Abstract
Background:
Fan therapy is often suggested for relieving the symptom of dyspnea in patients with advanced cancer, but relevant literature among Asians is limited.
Objective:
Phase 2 clinical trial to assess the clinical feasibility and outcome of using an electric fan to alleviate the symptom of dyspnea in Chinese patients with advanced cancer.
Methods:
Thirty patients with advanced cancer having unresolved breathlessness were recruited from Hospice and Palliative Care Centre of Kiang Wu Hospital in Macau. Participants were randomly and equally allocated to the experimental group and the control group, respectively.
Results:
T test was used to analyze the data collected. There was a significant difference in the NRS scores of the experimental group (P < .01), indicating a significant reduction in the patients’ sensation of breathlessness after fan therapy, whereas no significant difference was found in the objective statistic results of RR and SpO2. No significant difference (P > .05) was found in the control group for all the 3 variables before and after routine treatment.
Conclusion:
The results of the study suggested that fan therapy could be effective in alleviating dyspnea in Chinese patients with advanced cancer. It should be considered as one of the nonpharmacological treatment option. Future large-scale phase 3 clinical trials are warranted.
Background
Dyspnea or breathlessness is a subjective sensation. Apart from the subjective experience of breathing difficulty and discomfort, patients with dyspnea may as well have psychological changes such as fear, anxiety, and depression. 1 Dyspnea is frequently experienced by patients with advanced cancer, which increases the sensation of breathing difficulty and may alter patients’ quality of life. 2 -4 According to a study on breathlessness in patients with advanced cancer in the United States, moderate dyspnea occurs in over 55% of patients with terminal cancer. 5 In addition, previous study demonstrated that dyspnea carries inverse correlation with the length of survival. 4 Dyspnea occurs in patients with advanced cancer and bothers them to various extents. It especially affects patients with lung cancer, with up to 46% of patients with lung cancer experienced different level of dyspnea. 1
Although most physical symptoms could generally be well controlled at the end of life, dyspnea often remains a clinical challenge in palliative care practice. At present, commonly used nursing interventions include supplemental oxygen and medications. 6,7 However, drug therapy was not completely effective in relieving dyspnea in all patients with advanced cancer, and the side effect may become intolerable to our patients. Furthermore, oxygen therapy tends to be less effective in the management of chronic dyspnea. 6 As a result, some academics suggested that fan therapy may take the place of oxygen therapy in clinical use and may possibly have the same outcome in alleviating patients’ breathlessness. 8,9 According to Cochrane systematic review in the management of dyspnea in patients with terminal illness, the efficacy of fan use is still inconclusive and subject to ongoing studies. 10
The design of this study aims to fill the gap of fan therapy in Chinese population with advanced cancer, as previous studies mostly targeted on Western population. 11,12 In Chinese culture, it was believed to be disrespectful and ominous to tell someone that he or she was dying, which may hinder appropriate palliative service delivery. Besides, Chinese patients’ beliefs in traditional Chinese medicine may bear an important role in their acceptance toward fan intervention. This would be reiterated in-depth in the Discussion section. 13
Methods
Data were collected from September 2012 to May 2014. The study took place in the Hospice and Palliative Care Centre of Kiang Wu Hospital. It is the only inpatient palliative care unit for patients with advanced cancer in Macau. It comprised 30 inpatient hospice bed, with a mean monthly admission of 34 patients. In total, 30 patients with advanced cancer having dyspnea symptoms were recruited. Advanced cancer was defined by radiologically confirmed local–regional or distant metastasis. All recruited participants were capable of expressing their subjective sensation of breathlessness and experienced a dyspnea level of numerical rating scale (NRS) of 3 or above. Patients with fever, acute difficulty in breathing, mentally incompetent, or unwilling to take part in the study were excluded.
This phase 2 pilot study was formally approved by the Research Committee of Kiang Wu Hospital. Written consent was obtained from all participants. In our single-blinded trial, patients were randomly assigned to the experimental group or the control group. Based on ethical concerns, patients in both arms of the study would receive the same nursing interventions when they experience dyspnea, which include supplementary oxygen, rescue drugs according to doctors’ prescription, and positioned in a half-lying sitting posture. Patients in the experimental group were given fan therapy, which involved the use of an electric fan for 5 minutes. Clinical parameters including verbal NRS, respiratory rate (RR), and oxygen saturation (SpO2) were recorded before and after the usage of fan. Patients in the control group were not given a fan but were accompanied by their caregivers for 5 minutes. Measurements including verbal NRS, RR, and SpO2 were also recorded as in the intervention group. Methodology and data collection details are summarized in Figure 1.
