Original Article

Hand‑held Fan Airflow Stimulation Relieves

Dyspnea in Lung Cancer Patients
Ni Luh Putu Dewi Puspawati1, Ratna Sitorus2, Tuti Herawati2
1
Medical Surgical Nursing, Wira Medika Bali Health College, Bali, 2Medical Surgical Nursing, Faculty of Nursing, University of
Indonesia, Depok, Indonesia

Corresponding author: Ni Luh Putu Dewi Puspawati, BSN, MN

Medical Surgical Nursing, Wira Medika Bali Health College, Bali, Indonesia

Tel/Fax: (+62361) 427699

E‑mail: puspa_wika@yahoo.com

Received: December 13, 2016, Accepted: February 12, 2017

ABSTRACT
Objective: The main symptom of lung cancer is dyspnea which stimulation significantly influenced dyspnea scale  (P = 0.003)
can lead to depression, anxiety, limited independent activities, and respiratory rate (RR) (P  =  0.008). Combination of airflow
and decreased quality of life. The purpose of this study was stimulation and diaphragmatic breathing can lower both
to identify the effect of airflow stimulation from a hand‑held
dyspnea scale and RR significantly (P < 0.0001). Conclusions: This
fan as nonpharmacological palliative intervention on dyspnea
in patients with lung cancer. Methods: This study used open, combination can be applied on nonhypoxemic dyspneic lung
randomized, controlled, crossover trial design involved 21 cancer patients.
participants. Diaphragmatic breathing technique was used in
control arm. Results: Wilcoxon test result showed that airflow Key words: Dyspnea, hand‑held fan, lung cancer

Introduction became the most common noninfection respiratory cases

hospitalized in some hospitals in Indonesia.[3,4]
Lung cancer prevalence with high mortality is
Lung cancer causes nonspecific manifestations such as
increasing. The World Health Organization (WHO)
dyspnea, hemoptysis, chronic cough, weight loss, and other
revealed that lung cancer was one of the five most
symptoms commonly found in other lung diseases. Dyspnea
common types of cancer in the world. Lung cancer
occurs in 90% of lung cancer and its prevalence increases
caused 1.59 million deaths of 8.2 million cancer‑related
near the end of life.[5] Dyspnea in lung cancer patients is
deaths worldwide in the year 2012.[1] The WHO data for
very intrusive and causes discomfort.[6] Dyspnea limits
Indonesia showed noncommunicable diseases including
activities[7] so that patients require assistance to perform
cancer caused 13% death and became the third largest
cause in the year 2012. [2] Lung cancer particularly This is an open access article distributed under the terms of the
Creative Commons Attribution‑NonCommercial‑ShareAlike 3.0
Access this article online License, which allows others to remix, tweak, and build upon the
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DOI: Cite this article as: Puspawati NL, Sitorus R, Herawati T. Hand-held
10.4103/apjon.apjon_14_17 fan airflow stimulation relieves dyspnea in lung cancer patients. Asia
Pac J Oncol Nurs 2017;4:162-7.

162 © 2017 Ann & Joshua Medical Publishing Co. Ltd | Published by Wolters Kluwer - Medknow
 Puspawati, et al.: Fan Airflow Stimulation Relieves Dyspnea in Lung Cancer

