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Palliative cancer care - dyspnoea - Background information
Malignant causes of dyspnoea - further information

  • Upper airway obstruction can be caused by intraluminal tumour, spread of a primary bronchial carcinoma into the base of the trachea, or extrinsic compression by a tumour or mediastinal masses. It is a potentially life-threatening cause of dyspnoea but may be reversible:
    • Dyspnoea is a common presentation of major airway obstruction. Other features that suggest the presence of upper airway obstruction include stridor, wheeze not responding to bronchodilators, lung collapse, and persistent cough or haemoptysis with a normal chest radiograph [Warrell et al, 2003b; Doyle et al, 2004].
  • Superior vena cava (SVC) obstruction is usually due to metastases in the upper mediastinal lymph nodes that cause extrinsic pressure, but it can also be caused by intraluminal thrombosis, external compression by the tumour, or direct invasion of the vessel wall by the tumour. Around 80% of cases are caused by lung cancer:
    • Half of people with SVC obstruction experience dyspnoea; other common symptoms include neck and facial swelling, venous distention, a choking sensation, and a feeling of fullness in the head.
    • Major airway obstruction may occur if the tumour causing the SVC obstruction is also compressing the trachea [Davis, 1997; Twycross and Wilcock, 2001; Doyle et al, 2004].
  • Bronchial obstruction by the tumour may lead to loss of lung volume by causing collapse or by predisposing to consolidation distal to the tumour.
  • A pleural effusion forms when excess pleural fluid is produced and/or not enough is reabsorbed. Clinically, it is detectable when at least 500 mL of fluid is present:
    • In people with cancer, pleural effusion often occurs due to the tumour obstructing lymphatic transport in the pleura or regional lymph nodes. Most pleural effusions in the setting of cancer occur in people with lung, breast, or ovarian cancer, or lymphoma [Twycross and Wilcock, 2001].
  • Pericardial effusion can occur when the pericardium becomes infiltrated with tumour, and lymphatic and venous drainage of the pericardium is obstructed:
    • Cancers that cause pericardial effusion include breast, lung, ovarian, and gastrointestinal cancer and non-Hodgkin's lymphoma. Symptoms include dyspnoea, orthopnoea, and cough.
    • If the effusion increases in volume, cardiac tamponade can occur, causing severe dyspnoea, hypotension, and tachycardia [Warrell et al, 2003c].
  • Lymphangitis carcinomatosa is caused by diffuse infiltration of lymphatic vessels in the lungs by malignant disease (most commonly breast and primary lung tumours). This obstructs pulmonary lymphatic drainage and leads to pulmonary congestion [Twycross and Wilcock, 2001; Warrell et al, 2003b].

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