Managing Dyspnea in Patients with Advanced Chronic Obstructive Pulmonary Disease: A Canadian Thoracic Society Clinical Practice Guideline

Abstract

Dyspnea is a cardinal symptom of chronic obstructive pulmonary disease (COPD), and its severity and magnitude increases as the disease progresses, leading to significant disability and a negative effect on quality of life. Refractory dyspnea is a common and difficult symptom to treat in patients with advanced COPD. There are many questions concerning optimal management and, specifically, whether various therapies are effective in this setting. The present document was compiled to address these important clinical issues using an evidence-based systematic review process led by a representative interprofessional panel of experts. The evidence supports the benefits of oral opioids, neuromuscular electrical stimulation, chest wall vibration, walking aids and pursed-lip breathing in the management of dyspnea in the individual patient with advanced COPD. Oxygen is recommended for COPD patients with resting hypoxemia, but its use for the targeted management of dyspnea in this setting should be reserved for patients who receive symptomatic benefit. There is insufficient evidence to support the routine use of anxiolytic medications, nebulized opioids, acupuncture, acupressure, distractive auditory stimuli (music), relaxation, handheld fans, counselling programs or psychotherapy. There is also no evidence to support the use of supplemental oxygen to reduce dyspnea in nonhypoxemic patients with advanced COPD. Recognizing the current unfamiliarity with prescribing and dosing of opioid therapy in this setting, a potential approach for their use is illustrated. The role of opioid and other effective therapies in the comprehensive management of refractory dyspnea in patients with advanced COPD is discussed.

Perspectives of patients, family caregivers and physicians about the use of opioids for refractory dyspnea in advanced chronic obstructive pulmonary disease

“…The Canadian Medical Association's code of ethics reminds us of our responsibility to "first consider the wellbeing of the patient" and that doing so requires our engagement in "lifelong learning to maintain and improve … professional knowledge, skills, and attitudes." 39 Evidence is accumulating to suggest that soon the appropriate question will no longer be if we should prescribe opioids to help palliate refractory dyspnea in patients living with advanced COPD, but rather how to do this competently 7,40 and when.…”

'INSPIRED' Approaches to Better Care for Patients with Advanced COPD

“…e Canadian oracic Society (CTS) has recently released a clinical practice guideline [20] (available via www.copd guidelines.ca) that presents an evidence-based approach to dyspnea management (see Figure 1).…”

“…is clinical practice guideline [20] builds on the concept of the 'dyspnea ladder' described some years ago [21] and emphasizes a stepwise approach to palliation of refractory dyspnea using conventional therapies, non-pharmacological approaches and carefully initiated and titrated opioids.…”

“…Nevertheless, long-held fears of further depressing respiration continue to limit more widespread acceptance by physicians [35] despite recommendations for their use in several recent professional society statements and/or clinical practice guidelines [20,36,37]. ualitative studies indicate e cacy and acceptability from patient and caregiver perspectives [35].…”

A Comparative Study of 3 Portable Oxygen Concentrators During a 6-Minute Walk Test in Patients With Chronic Lung Disease

“…1,2 Supplemental oxygen improves exercise performance, enhances exercise training, and reduces dyspnea. 3,4 Patients with chronic lung disease using LTOT benefit from an active lifestyle, and portable oxygen systems are of particular interest to this patient population. The challenge for clinicians is in selecting the most appropriate portable oxygen system and meeting the patients' current and future clinical and physical needs.…”