Guide to Pain Management in Low-Resource Settings

Case report—part one
Mr. Tarik Al-Khater is a 65-year-old man with an ath-
letic constitution. He used to work as a postman in Bar-
bar, Northern Sudan, and remained active doing fi tness 
exercises until a year ago. Twenty years ago, he had quit 
smoking, having accumulated 10 “pack years” (one “pack 
year” means smoking 20 cigarettes per day throughout 
one year). Up to 2 years ago, he had never been ill, though 
he had undergone an appendectomy and osteosynthet-
ic surgery for a tibial fracture. Th
  en at the age of 63, he 
received a diagnosis of pulmonary emphysema and dia-
betes mellitus. Nine months ago, he suff ered a herniated 
lumbar disk and underwent surgery because of muscle 
weakness of the right thighs. Furthermore, there remained 
a mixed pain syndrome of the lower back, right hip, and 
right knee, with a dominating neuropathic component 
(burning pain). Mr. K. sought consultation with his doc-
tor, who established a successful medication regimen with 
a combination of tramadol and carbamazepine. Being 
able to move a lot better, Mr. K. became more aware of 
his dyspnea and exhaustion following relatively short dis-
tances of walking. His wife also noticed that he had sig-
nifi cant weight loss and a constant cough during the last 
couple of months. An X-ray of the thorax showed a prom-
inence of the right hilum of the lung. He was sent to Atba-
ra for further examination. Unfortunately, the CT detect-
ed a central tumor of the right bronchial system, which by 
bronchoscopy was histologically classifi ed as a non-small-
cell lung cancer. Furthermore, scintigraphic and X-ray ex-
aminations reveal scattered bone metastases, such as in 
the lumbar spine and the right knee.
What are the causes and risk 
factors for lung cancer?
Th
  ere are endogenous factors for the onset of lung can-
cer (genetic disposition, active HIV infection, pulmo-
nary fi brosis, and scarring following parenchyma injury 
or tuberculosis). Exogenous conditions considered as 
risk factors are smoking in the fi rst place (partly respon-
sible in 90% of lung cancer deaths) as well as exposure 
to dust and particles such as asbestos, chromates, and 
polycyclic aromatics or to radiation from uranium, ra-
don, or even medical radiation therapy.

164
Th
 omas Jehser
How does lung cancer start?
Bronchial carcinomas mostly start in the central airway 
region and less often in the more peripheral smaller 
bronchi. Th
 e fi rst and most noticeable symptom is a 
nonproductive persistent cough (suspicious when last-
ing longer than 6 weeks). Other primary symptoms are 
hemoptysis, dyspnea or chest pain, and rarer symptoms 
are hoarseness, anxiety, fever, and mucoid expectoration 
or paraneoplastic syndromes or signs following any kind 
of early metastasis (Box 1). Th
  e histological analysis dif-
ferentiates small-cell (13%) from non-small-cell (81%) 
carcinomas. Six percent of analyses deliver no distinct 
result (anaplastic carcinoma). Other malignancies or 
space-consuming processes of the thorax are pleural 
mesotheliomas, thymomas, metastases of extrathoracic 
tumors, or infectious diseases (Box 2). An accurate dif-
ferential diagnosis of thoracic discomfort therefore has 
to consider tumorous illnesses.
Case report—part two
Unfortunately, tumor metastasis was detected at the 
moment of initial diagnosis, and the primary growth 
was located in a very central position. Breathing ca-
pacity—when tested—was limited to a FEV
1
 of 1.1 
L. Th
 erefore it was decided that a surgical resection 
would be impossible. For symptomatic treatment, Mr. 
K. was treated by radiotherapy at the tumor region 
(cumulative dose of 46 Gy) following radiation of the 
bone metastasis at the spine (36 Gy) and the knee (8 
Gy). In the course of treatment, blood testing revealed 
elevated hepatic transaminases. Since no hepatic me-
tastasis was found, the carbamazepine component of 
the pain medication was suspected to be responsible. 
After the completion of radiotherapy, Mr. K. experi-
enced much better breathing and almost no pain, al-
though the medication had been reduced to metamizol 
q.i.d. and tramadol p.r.n.
What are the disease trajectory  
and treatment options?