daily activities including personal care needs.[8] Therefore, patient and investigator. Concealment was carried out by
dyspnea is correlated with lower quality of life and poor keeping the results of block randomization in a sealed
clinical outcomes.[7] numbered envelope. Investigator would open the envelope
Dyspnea management can be a combination of right before providing the treatment.
definitive, palliative, or supportive interventions. Definitive
interventions such as surgery, chemotherapy, radiotherapy,
Ethical consideration
and thoracentesis. Palliative or supportive intervention This research was approved by the Institutional
including oxygen administration, pharmacological, and Ethical Review Board Committee members at nursing
nonpharmacological therapy. Oxygen administration is faculty of University of Indonesia (No. 0288/UN2.
beneficial for patients with hypoxemia at rest or minimal F12.D/HKP. 02.04/2015). Prior to the research, the
activity. [9] Oxygen administration is insignificantly potential participants were informed with verbal and written
beneficial to reduce dyspnea in nonhypoxemic patients. description about procedures and that they could withdraw
The previous study showed that palliative oxygen did not from the study. Participants who agreed to participate in
improve dyspnea in mild hypoxemia or nonhypoxemia.[10] the study provided consent before measurement. Oxygen
Oxygen administration should be observed because it may saturation was measured to determine whether the patient
cause side effects. Oxygen administration through nasal was eligible or not. Oxygen saturation was monitored
cannula continuously may cause irritation on nasal mucous continuously during treatment to prevent hypoxemia.
membrane, epistaxis, and discomfort.[10] Long‑term oxygen Subjects
therapy may cause side effects such as oxygen toxicity and
Participants were recruited from the respiratory ward
hypercapnic respiratory failure.[11,12]
in one of the national referral hospitals in Indonesia.
Alternative methods to relieve chronic dyspnea are
Investigator made a list of potential participants that was
developing. Some of them use airflow stimulation. The
sorted by date of patient’s admission. Participants were
study showed that oxygen administration and airflow can
then selected by consecutive sampling based on sampling
relieve dyspnea and there was no significant difference
criteria. Participants for this study were diagnosed with
between both interventions.[13] A study by Schwartzstein
lung cancer or tumor, had dyspnea Modified Borg
et al. in healthy participants showed results that cold airflow
Scale (MBS) on 1–6, oxygen saturation >90%, hemoglobin
directed toward the face on cheeks, nasal mucosa, and
concentrations >10 g/dl, and received oxygen therapy
pharynx may decrease dyspnea significantly.[14] Research
through nasal cannula if only necessary. Patients who
conducted by Baltzan et al. found that airflow from a 42 cm
experienced fever (>38° C) for 48 h prior to the study were
diameter fan directed toward the face can reduce dyspnea
excluded from the study. Participants who met the criteria
in chronic obstructive pulmonary disease patients.[15]
were divided into control and intervention group by block
The fan is then used as a supportive intervention for
dyspnea management. However, a systematic review randomization. Investigator allocated the participants into
concluded that the use of fan does not have sufficient evidence each arm based on block randomization result precisely
of relieving dyspnea in patients with nonmalignancy and after collecting pretest data and before providing the
advanced malignancy disease.[16] Therefore, it is necessary treatment.
to study the impact of airflow stimulation from a fan or Outcome measures
hand‑held fan on dyspnea, especially in nonhypoxemic
Some participant’s characteristics and primary outcome
lung cancer patients.
in this study were measured. Characteristics assessed
were age, dyspnea scale, qualitative characteristic of
Methods dyspnea sensed by participant, medication use, flow
Study design of oxygen therapy received, and oxygen saturation.
We aimed to identify the effect of airflow stimulation from Oxygen saturation was measured and monitored by pulse
a hand‑held fan on dyspnea in patients with lung cancer. We oximetry (Elitech Pulse Oxymeter Finger‑Tip Fox‑1). Speed
compared it to the nonpharmacological interventions that of hand‑held fan airflow was measured by a Mini Digital
can be performed to relieve dyspnea in lung cancer. This Anemometer (Anemometer HT‑81). Primary outcome
study used an open, randomized, controlled, crossover trial was dyspnea. Dyspnea was measured subjectively and
design. Block randomization was performed by coauthor objectively. Subjective parameter was MBS,[18] and objective
to determine the treatment sequences. The results would parameters were respiratory rate (RR), use of accessory
allocate which participant would be initially in control or muscles, and nasal flaring presence.[19,20] MBS was used
intervention group.[17] The result was concealed from the as a screening tool and assess dyspnea subjectively. The

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 Puspawati, et al.: Fan Airflow Stimulation Relieves Dyspnea in Lung Cancer

MBS is a validated 0–10 ratio scale to rate the severity of to do diaphragmatic breathing exercise and got airflow
dyspnea.[21,22] Signs as objective parameters were observed stimulation from a hand‑held fan. Each treatment was
by investigator. The measurements were performed right performed for 5 min in every participant. Each treatment
before (pretest) and after (posttest) treatment in each case. was done 2 times in 2 periods and take turns on each
participant.[25] Treatments were performed crossways in
Interventions both groups after a washout period for 1 h.[26] The detail of
Airflow stimulation from hand‑held fan was used as study procedure is presented in Figure 1.
adjunct to diaphragmatic breathing exercise, oxygen, and
pharmacotherapy. Intervention with hand‑held fan in this Statistical analysis
study combined the principles of previous research about We summarized the baseline characteristic into
airflow from fan.[11,14,23,24] A wet damp cloth was used to wipe descriptive statistics, including median, mean, standard
participant’s face without drying, and then airflow from deviation, range, 95% confidence interval, and frequencies.
hand‑held fan was given.[11,24] Hand‑held fan that we used We conducted a pretest to check the assumption of
in this study was a small hand‑held fan with three bladed negligible carryover effects.[27] Pretest results showed no
propellers.[23] The speed of airflow was 4 km/h[14] measured evidence of relevant carryover effects. This study was
by a Mini Digital Anemometer. This intervention would be then analyzed as a crossover study. A two‑sided P < 0.05
compared to diaphragmatic breathing exercise as a control. was considered to be statistically significant. Normality
Par ticipants received treatment based on the pretest showed that only pretreatment RR in both groups
randomization result written inside the envelope. can be assumed to have normal distribution. Therefore,
Participants who were initially allocated to be in control Wilcoxon signed‑ranks were used to analyze the difference
group were guided to do a diaphragmatic breathing between before and after treatments in each group for
exercise. Participants in the intervention group were guided numerical variables. Meanwhile, accessory muscle used as a

