Oxygen for end-of-life lung cancer care: managing dyspnea and hypoxemia

Abstract

Oxygen is commonly prescribed for lung cancer patients with advancing disease. Indications include hypoxemia and dyspnea. Reversal of hypoxemia in some cases will alleviate dyspnea. Oxygen is sometimes prescribed for non-hypoxemic patients to relieve dyspnea. While some patients may derive symptomatic benefit, recent studies demonstrate that compressed room air is just as effective. This raises the question as to whether to continue their oxygen. The most efficacious treatment for dyspnea is pharmacotherapy–particularly opioids. Adjunctive therapies include pursed lips breathing and a fan blowing toward the patient. Some patients may come to require high-flow oxygen. High-flow delivery devices include masks, high-flow nasal oxygen and reservoir cannulas. Each device has advantages and drawbacks. Eventually, it may be impossible or impractical to maintain a SpO₂ > 90%. The overall goal in these patients is comfort rather than a target SpO₂. It may eventually be advisable to remove continuous oximetry and transition focus to pharmacological management to achieve patient comfort.

Keywords::

• adjunctive therapy
• benzodiazepines
• dyspnea
• high-flow oxygen
• lung cancer
• opioids
• oxygen
• pharmacotherapy

Financial & competing interests disclosure

B Tiep is the inventor of several oxygen delivery devices and receives royalties for some of them through CHAD Therapeutics Inc., division of Inovo, which is a division of Drive Medical Inc. He is a consultant for CHAD Therapeutics and Nonin Medical Inc. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

No writing assistance was utilized in the production of this manuscript.

Key issues

• • Overall goal of care at the end of life is comfort. Control of dyspnea and pain are important components.

• • The indications for oxygen therapy for advanced lung cancer patients are to prevent hypoxemia and relieve dyspnea.

• • Oxygen therapy for the hypoxemic patient will often but not always alleviate dyspnea.

• • Oxygen therapy for the dyspneic non-hypoxemic patient is no more effective than compressed room air in relieving dyspnea.

• • Non-hypoxemic patients who gain symptomatic relief from oxygen should continue on it as a transition to pharmacotherapy.

• • The cornerstone basic treatment for dyspnea is pharmacotherapy – particularly opioids.

• • There are adjunctive therapies available for dyspnea management that include pursed lips breathing and fan blowing air toward the patient.

• • Patients who require high flow oxygen have several systems and delivery devices open to them including non-rebreather masks, high-flow nasal oxygen and reservoir cannulas.

• • In some patients, there is a point beyond which it is not possible or practical to reach target oxygen saturation. For those patients it is advisable to rely more heavily on pharmacological management.

• • Continuous monitoring of pulse oximetry at the end of life can be disquieting and counterproductive. It should not be the focus of attention for the patient or family.

Notes