Tumor diseases may cause local, regional, and systemic 
functional disorders, symptoms, and complications. Th
 e 
local eff ects of lung cancer are airway obstruction and 
infi ltration of neighboring tissues. Th
  is may lead to mu-
coid impaction, retrostenotic pneumonia, hemorrhage, 
or pleural eff usion. Th
  e regional spreading of the tumor 
follows continuous infi ltration of the mediastinum, the 
pleura, or the axilla or spreads via local lymph vessels.
Symptoms of regional spreading are weakness; 
loss of appetite and weight; congestion of head and 
neck vessels; infi ltration into the mediastinum, axilla, 
and chest wall with mixed pain in the arm, shoulder, 
chest and upper back; dysphagia; or neurological dis-
orders (palsy of the arm, Horner syndrome, or para-
plegia). Th
 e systemic dissemination of primary lung 
tumors via the bloodstream or lymphatic pathways 
causes symptoms and disorders according to the quan-
tity and location of the metastases. Patients may now 
suff er from neurological, metabolic, cardiovascular or 
gastrointestinal disorders (Box 3). Common locations 
of dissemination of lung cancer are thoracic and cer-
vical lymph nodes, bone, pleura, the brain and its lin-
ings, the liver, and the adrenal glands. Very seldom are 
the spleen, heart, skin, eye (choroid coat), kidney, or 
pancreas affl
  icted.
Box 1. Common symptoms of beginning 
lung cancer
Persistent cough
Hemoptysis
Dyspnea
Chest pain
Hoarseness
Fever, mucoid impaction
Other pain locations
Loss of appetite, weight, and strength
Paraneoplastic syndromes
Cushing syndrome
Herpes zoster
Peripheral neuropathy
Venous thrombosis
Box 2. Common extrathoracic diseases and 
infections with pulmonary manifestation
Breast cancer
Rectal cancer
Renal cancer
Malignant melanoma
Sarcomas
Aspergillosis
Tuberculosis
Helminthiasis

Lung Cancer with Breathing Problems
165
Case report—part three
Mr. K. has been ill with lung cancer for 7 months now. 
Four weeks ago, he lost his appetite, and he feels sick 
quite often. He has lost weight continuously (about 30% 
of his initial body weight within one and a half years). 
Although carbamazepine has been stopped, the blood 
tests show high values for liver transaminases, accompa-
nied by upper abdominal pain. A physical examination 
reveals an upper abdominal mass, and ultrasonography 
detects multiple metastases in the liver and also in both 
adrenal glands.
The oncologist recommends chemotherapy, 
which would have to be conducted in the regional hos-
pital. Mr. K. is reluctant to return to the hospital in 
Atbara, the capital, and asks his friends and relatives 
for information on traditional treatment options they 
might have heard of.
What are the treatment options     
in advanced lung cancer?
Treatment options include:
•  Surgical therapy (curative or palliative)
•  Radiotherapy (neoadjuvant, palliative, or symptom-
targeted)
•  Chemotherapy and other pharmacological therapy 
(palliative)
• Naturopathy (palliative)
•  Palliative care (adjuvant)
Of course, the very best therapy would be the 
prevention of risk factors, but primary prevention pro-
cedures are not established. Diagnostic evaluation at the 
earliest time is crucial for the course of the illness.
Curative surgery needs the diagnosis of a low 
stage of disease (0–IIIa) in order to make eradication of 
the tumor possible by resection. Potential techniques 
include lobe resection, (pleuro-) pneumonectomy, or 
bronchial reconstruction. Additional options are dissec-
tions of lymph nodes and reconstruction of pericardium 
and blood vessels. Th
  e degree of ventilatory restriction 
depends on the magnitude of resection. Surgical treat-
ment needs to be conducted in a specialized clinical de-
partment. Postoperative rehabilitation is possible in the 
outpatient setting and must not be disregarded. Palliative 
surgery is done to remove metastases of extrathoracic 
tumors or local relapse as well as for draining of second-
ary infection such as empyema. Endoscopic or vascular 
interventions help with the reopening of airways and 
vessels by stenting or by laser or cryoextraction.