Assessed for eligibility (n = 27)

Not meeting inclusion criteria
(n = 6)
• MBS < 0 (n = 1)
• Not cancer-related
dyspnea (n = 2)
Eligible (n = 21)
• SaO2 < 90% (n = 2)
• Decline to participate; not
interested (n = 1)
Randomized (n = 21)

Allocated to intervention
llocated to control (n = 10) (n = 11)

Completed intervention
Completed control (n = 10) (n = 11)

Completed washout period Completed washout period

(n = 10) (n = 11)

Completed intervention
(n = 10) Completed control (n = 11)

Figure 1: CONSORT flow diagram. MBS = Modified Borg Scale; SaO2 = Oxygen saturation

164 Asia‑Pacific Journal of Oncology Nursing • Volume 4 • Issue 2 • April-June 2017

 Puspawati, et al.: Fan Airflow Stimulation Relieves Dyspnea in Lung Cancer

categorical variable was analyzed by Marginal homogeneity

Table 1: Dyspnea scale and respiratory rate in control group
test. We did not analyze nasal flaring or nostril breathing (n=21)
presence because its data were not dichotomous. On
Parameters Mean±SD Median (minimum‑maximum) P
treatment, analysis was conducted to compare the change
MBS
between two treatments using Wilcoxon signed‑ranks test Pre 2.52±0.75 2 (1.00‑4.00) 0.001
for numerical variables.[28‑30] We did not compare accessory Post 1.83±0.76 2 (0.50‑3.00)
muscle use because there was no difference in frequencies RR
between before and after in each treatment. Pre 28.05±1.69 28 (25.00‑32.00) 0.001
Post 26.00±1.18 26 (24.00‑29.00)
Results MBS: Modified Borg Scale, RR: Respiratory rate, SD: Standard deviation

This study was conducted from May to July 2015.

Twenty‑one patients with lung tumor and cancer were Table 2: Dyspnea scale and respiratory rate in intervention
involved in this study. Each participant had double role group (n=21)
as control and treatment participants. Data were recorded Parameters Mean±SD Median (minimum‑maximum) P
as control group when participants were guided to do MBS
Pre 2.57±0.75 2 (2.00‑4.00) 0.001
diaphragmatic breathing exercise only. The intervention
Post 1.36±0.73 1 (0.50‑3.00)
group was stated when participant received a combination
RR
of diaphragmatic breathing exercise and hand‑held fan Pre 28.38±1.32 28 (26.00‑31.00) 0.001
airflow stimulation. Post 25.67±1.07 26 (24.00‑29.00)
MBS: Modified Borg Scale, RR: Respiratory rate, SD: Standard deviation
Patient characteristics
Characteristic assessment in this study found age average
about 53.38 (±9.21) years. The youngest participant was Table 3: Difference of dyspnea scale and respiratory rate change
between groups
38 years old and the oldest was 69 years old. The average
Parameters Mean±SD Median (minimummaximum) P
of oxygen saturation was 94.19 (±1.5%). The majority of
MBS
participants (85.7%) were on supplemental oxygen at the
Control 0.69±0.46 1 (0‑1) 0.003
time of enrollment. Median use of supplemental oxygen was Intervention 1.21±0.56 1 (0‑2)
2 L/min with a range of 1–3 L/min. Mostly patients used RR
analgesics and steroids (47.6%). Most of the participants Control 2.05±0.80 2 (1‑3) 0.008
felt “chest tightness” (71.4%) and no participants felt “air Intervention 2.71±0.85 3 (1‑4)
MBS: Modified Borg Scale, RR: Respiratory rate, SD: Standard deviation
hunger.” These characteristics were homogeneous in both
groups because they compared it to themselves.
on skin which is innervated by sensory nerve branches of the
Change in parameters trigeminal nerve. This study used hand‑held fan to produce
Data for each parameter (before and after) were compared airflow directed to patient’s face. The result showed that
to identify the effect of every treatment given. There were airflow stimulation from a hand‑held fan was effective to
significant changes on dyspnea scale and RR in each group. decrease dyspnea (P = 0.003). We used the combination of
Details are presented in Tables 1 and 2. There were no changes cool sensation and airflow with a speed of 4 km/h. This
in accessory muscle use and nostril breathing presence in speed met patient’s comfort. This combination produced
each group so that we did not analyze it to compare the airflow stimulus and cooling sensation on participant’s
difference of changes between groups. Only numerical data face. There was no clear mechanism about it, but it is
were continued to be compared between the control and believed that stimulation was detected by respiratory
intervention arm. We analyzed the different effects in each system mechanoreceptors.[14] Stimulus was then passed
arm by subtracting pre‑ and post‑test data of each group. following the trigeminal nerve pathways to the brainstem
These results were then analyzed by Wilcoxon signed‑rank and thalamus to proceed to somatosensory cortex.[32,33] The
test. There were significant differences between each group somatosensory cortex is one part in the cortex that perceives
on dyspnea MBS and RR. Details are presented in Table 3. a sensation of dyspnea.[34] This stimulation changes the
feedback of re‑afferent impulse to the somatosensory cortex
Discussion and modifies dyspnea perception. This modification will
Patients with dyspnea generally feel more comfortable decrease sensation of dyspnea.[14]
near an open window or in front of the fan[14,31] so that The combination of airflow stimulation of hand‑held
dyspnea is reduced. Its mechanism uses mechanoreceptors fan and diaphragmatic breathing significantly influenced

