How to manage breathlessness in a patient with laryngeal (larynx) cancer?

Management of Breathlessness in Laryngeal Cancer

For patients with laryngeal cancer experiencing breathlessness, immediately assess for airway obstruction and treat reversible causes, then use a combination of interventional procedures for mechanical obstruction and opioids for symptomatic dyspnea relief.

Immediate Assessment and Airway Management

Evaluate the airway urgently to determine if breathlessness is due to mechanical obstruction from the tumor itself, which requires immediate intervention to prevent life-threatening airway compromise. 1

For Symptomatic Central Airway Obstruction:

• Therapeutic bronchoscopy with mechanical debridement, tumor ablation, or airway stent placement should be performed for patients with symptomatic central airway obstruction, as these interventions improve symptoms and quality of life 1

• If time permits and adequate surgical instrumentation is available, debulk the obstructing laryngeal tumor using CO2 laser or cold-steel techniques to stabilize the emergency situation and convert to elective definitive treatment without requiring tracheostomy 2

• Palliative external beam radiotherapy (EBRT) alleviates thoracic symptoms in patients not candidates for curative therapy, with higher dose regimens (≥30 Gy/10 fractions) providing modest survival improvements in good performance status patients 1

• For poor performance status or extensive disease burden, use shorter fractionation schedules (20 Gy in 5 fractions, 17 Gy in 2 weekly fractions, or 10 Gy in 1 fraction) 1

Comprehensive Evaluation of Treatable Causes

A prompt and comprehensive evaluation must address all potentially reversible causes of dyspnea, including COPD, cardiac disease, pleural disease, hematologic conditions, nutritional deficits, and neuromuscular conditions, as breathlessness significantly worsens quality of life and impedes cancer treatment 1

The cause of breathlessness in advanced cancer is usually multifactorial, requiring assessment of both tumor-related and non-tumor factors 3

Pharmacological Management of Dyspnea

Opioids as First-Line Treatment:

Opioids are the only pharmacological agents with sufficient evidence for dyspnea palliation and should be the primary symptomatic treatment. 4, 5

• For opioid-naïve patients, start with morphine 2.5-5 mg PO every 4 hours or 1-2.5 mg subcutaneously every 4 hours 4

• Alternative dosing: 2.5-10 mg PO every 2-4 hours as needed for breakthrough dyspnea 5

• For patients already on chronic opioids, increase the dose by 25% for breakthrough dyspnea 5

• Avoid morphine in severe renal insufficiency and adjust dosing intervals based on renal function 5

Adjunctive Medications:

• Use benzodiazepines (such as lorazepam) when opioids provide insufficient relief, particularly for anxiety associated with breathlessness 5

• For refractory dyspnea in dying patients, consider terminal sedation with benzodiazepines in addition to opioids 5

Non-Pharmacological Interventions

Non-pharmacological approaches are currently the most effective for the greatest number of patients and should be implemented alongside pharmacological management. 3

Immediate Comfort Measures:

• Direct cool air at the patient's face using a hand-held fan 1, 4, 5

• Position the patient in a coachman's seat or with upper body elevated 4, 5

• Ensure cooler room temperature and open windows 4, 5

• Provide supplemental oxygen only if the patient is hypoxemic or reports subjective relief 5

Rehabilitation Approaches:

• Implement pulmonary rehabilitation and exercise training programs to decrease dyspnea intensity 5

• Use walking aids or frames to reduce respiratory muscle demand 5

• Teach respiratory training and breathing techniques, including use of a poem as a mantra to help breathing and relaxation during crises 1, 5

• Provide home physical therapy visits to teach energy conservation techniques 1

Palliative Care Integration

Early palliative care consultation should be integrated for symptom management, as this approach improves quality of life and breathlessness control. 1

• A palliative care intervention including team assessment, physical therapy, and breathing techniques reduced breathlessness by 1.29 points (scale 0-10) in advanced cancer patients 1

• 68% of participants reported significant impact from breathlessness support services 1

• Consider specialized breathlessness services as innovative and effective models of care when provided as part of a network of services 3

Advanced Interventions for Severe Cases

• Consider noninvasive positive-pressure ventilation (CPAP, BiPAP) for severe reversible conditions 5

• Palliative care consultation is recommended for patients with limited life expectancy and refractory symptoms 5

Critical Pitfalls to Avoid

• Do not delay airway intervention in patients with imminent obstruction - mechanical relief takes priority over medical management 2

• Do not rely solely on oxygen therapy - it should only be used for documented hypoxemia or subjective benefit, not routinely for all dyspneic patients 5

• Do not undertreat dyspnea due to opioid concerns - opioids are evidence-based first-line therapy and should be titrated to effect 4, 5

• Proximal airway obstruction is more amenable to endobronchial interventions, while distal obstruction (lobar or segmental bronchi) responds better to radiotherapy approaches 1