Radiotherapy alone cannot be used with a cu-
rative intention. In combination with chemotherapy, it 
may reduce the size of the tumor (downstaging), which 
might open the route to successful surgery (neoadjuvant 
strategy) and to an extension of survival time. Palliative 
radiotherapy intends to reduce the activity of metasta-
ses, which may result in reduction of pain (bones, liver, 
CNS, and pleura), blood congestion (superior vena cava 
syndrome caused by lymph node metastases of the me-
diastinum), or neurological disorders (CNS).
Systemic pharmacological therapies (chemo-
therapeutic, antihormone therapy, and others) work 
in a palliative way to reduce the bulk mass or the tu-
mor growth rate, allowing prolongation of survival. 
Th
  eir application usually weakens the general condi-
tion of the patient. It is therefore necessary to consid-
er the quality of life of individual patients from their 
personal perspective.
Are there therapeutic alternatives 
to surgery, chemotherapy,             
and radiotherapy?
Alternative (or complimentary) treatment strategies are 
based on traditional and empirical concepts. Th
 ey may 
be looked at as palliative and should not replace sci-
entifi c medical eff orts. Using a palliative perspective, 
these strategies may very well be of great meaning and 
eff ectiveness within the individual disease trajectory. It 
Box 3.  Common general disorders in lung cancer patients
Neurological: Limb palsy, hemiparesis, paraparesis, pain, delirium, epileptic seizures
Metabolic: Diabetes mellitus, SIADH (syndrome of inappropriate antidiuretic hormone 
hypersecretion), anemia, thrombocytosis, thrombopenia, hypercalcemia
Cardiovascular: Hypotension, thrombosis, superior (or inferior) vena cava congestion
Gastrointestinal: Nausea, vomiting, bowel obstruction, liver failure

166
Th
 omas Jehser
is often quite astonishing how they help the patient and 
their relatives face the illness with more understanding 
and to deal better with feelings of helplessness, which 
again might help to direct the path of disease to a cer-
tain extent.
According to the WHO, “Palliative care is an 
approach that improves the quality of life of patients 
and their families facing the problems associated with 
life-threatening illness, through the prevention and re-
lief of suff ering by means of early identifi cation and im-
peccable assessment and treatment of pain and other 
problems, physical, psychosocial and spiritual.” Th
 e 
founder of modern palliative care, Dame Cicely Saun-
ders (1918–2005), developed her fundamental ideas 
when she was trying to ease and diminish cancer pain 
by looking at it from more than a “physical” perspective. 
So she inaugurated treatment strategies for the psycho-
logical, social, and spiritual needs of the patients besides 
taking care of their physical condition, according to the 
concept of “total pain.” Palliative care, therefore, eases 
physical suff ering and provides information and under-
standing within the social context of the patient. In the 
same way, it delivers consolation and assistance to help 
with anxiety and emotional pain caused by the threat-
ened loss of one’s relations and life.
Case report—part four
Mr. K. fi nally agrees to have chemotherapy. After fi nding 
transportation, he visits the district hospital in Atbara 
routinely for the treatments and the necessary examina-
tions and feels somehow safe and stabilized, although he 
has to take antibiotics for a short term of pyogenic bron-
chitis. He meets other patients—many of them much 
younger than himself—who tell him about side eff ects, 
which he fi nds to be irrelevant to himself at this point. 
He gets a lot of relief when he fi nds a group supervised by 
a health care worker in his home town where they prac-
tice breathing and relaxation techniques. With the help 
of his family and friends he also gets advice from a tradi-
tional healer, who recommends an additional composite 
medication consisting of herbal and mineral substances. 
In personal meetings with his spiritual adviser Sheikh 
Farshi, he learns to talk to his wife and three children 
about the possible consequences of a fatal disease for the 
family and their fi nancial aff airs.
After the next course of chemotherapy, he suff ers 
from vomiting and weakness for the fi rst time following 
such a treatment. Again he feels abdominal and back 
pain, as well as some dyspnea at rest. Shortly afterwards, 
a scleral icterus begins, and Mr. K. shows periods of dis-
orientation and depression. His family takes him again 
to the Atbara district hospital for examination. It turns 
out there that he has developed a serious bone marrow 
insuffi
  ciency so that no further chemotherapy can be giv-
en. He is now sent home to talk with his family doctor 
about further action that might be taken.
What are the consequences of 
dyspnea, and how is it treated?