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 Puspawati, et al.: Fan Airflow Stimulation Relieves Dyspnea in Lung Cancer

dyspnea sensation (P < 0.001). The mean of MBS Nostril breathing is associated with tachypnea, and it was
was decreased after the intervention (1.21 units) and found in breathing frequency of 34–40 times/min.[40] All
also the median (1 unit). This change compared to the the participants in this study had RR <34 times/min thus
minimal clinical significant difference for MBS that is nostril breathing did not present.
1 unit.[35] Comparison showed that airflow stimulation
from hand‑held fan combined with diaphragmatic Conclusion
breathing was clinically significant to relieve dyspnea. Airflow stimulation from hand‑held fan decreased
This combination was more effective and beneficial for dyspnea sensation and breathing frequency in nonhypoxemic
patients when compared to the diaphragmatic breathing dyspneic lung cancer patients. It had no effect on nasal
exercise alone. flaring and respiratory accessory muscle use. This study
The results showed that hand‑held fan airflow stimulation has several implications in palliative nursing such as to
can lower the frequency of breathing in patients with lung enhance nursing knowledge about nursing interventions
cancer significantly (P = 0.008). The combination with for patients with lung cancer who experience dyspnea.
diaphragmatic breathing provided significant effect on Nurses also can perform health education to nonhypoxemic
breathing frequency (P < 0.001). Frequency of breathing patients to relieve dyspnea using airflow stimulation from
decreased after treatment because the diaphragmatic hand‑held fan combined with diaphragmatic breathing.
breathing trains the patient to take deeper breaths and The use of hand‑held fan airflow may anticipate improper
more effectively maintain lung expansion.[36,37] However, the oxygen administration for example in nonhypoxemic
frequency of breathing posttreatment was still considered patients. Study with larger sample size and more sensitive
as tachypnea which is more than 25 times/min.[38] It may objective parameter is still needed to evaluate the impact
happen because the interventions focused on modifying of airflow stimulation, particularly on dyspnea physiologic
dyspnea perception and were not focused on addressing parameters. This study is expected to increase motivation
dyspnea cause.[23] Frequency of breathing is a compensation and effort to think critically about nonpharmacological
to maintain adequate oxygenation. The mean oxygen intervention to decrease dyspnea sensation. The result may
saturation was not considered hypoxemia (94.2%) but it become the background for further research on trigeminal
was lower than when participants received supplemental nerve stimulation and dyspnea.
oxygen (98%–99%). Decline in oxygen saturation caused Financial support and sponsorship
the participant to take breaths more frequently than normal
Nil.
rate. Related to dyspnea sensation, tachypnea posttreatment
was considered reasonable because patient still felt dyspnea Conflicts of interest
sensation after treatment. There are no conflicts of interest.
This study found no effect of airflow stimulation from a
hand‑held fan on the use of respiratory accessory muscles. References
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