to an
increased work of breathing
from e.g. airway narrowing
or increased stiffness of the
lung parenchyma the level
of central motor command
signal needed to generate
the necessary ventilation is
increased when the effort
expended in breathing is
not matched by resulting
ventilation, dyspnoea
results.
Abnormal breathing
patterns common with
conditions affecting the lung
parenchyma (see previous
section) possibly mediated
via stimulation of pulmonary
vagal receptors.
Blood gas abnormalities
there is no direct
relationship with degree of
dyspnea, some hypoxic
patients are not dyspneic
and vice versa.
Hypercapnia and hypoxia
appear to be dyspnogenic
Lymphangitis carcinomatosis
Tumor obstructing an airway,
pleural effusions, pleural
disease e.g. mesothelioma,
Fibrosis following pulmonary
emboli, radiotherapy,
chemotherapy (e.g. bleomycin).
Conditions affecting the
compliance of the chest
wall/diaphragm e.g.
Hepatomegaly/ascites
splinting diaphragm
pleural disease e.g.
mesothelioma
chest wall infiltration by
tumour
Co morbid conditions e.g.
asthma, COPD, interstitial lung
disease
Lymphangitis carcinomatosis
Pulmonary congestion e.g.
from SVCO, heart failure,
Pulmonary emboli (PEs),
pericardial effusion.
Hypoxia is a consequence of
many conditions associated
with cancer including
PEs
Pleural effusions
Lymphangitis
carcinomatosis
Treatment of cancer, often
palliative care mainstay,
although trial of high-dose
steroids (60mg
prednisolone then taper,
often used)
Standard
oncological/surgical
treatment according to
patients condition e.g. RT
&/or stenting etc
Prevention of fibrosis where
possible by early standard
intervention in these
conditions (e.g.
anticoagulation or steroids)
or prevention by
surveillance during cancer
therapy & careful control of
chemo-radiation dosage
Treat as appropriate
Ensure optimum treatment
of co-existing conditions
Treat underlying condition
& palliation
Standard therapy for
underlying cancer or
treatment of complication of
cancer, prevention where
possible (e.g. LMWH in
high risk patients)
Assess contribution of
hypoxia to breathlessness
in that individual and treat
conditions as appropriate
 in their own right but to Diaphragmatic splinting
varying degrees in different e.g. ascites or
individuals. hepatomegaly
infections
CNS activation through Some anxieties associated with Anxiety management using
emotional response dyspneic episodes the following alone or in
(limbic system), fear reminding patient they combination.
(amygdala) and higher have cancer and are non-
cortical experience very ill, pharmacological
(cognitions and previous anxiety of dying anxiety
experience) gasping for breath management
fear/anxiety provoked strategies (see
by idea that text)
breathlessness is in pharmacological
itself harmful management of
fear/anxiety provoked fear and anxiety by
by idea that phenothiazines,
breathlessness at butyrophenones, or
some point may be benzodiazepines
uncontrollable cognitive
fear/anxiety provoked approaches such
by the feeling of being as cognitive
breathless behavioral therapy
memory of relative (CBT) or education
dying with unrelieved availability of
breathlessness clinicians skilled in
the management of
the symptom
24
Based on ATS consensus statement and references3,8,28,32,44,a

a
Ripamonti C (1999) Management of dyspnea in advanced cancer patients. Support
Care Cancer 7: 233243