Dyspnea is defi ned as a subjective experience of breath-
ing discomfort, consisting of diff erent conditions that 
all lead to an increased breathing eff ort, either needing 
more strength or a higher respiratory rate. Th
 is experi-
ence is also infl uenced by interactions among physical 
and emotional conditions. Dyspnea may be caused by, 
but is not at all identical to, respiratory insuffi
  ciency. 
While dyspnea is a subjective sensation of the patient, 
respiratory insuffi
  ciency is a “physiological” phenom-
enon that can be exactly quantifi ed by testing. Th
 ere are 
multiple causes for respiratory insuffi
  ciency originating 
in the pulmonary, cardiac, vascular, bony, muscular, and 
nervous systems. Th
  e amount of resulting dyspnea de-
pends heavily on the course of development of respira-
tory insuffi
  ciency and its profoundness. Th
 erefore, some 
patients may be able to live with a greatly decreased re-
spiratory capacity without feeling any dyspnea at rest, 
while others with minor respiratory insuffi
  ciency  may 
suff er intense shortness of breath. Feeling dyspnea eas-
ily causes anxiety, and vice versa. Th
 e diff erentiation of 
shortness of breath therefore requires the clinician to 
evaluate not only vital capacity and FEV
1
, but also the 
general condition of the patient, so as to avoid underes-
timation of the problem.
For therapy for dyspnea to be eff ective, knowl-
edge of its physiology is helpful. In case of a possible 
treatment of underlying causes, such as bronchospasm 
or anemia, priority is given to this type of therapy. As 
one symptom of dyspnea deals with some sort of agita-
tion, sedative treatment allows successful symptom con-
trol, which might even help the breathing system to run 
more effi
  ciently.
Besides sedative drugs such as benzodiazepines, 
morphine is probably the most important remedy avail-
able for this important clinical situation. Morphine re-
duces the subjective “air hunger” signifi cantly, regardless 
of the actual physiological need for O
2
 and CO
2
 transport 

Lung Cancer with Breathing Problems
167
and exchange. Other drugs such as haloperidol, cannabi-
nol, and doxepin help to reduce the psychological distress 
and agitation. Besides pharmacotherapy, the treatment 
of cutaneous trigger zones by massage, cognitive and be-
havioral distraction, and even simply directing fresh air 
toward the face stimulating trigeminal receptors, with a 
direct infl uence on breathing frequency, are means that 
lead to reproducible relief of suff ering. Th
  e availability of 
morphine, oxygen, and a fan may therefore be the most 
important means and, most of the time, are suffi
  cient to 
control even advanced stages of dyspnea.
Besides dyspnea, what else should 
be considered in the treatment of 
lung cancer?
Most often lung cancer is a progressive disease accom-
panied by complications caused by tumor metasta-
ses and general physical exhaustion. Th
 ese complica-
tions often go along with pain and dyspnea and lead to 
enormous psychological suff ering, which needs to be 
addressed by appropriate treatment and honest infor-
mation about the therapeutic options. In this way it is 
possible to infl uence the patient’s perspective regarding 
his or her personal quality of life.
• Th
  e wide range of treatments targeting the diff er-
ent possible complications include:
•  Medication (e.g., analgetics, antibiotics, broncho-
dilators, corticosteroids).
•  Substitution of albumin, erythrocytes, electro-
lytes, fl uids, and caloric agents.
•  Radiotherapy (to treat lytic bone lesions, tumor 
obstruction of central airways, superior vena cava 
syndrome, or intracranial pressure).
•  Surgical, endoscopic, and intravascular inter-
ventions.
Complementary treatment off ers  exercise 
(physiotherapy), psychological or spiritual support, 
as well as receptive and imaginative therapies (mas-
sage, musical therapy, and active relaxation tech-
niques). A great number of patients carrying progres-
sive lung cancers die from the complications of their 
illness rather than from the lung cancer itself. During 
the fi nal period of life, supporting and comforting the 
patient by lowering anxiety, agitation, weakness, pain, 
and dyspnea is most important. When clinicians have 
provided comprehensive instructions and are available 
as a backup if needed, this support may be provided by 
family members at home.