Data collection flowchart.
Baseline demographics, medical diagnoses, hemoglobin level, and drug treatments were recorded for analysis. Room temperature and humidity where the study took place were also recorded. Patients were given oxygen therapy if they have documented hypoxemia. Verbal NRS was screened on a colored picture containing figures and words, scoring from 0 to 10 indicating the scale from “no shortness of breath” to “very severe shortness of breath.” Verbal NRS was used for participants to indicate the degree of breathlessness by saying or pointing by hand. In addition, finger pulse oximeter and timer were used to record SpO2 and RR.
During the study, the fan was ensured to be directed at the participant’s face, with low rate of air flow. The distance and location of the fan were decided according to patients’ preference. The model of fan used was Midea FT23-8HC, China desk fan with product safety certification, its blades sized 9 in, and the approximate size of the fan is 284 × 179 × 316 cm.
Results
In total, 45 patients were approached. Five patients refused to participate in the study, whereas 10 patients were excluded due to critically ill condition or passed away. Thirty patients completed the study, and their results were analyzed by t test using SPSS 15.0 software. Both groups show comparable baseline demographics in terms of gender, education level, marital status, employment situation, and religion (Table 1). The main cancer diagnosis was carcinoma of the lung, with 40% in the experimental group and 46.7% in the control group.
Basic Information of Participants.a
a N = 30.
Over 40% of the participants were patients with lung cancer. Other diagnoses include colorectal cancer, carcinoma of the stomach, lymphoma, breast cancer, and prostate cancer. Except for 1 participant, the majority (96.7%) required oxygen therapy during the study. Oxygen saturation of participants remained static. The mean hemoglobin level of the experimental and control groups was 10.94 and 10.21, respectively. There was no significant difference in terms of self-rating breathlessness scale, SpO2, and RR between the 2 groups before intervention (Table 2).
Clinical Parameters of Participants Before Intervention.
During the intervention period, the average temperature was 22°C, while humidity was 62.7%. In the experimental group, participants’ self-reported breathlessness score was 6.13 and 4.60 (pre- and postfan usage), respectively, representing a 1.53 improvement in self-reported breathlessness after the intervention. In contrary, the self-reported breathlessness score in the control group improved by 0.13 point only. The independent sample t test showed a significant degree of breathlessness improvement in the experimental group after fan therapy (P < .01). Other measured parameters including RR and SpO2 showed no significant difference (P > .05; Table 3). In conclusion of the aforesaid results, fan therapy was effective in alleviating patients’ subjective experience of breathlessness, but there was no significant difference found in objective indicators including RR and SpO2.
Comparative Analysis of the Respiratory Changes in Participants After Fan Therapy and Routine Treatments.
After completing the second assessment of respiratory parameters, the control group was given fan therapy intervention as the experimental group, and their respiratory parameters were recorded again. However, there was no significant difference in terms of self-reported breathlessness scale, RR, and SpO2. According to the results (Tables 3 and 4), fan therapy should be given to patients immediately when they experience dyspnea in order to alleviate their subjective sense of breathlessness, since a delay in fan therapy failed to show an improvement in their self-reported breathlessness.
Comparative Analysis of the Respiratory Changes in the Control Group Receiving Fan Therapy After No-Intervention Treatment.
Discussion
Current evidence supports the usage of fan as nonpharmacological intervention for dyspnea in patients with advanced cancer. In 1987, Schwartzstein et al 11 published their results on 16 healthy individuals with cold air directed at the cheek to see its effects on reducing shortness of breath. Using a modified Borg scale to assess patients’ subjective sensation of breathlessness, they found that cold air directed on the face significantly reduced breathlessness without causing obvious reduction in ventilation. Afterward, in 2010, Galbraith 12 conducted a clinical trial with handheld fan directed to the face and the leg of 50 patients with advanced dyspnea and tested patients’ visual analog scale (VAS) before and after the use of fan. They found that there was a significant decrease in VAS after the use of fan directed to the face, but there was no effect when the fan was directed to the leg. The results of our study add further evidence in the usage of fan therapy in dyspnea relief in patients with advanced cancer. Indeed, it was the first randomized controlled trial on fan therapy in Asian population.
