Waterboarding for breathlessness?
I love that we have some evidence supporting the use of a handheld fan in breathlessness. It is quirky, lateral thinking that appeals to me and I believe is part of the ethos of palliative care, holistically trying to resolve an issue by using all methodological routes available to us.
It’s largely part of standard practice and although further research is recommended, it seems effective in select patients and has no side effect profile (1,2,3). In Galbraith’s study there was a significant difference in the visual analogue scale (VAS) for breathlessness (P=0.003).
However, there is not a completely clear picture!
In Bausewain’s study (1) the paper reads, “This study does not allow a conclusion about the effectiveness of a HHF (Hand Held Fan) to relieve breathlessness.” Also, I note Mr Cochrane, which states there is not enough evidence to judge (4) (2008, updated 2013, now awaiting further update). The sad news doesn’t stop there, unfortunately, it looks like there will not be another trial regarding our beloved hand held fan, because it has been deemed the value of information for changing practice or policy is unlikely to justify the expense (5).
Anyway, the above was done on the back of previous research that cold facial stimulation reduced breathlessness (6) and exercise induced dyspnoea in COPD was reduced using a fan (7).
All of this research doesn’t seem to have a clear mechanism by which blowing on someone’s face works!
Sure, there have been proposals, such as; the diving response, which causes ventilator depression when the trigeminal area of the face is cooled, or by the cooling of nasal / oral mucosal receptors, or via a decreased central respiratory drive (8).
Basically, we don’t know how it is working, but have a pretty strong inclination it is.
The beauty in good palliative care (and indeed all of medicine) is simplicity, and that is what appeals to me about the fan. Given one of the mechanism we propose is cooling the face down, the question becomes … why don’t we try that by other methods?
Stick a flannel on their forehead, spray them with cool water spray, what about a cooling pillow? Bung them in the fridge.
I want the stormy Atlantic ocean on my face.
Indeed, if as we believe mindfulness also helps breathlessness, stick a virtual reality helmet on my eyes. Virtually put me on a fishing trawler in the stormy north seas. Or more likely on a calm beach with a gentle breeze, or moving in an open top fancy car. All the while fanning and spraying me cool. If nothing else the sensory overload would distract.
I have witnessed patients who are short of breath ask for a cold drink, and what do they do instinctivly but raise their cold glass to their forehead to cool them down.
Anywhichway, why don’t we empty the Cif spray bottle, give it a clean, fill it with water, put in a fridge and when we have a panic attack / feel breathless, soak the face with a fine mist! Or stick a cold flannel on the forehead. Just an idea, easy trial, could even cross over (or double) trial of n of 1. We could use the validated VAS score and even compare with existing trials. A negative result would even suggest an alternative mechanism.
- Bausewein, C., Booth, S., Gysels, M., Kuhnbach, R., and Higginson, I.J. Effectiveness of a hand-held fan for breathlessness: a randomised phase II trial. BMC Palliat Care. 2010; 9: 22
- Galbraith, S., Fagan, P., Perkins, P., Lynch, A., and Booth, S. Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. J Pain Symptom Manage. 2010; 39: 831–838
- Ekstrom, M.P., Abernethy, A.P., and Currow, D.C. The management of chronic breathlessness in patients with advanced and terminal illness. BMJ. 2015; 349: g7617
- Bausewein, C., Booth, S., Gysels, M., and Higginson, I. Non-pharmacological interventions for breathlessness in advanced stages of malignant and non-malignant diseases. Cochrane Database Syst Rev. 2008; : CD005623
- Johnson MJ, Booth S, Currow DC, Lam LT, Phillips JL. A Mixed-Methods, Randomized, Controlled Feasibility Trial to Inform the Design of a Phase III Trial to Test the Effect of the Handheld Fan on Physical Activity and Carer Anxiety in Patients With Refractory Breathlessness. J Pain Symptom Manage. 2016 May;51(5):807-15. Doi 10.1016/j.jpainsymman.2015.11.026. Epub 2016 Feb 12. PubMed PMID: 26880253.
- Schwartzstein RM, Lahive K, Pope A, Weinberger SE, Weiss JW. Cold facial stimulation reduces breathlessness induced in normal subjects. American Review of Respiratory Disease. 1987;136(1):58–61.
- Baltzan M. Fan to palliate exercise-induced dyspnea with severe COPD [abstract] American Journal of Respiratory and Critical Care Medicine. 2000;161(3 Suppl):A59.
- Marchetti, N., Travaline, J.M., and Criner, G.L. Air current applied to the face of COPD patients enhances leg ergometry performance. ([abstract])Am J Respir Crit Care Med. 2004; 169: A773