Case report—part fi ve
Mr. K. has returned home and is mostly resting in a com-
fortable chair in the living room. His wife and two of the 
three children live with him in the house. Neighbors and 
some other family members visit quite regularly so that 
the patient participates in what is going on around him to 
a certain extent. Mr. K. has started to smoke again (about 
three cigarettes on a good day), which he claims “does not 
make any diff erence” at this point and reminds him of the 
“good old days” when he was a young postman in his origi-
nal home town. Smoking also gets him to walk a few steps, 
because his family insists that smoking is only allowed 
outside. Th
  e family doctor regularly visits the patient twice 
a week. He has instructed Mrs. K. and one of the sons to 
administer morphine via a subcutaneous route using ti-
tration doses in case of pain or dyspnea, which has been 
occurring several times during the evenings and nights. 
One day Mr. K. stumbles on his way back to his chair 
and is afraid of falling again after this incident. Th
 e next 
day he does not leave his bed and seems to be more dis-
oriented than ever. Th
  e visiting community nurse admin-
isters a sedative drug to the more and more agitated Mr. 
K. and calls for the family doctor. When the doctor comes 
in the next day, the general condition of Mr. K. has wors-
ened. He dreams heavily, is feverish, and shows seizures of 
his right arm and his face. Th
  e doctor decides to leave Mr. 
K. in Barbar, since he sees no further options for specifi c 
treatment, as he explains patiently to the anxious family. 
Again a sedative is given subcutaneously, and the patient’s 
agitation subsides, which helps the family to remain at his 
side constantly, though weeping a lot. At the end of this 
day, Mr. K. dies without regaining consciousness or show-
ing signs of agitation or suff ering, especially dyspnea.
Pearls of wisdom
Understand that:
•  Lung cancer is a life-threatening disease.
• Th
  e character of breathing problems helps you to 
decide on their treatment.
•  Lung cancer causes pain problems, which can be 
treated.
•  Palliative care can be given to patients with lung 
cancer.
•  Morphine and a fan may, in most cases, be suffi
  -
cient to prevent the patient from suff ocating.
• Th
 e necessary dose of morphine is not given 
as milligrams per kilogram of body weight, but 

168
Th
 omas Jehser
rather by titration in small repetitive doses until 
an eff ective dose is achieved.
• Th
  e positive eff ects of morphine far outweigh the 
risk of respiratory depression by opioids, since ti-
tration allows fi nding the balance between reduc-
tion of dyspnea and the typical side eff ect of re-
spiratory depression.
•  Morphine should be given subcutaneously to al-
low fast onset of action in acute situations of dys-
pnea, if the intravenous route is not available.
•  Patients with dyspnea in end-stage lung cancer 
not only need pharmacotherapy, but especially 
require a team of caring family members, health 
care workers, friends, and spiritual advisors.
•  Anything that helps the patient should be used, 
because in palliative care, reservations about 
complimentary, alternative, or traditional medi-
cine are not justifi ed.
References
[1]  Alberg AJ, Samet JM Epidemiology of lung cancer. Chest 2003;123:21.
[2] American 
Th
 oracic Society. Dyspnea: mechanisms, assessment and 
management, a consensus statement. Am J Respir Crit Care Med 
1999;159:321.
[3]  Bruera E, MacEachern T, Ripamonti C, Hanson J. Subcutaneous mor-
phine for dyspnea in cancer patients. Ann Intern Med 1993;119:906.
[4]  Colice GL. Detecting lung cancer as a cause of hemoptysis in pa-
tients with a normal chest radiograph: bronchoscopy vs. CT. Chest 
1997;111:877.
[5]  Harrington SE, Smith TJ. Th
  e role of chemotherapy at the end of life: 
“when is enough, enough?” JAMA 2008;299:2667.
[6]  Holty JEC, Gould MK. When in doubt should we cut it out? Th
  e role of 
surgery in non-small cell lung cancer. Th
 orax 2006;61:554.
[7]  Silvestri GA, Spiro SG. Carcinoma of the bronchus 60 years later. Th
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[8]  Toloza EM, Harpole L, McCrory DC. Noninvasive stating of non-small 
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169
Guide to Pain Management in Low-Resource Settings, edited by Andreas Kopf and Nilesh B. Patel. IASP, Seattle, © 2010. All rights reserved. Th
  is material may be used for educational 
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