Respiratory and Cardiac Problems
Dyspnea (difficulty breathing) | Cough | Hemoptysis (blood in sputum) | Cardiac problems of cancer (update 1/16/2005)
Respiratory problems are very common in patients with cancer, especially those with lung cancer and metastasis to the lungs; but may also occur in other patients with advanced cancer, even without evidence of lung involvement. Respiratory problems are common in AIDS and are most frequently related to pneumocystis carinii pneumonia, mycobacterium infections, histoplasmosis, and coccidiomycosis. Difficulty breathing (dyspnea) is the most common respiratory problem of terminal illness. Other problems include cough and blood in the sputum (hemoptysis). Except for preexisting conditions, cardiovascular problems are less common in cancer or AIDS. The most common cardiac problems in cancer are fluid around the heart (pericardial effusion) and compression of the heart (cardiac tamponade) - both of which lead to dyspnea.
Dyspnea (breathlessness, difficulty breathing) is the most common and troublesome respiratory problem of patients with advanced cancer; and is also common in AIDS as well as degenerative neurological diseases. Assessment of dyspnea is based on the patient's report. A visual analogue scale (VAS), with measures of 1-10 with 10 being worst or verbal categoric scale, with measures of none, mild, moderate, or severe are commonly used. Objective measurements such as respiratory rate, oxygen saturation, and arterial blood gases do not measure dyspnea.
| Anxiety and dyspnea exacerbate one another in a "vicious cycle," so that assessment and treatment of dyspnea should also include assessment and treatment of anxiety. |
Dyspnea may occur on exertion or at rest, and is influenced by factors such as exercise, posture, cough, and environmental conditions, especially temperature and humidity.
There are a number of causes of dyspnea. The more common causes and identifying characteristics of dyspnea in patients with cancer are shown below. While this information is specific to cancer, several of the causes are also common in patients with other diagnoses, especially pneumonia. Many causes of dyspnea are treatable and, when possible, it is important to determine the specific etiology of dyspnea in the patient so that the cause rather than only the symptom is addressed. Causes and characteristics of dyspnea in patients with cancer include:
Obstruction of oxygen flow from primary or secondary tumor or enlarged lymph nodes: Progressive or rapidly increasing dyspnea, blood in sputum, noisy breathing, chronic cough, choking, and/or pneumonia:
Pleural effusion is fluid in the intrapleural spaces or sacks covering the lungs: Dyspnea with occasionally trachea displacement toward unaffected side. Breath sounds vary according to area of lung. Pleural effusions are most common with lung or breast cancer and also lymphoma or leukemia.
Pneumonia is common; risk factors include debility, immobility, and/or ineffective - especially shallow - breathing: Dyspnea with elevated temperature, purulent sputum (but not always present), decreased breath sounds. There may also be pleural effusion present:
Pulmonary thromboemboli are often related to debility and immobility. Sudden onset of dyspnea with rapid breathing, rapid heart rate, cough, chest pain, and blood in sputum. Among the tumors associated with emboli are leukemia, prostate, breast, and colon..
Pericardial effusions (fluid around the heart) may precede the cardiac emergency of cardiac tamponade (fluid compression of the heart): Dyspnea with cough, chest pain, need to keep head elevated to breathe, and weakness. There may be pleural effusion, edema, distention of neck veins, rapid heart rate and rapid breathing rate. Pericardial effusions are often associated with primary lung tumors or breast cancer; and also lymphoma, leukemia, and metastatic melanoma.
Ascites is the accumulation of fluid (from the liver) in the abdomen, with the fluid eventually causing pressure on the lungs: Dyspnea with abdominal distention (from fluid) and tenderness, general discomfort, need to keep head elevated to breath, rapid breathing rate, and pleural effusion. There may be GI symptoms such as early satiation, indigestion, and other GI problems. Ascites is often related to tumors in ovaries, endometrium, breast, colon, stomach, pancreas, and colon.
