Beyond bronchodilators for dyspnea in COPD

We don’t need any more systematic reviews on pulmonary rehabilitation; we just need to get patients doing pulmonary rehabilitation.

That was one of the key messages at the Respiratory Insights Forum in Melbourne for management of COPD patients beyond core therapy with bronchodilators.

Professor Jean Bourbeau said we understood a lot of the mechanism of impact that bronchodilators had on respiratory mechanics, but there was still more to learn about other interventions.

Director of the COPD Clinic and Pulmonary Rehabilitation Unit at the McGill University Health Centre in Montreal, Professor Bourbeau said much of the main focus of pulmonary rehabilitation had been physical training to improve capacity.

“But what we are discovering, especially in the last ten years, is that it is not enough to achieve capacity if people are not going to manage their disease better or adopt healthy habits such as physical activity. And we know that increasing exercise capacity doesn’t equal increasing physical activity.”

He said the psychological component of pulmonary rehabilitation was complementary to the physical component.

“To reach the goal of increasing physical activity, you really have to work on the behavioral part. And this is one of the challenges and where self-management has to be integrated into pulmonary rehabilitation.”

As with smoking cessation programs, an active model that comprised patients’ needs, goals and motivations, self-efficacy, removal of internal and external barriers, and confidence would progressively improve healthy habits.

“Certainly pulmonary rehabilitation is something that all these patients should have. Sometimes we need to go beyond physiological responses to target not only the underlying disease,” he said.

Professor Bourbeau said physical training effects could not explain improvements in COPD patients within the first two weeks of pulmonary rehabilitation.

“Therefore there has to be either something related to breathing technique or coping that the patient has learnt, and/or control of anxiety.”

He said a Canadian study had shown a significant association between dyspnea intensity and breathing-related anxiety. Improvements after pulmonary rehabilitation were more consistently seen in the affective and symptom impact domains of dyspnea than in the sensory-perceptual domain1.

Other non-pharmacological interventions such as pursed lip breathing were recommended for relieving dyspnea in Canadian clinical practice guidelines2.

Professor Bourbeau said oxygen was not often used and any mechanism [of action] was not well understood but there was some limited evidence for its use in a minority of patients.

“It’s not having an impact on lung mechanics, but more by changing breathing frequency whereas if they slow down, patients are going to have less dynamic hyperinflation.”

“It seems to work but we don’t know if it’s a peripheral effect or a central effect. And we have no way to predict who is going to respond.”

“I usually do a n-of-1 trial demonstrating the objective improvement in alleviating symptoms. Oxygen doesn’t apply to the whole COPD population. It is the exception.”

Professor Bourbeau said that opioids were useful in managing breathlessness.

In one Canadian study immediate-release oral morphine decreased exertional breathlessness and improved exercise endurance in advanced COPD3. The improvements followed maximal bronchodilation with 400ug of inhaled salbutamol.

“I do think we have to alleviate this symptom and help them be more functional. It’s not only a question of relieving the symptoms but allowing them to do more as well.”


  1. Wadell K et al. Impact of Pulmonary Rehabilitation on the Major Dimensions of Dyspnea in COPD. COPD. 2013;10:425-35.
  2. Marciniuk DD et al. Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: A Canadian Thoracic Society clinical practice guideline. Can Respir J. 2011;18(2):69-78.
  3. Abdallah SJ et al. Effect of morphine on breathlessness and exercise endurance in advanced COPD: a randomised crossover trial. ERJ. 2017; 50: 1701235.

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