According to previous literature, patients’ subjective sensation of breathlessness was generally assessed by tools including Modified Borg Scale, VAS, or NRS. In this study, we used verbal NRS to measure subjective experience of breathlessness. It is mainly based on the concern that our participants were patients with advanced cancer who might found the written form difficult to administer. Furthermore, the data collection process was to be done with the participants being at rest. Morris et al found in their research that verbal NRS scores of breathlessness were preferred by participants to the VAS in assessing dyspnea. 14
Dyspnea has been defined as a “subjective experience of breathing discomfort that consists of qualitatively distinctly sensations varying in intensity.” Although dyspnea assessment has been an active area of research for many decades, the complex etiology of dyspnea, both pathophysiological and psychosocial, has proven challenging in developing tools that capture its multiple dimensions. In our study, a cutoff value of verbal NRS 3 or above for dyspnea was chosen, which is mainly based on our experience that this level often signifies a level of distress for our patients. Indeed, a recent published article has also pointed out a significant distributional overlap between mild and moderate dyspnea using the verbal NRS. 15
In our study, one of the interesting findings was that delayed intervention in the control group did not generate a significant reduction in NRS breathlessness as observed in the intervention group. One of our postulation is that, in contrast to pain, the mechanism of cancer-related dyspnea is less understood. Dyspnea often precipitates physical and psychological distress and has been well known to be associated with both anxiety and depression. Furthermore, one of the most complex aspects of dyspnea as compared to pain is the fact that the majority of patients develop intermittent dyspnea. 16 This may explain why the immediate provision of fan therapy could gain a significant relief in dyspnea while a delayed intervention did not show similar results.
The journey to excellence in palliative care often requires clinicians to first connect to persons with illness on a human–human level and to consider their individualized care needs, taking into account of intercultural variations. In our study, although Chinese participants accepted fan therapy as a way to alleviate breathlessness, some of them did not continue the use of fan after the trial and expressed that they were worried about getting a cold or headache due to their exposure to the wind for a long time. For those who agree to continue with fan therapy, the majority of them preferred the fan to be directed at them in the back-and-forth movement rather than a static continuous manner. Their concern is related to the local Chinese culture of Macau. Macau is a place where east meets west. Although most Chinese residents accept western medicine as their main stream of care, they are deeply influenced by traditional Chinese medicine at the same time. According to Chinese doctor Zheng, 17 people would get sick easily when their bodies are weak and might catch a cold after perspiration. This is caused by the “cold pathogen” (or “cold evil”) as noted in Chinese medicine. Another Chinese medicine practitioner Wang 18 also pointed out that if people are exposed to heavy and excess cold for such a long time (as in the case of continuous fan therapy), which exceeds their immunity and affordability, the cold will attack and harm the body. The cold that damages the body is called cold pathogen in Chinese medicine. These are interesting and important results to be noted, as different cultural background might influence patients’ choice of treatment. Although Macau Chinese patients showed similar effect in dyspnea improvement with fan therapy, resembling to previous foreign studies, patients may differ in their acceptance and habit of using the fan.
Limitations
The small sample number with the study being carried out in a single palliative care unit in Macau remains the major limitation. Besides, only a single model of fan was used, which may limit the generalizability. Third, various cutoffs and different dyspnea rating scale may affect the actual benefit observed in dyspnea relief.
Conclusion
We believe that future research on fan therapy can be carried out in regions with different cultural context so that evidence could be added toward the effect and patients’ acceptance on fan therapy. Besides, studies to evaluate the application of fan therapy for dyspnea caused by other advanced diseases (eg, chronic obstructive airway diseases and congestive heart failure) will be equally invaluable. In conclusion, our results suggested that fan therapy may be effective in alleviating dyspnea sensation in Chinese patients with advanced cancer, and future large-scale phase 3 clinical trials are warranted. Besides, we must take into account the acceptance of patients under different cultural context.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.