Anemia is caused by decreased or dysfunctional red blood cells and thus decreased ability to carry oxygen: Dyspnea with general fatigue, weakness, rapid heart rate, and headache: Anemia is often related to tumors in the liver and colon, leukemia, multiple myeloma; also secondary to chemotherapy. Erythropoietic agents are effective in the management of anemia and concurrent dyspnea.
Atelectasis (collapsed lung): Dyspnea with rapid respiratory rate (tachypnea), decreased chest wall movement unilaterally, deviation of apical impulse and trachea, varying breath sounds, but decreased sounds on affected side.
Superior vena cava syndrome (SVCS) is caused by obstruction of the superior vena cava (the second largest vein in the body): Dyspnea with engorged neck veins, facial swelling, changes in consciousness, cough, hoarseness, and noisy breathing. SVCS is an oncology emergency most often associated with mediastinal (chest) tumors, including lymphomas.
Other cardiac conditions also result in dyspnea: Chest pain, weakness, fatigue, and edema are common accompanying symptoms.
Respiratory muscle weakness: Dyspnea with general weakness, anorexia, severe weight loss (cachexia), and/or the presence of a paraneoplastic syndrome. Respiratory muscle weakness is often associated with paraneoplastic syndromes, anorexia, and/or cachexia.
Lymphangitis carcinomatosis is the infiltration of pulmonary lymph by tumors. Symptoms are similar to emphysema and the dyspnea is unexplained by other causes.
Loss of function can result from many processes in advanced disease: Dyspnea from far advanced disease, including pleural effusion, progressing to cardiac tamponade, pulmonary edema from cardiac failure, lymphangitis carcinomatosis, paralysis, and/or pneumonia:
Bronchiolitis obliterans occurs when sputum is not coughed up and accumulates in the bronchioles (small bronchi): Dyspnea unexplained by other causes; history of bone marrow transplant: (may occur six weeks to two years after treatment).
Preexisting conditions: Dyspnea associated with chronic bronchitis, emphysema, asthma, tuberculosis, or a neuromuscular disorder.
Treatment sequelae such as radiation fibrosis: Dyspnea associated with radiation or chemotherapy.
In all cases, the role of anxiety in resulting from or contributing to dyspnea should be considered and treated.
Managing dyspnea
Treatment of dyspnea is directed first to the cause and palliation; and if efforts to address the cause are unsuccessful, then to palliation of the symptom. Most of the causes listed above are amenable to treatment, at least in early stages or when the patient is relatively strong. Palliative treatment of dyspnea includes the below supportive measures:
| Morphine is the medication of choice for palliation of dyspnea (note that specific causes above indicate specific treatments). Morphine works by improving the quality of breathing and decreases both dyspnea and the anxiety that accompanies dyspnea. Nebulized morphine is considered by some to be more effective than oral or injected (parenteral) morphine, but has the potential to cause bronchospasm. Nebulized morphine is contraindicated in patients with COPD because of potential respiratory depression and worsening hypercapnia. |
Other measures (usually in combination with morphine or other opioid therapy include:
Preexisting or other conditions are treated as they are in any circumstances unless the patient is weakened, in which case some options are not available.
Cough is most commonly a problem in bronchogenic cancer (lung cancer with tumor in one or more bronchus). Cough may also be a complication of terminal illness and chronic illness such as bronchitis; and of respiratory or cardiac problems such as obstruction, loss of function, pneumonia, thromboembolus, pericardial effusion, superior vena cava syndrome, and congestive heart failure. Pathologic or severe cough may cause or contribute to loss of sleep, muscle strain, increased blood pressure, headache, ruptured blood vessels, and bone fracture. Causes and characteristics of cough in patients with cancer include:
Cough and dyspnea are often associated: See dyspnea figures in preceding section.
Aspiration (inhalation of sputum, other material): Cough with choking. Aspiration is associated with a variety of conditions, including obstruction and fistula (opening between trachea and esophagus.
Sputum retention is increasingly common as disease advances: Cough with choking; patient weak, weight loss significant, has respiratory infection. May include aspiration.
Vocal cord paralysis is common in primary or secondary tumors of neck or chest: Cough and hoarseness with presence of associated tumor.
Gastroesophageal reflux disease (GERD) is a common cause of cough unrelated to cancer or other life-threatening disease; except that bedfast or debilitated persons, especially those taking long-term high-dose steroids, may be more prone to developing the disorder: Cough with substernal (center of chest) burning pain, especially when lying on back after meals. Hoarseness or wheezing may also occur.
Congestive heart failure: Cough and a history or symptoms of cardiac disease, especially congestive heart failure (CHF), especially with anemia. CHF is characterized by fatigue, dyspnea, rapid heart rate (tachycardia), edema (legs, lungs, dependent/lowest part of body), increased frequency of urination at night (nocturia), chest pain, and cough.
Preexisting or other conditions: COPD, asthma, etc.
Cough associated with environmental factors such as allergens (pollen), dry air, cigarette smoke.
Managing Cough
Helping when cough is a problem includes at least some of the measures discussed under dyspnea; some measures, however, are different, e.g., increasing humidity. Treating the cause is always the first option when possible. If the causative factor cannot be resolved, the cough is treated according to its characteristics. Palliative treatment of cough includes:
A small amount of blood in the sputum is not necessarily a particularly unfavorable sign; and may come from a site other than the respiratory system, e.g., nose or gastrointestinal system (though gastrointestinal bleeding may be a very serious problem). Massive hemoptysis is usually a grave sign that death is near. Causes of hemoptysis include:
Managing hemoptysis
As with other problems of advanced disease, the first option is treatment of the cause when possible. Supportive measures for hemoptysis are limited, and include:
Cardiovascular Problems in Cancer
Cardiovascular problems related to cancer are less common than respiratory and other organ systems problems. Among the cardiac problems of cancer are pericardial effusions and cardiac tamponade, metastases to the heart, problems related to secondary problems of cancer (e.g., anemia, hyperthyroidism, SIADH, aldosteronism, amyloidosis), multiple systems organ failure, effects of treatment, primary pericardial tumors such as sarcoma or mesothelioma, and limited primarily to AIDS, primary cardiac lymphoma.
Other than pericardial effusion and cardiac tamponade, and some of the secondary problems noted above, most of these problems are difficult to treat other than palliatively in the context of terminal cancer. Except in patients who are very close to death, preexisting or other cardiac problems such as dysrythmias are treated as they would be normally. Tumors most likely to metastasize to the heart are lung, breast, melanoma, acute leukemia, lymphoma, and gastrointestinal - but the incidence of heart metastasis is low in any case.
Pericardial Effusions and Cardiac Tamponade
Cardiac tamponade (pathologic compression of the heart by fluid) is an oncology emergency caused by compression by large pericardial effusion (an effusion is fluid in a sack surrounding an organ, in this case, the pericardium surrounding the heart). The speed at which an effusion develops is significant, with more rapid effusions resulting in more severe tamponade.
The early symptoms of pericardial effusion are "nonspecific" cardiac symptoms such as chest discomfort and slight shortness of breath. As the effusion grows and develops into tamponade, primary symptoms become more severe, including dyspnea, cough, and deep pain in the center of the chest (sometimes relieved by bending over). Other manifestations of cardiac tamponade include rapid heart rate, rapid respiratory rate, changes in blood pressure, decreased consciousness, cyanosis (changes in color of nailbeds), neck vein distention, edema, and sometimes nausea and vomiting and abdominal pain.
Treatment includes draining the effusion, giving oxygen, sclerosis (drying the affected area by chemical or other means), and medications to improve cardiac function. Unfortunately, symptoms sometimes return within 48 hours. In some cases a pericardial drainage catheter is inserted or other surgical measures taken to prevent recurrence of the effusion.
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