Clinicians need to challenge the ‘pervasive nihilism’ regarding the management of breathlessness in chronic lung disease.

Professor David Currow told the Respiratory Insights Forum in Melbourne that too many people did not take the opportunity to recognise, assess and symptomatically treat breathlessness.

He warned there was evidence that even distressing symptoms were frequently not volunteered by patients to physicians.

A US study found open-ended questions returned a median of one symptom in a population of patients referred to a palliative medicine program¹. However a systematic assessment of symptoms revealed a median of ten symptoms.

Professor Currow, from IMPACCT (Improving Palliative, Aged and Chronic Care through Clinical Research and Translation) at University of Technology Sydney, said a comprehensive assessment of palliative care patients in Australia also found one in six had symptom distress reported as overwhelming².

“Breathing when well is subconscious and automatic. Breathing when not well requires concentration and effort. When patients say breathlessness is impacting their lives, we need to listen like we did with pain 30 years ago.”

He said acute breathlessness on a background of chronic breathlessness might also be a ‘harbinger of death’ in people with life-limiting disease.

A study, currently in press, of some 7,000 patients suggested breathlessness worsened in the week before death.

“Don’t just shrug your shoulders,” he said. “We often assume that someone else has looked for potentially reversible factors.”

Factors might include arrhythmias, worsening cardiac failure or worsening respiratory failure.

“There is a study of consecutive admissions to inpatient palliative care in the UK which showed that 50% of those people had a detectable DVT. It doesn’t mean it was symptomatic, it doesn’t mean they had a pulmonary embolus but they’ve got the disease there waiting.”

“And again I stress, it doesn’t mean we have to do something but we have to have thought: ‘Should we have a conversation about whether we look further?’”

“And the person might say they don’t want to look further. That’s perfectly okay. But we need to be aware that worsening breathlessness shouldn’t just be dismissed as an inevitable consequence of the disease.”

Management of breathlessness

Professor Currow said there was evidence for a range of non-pharmacological interventions to relieve breathlessness including walking aids, neuromuscular electrical stimulation to reverse de-conditioning and hand-held, battery-operated fans.

However most medications including benzodiazepines³ and anxiolytics⁴ were of no benefit. His own recent randomised controlled trial in patients with chronic breathlessness found sertraline had no benefit on breathlessness, performance status, anxiety or depression⁵.

The evidence was however strong for the use of low dose, regular, extended-release morphine – the most widely studied opiate – and now recommended in guidelines such as GOLD⁶.

“There are now a number of RCTs but at the end of the day we have a consistent signal for efficacy in terms of long-term follow-up. We’ve followed people out to a maximum of 660 days, although admittedly a mean of three months, and we haven’t seen tachyphylaxis, we haven’t seen respiratory depression at all.”

“It is reassuring – we’re talking only 30mg morphine per 24 hours – and it is clearly taking the edge off the sensation of breathlessness.”

“We will need lots of things to help keep people out of the emergency department. This is one of many things that we will need to put in place in order to achieve that.”

References

1. Homsi J et al. Symptom evaluation in palliative medicine: patient report vs systematic assessment. Support Care Cancer. 2006. 14(5):444-53. https://www.ncbi.nlm.nih.gov/pubmed/16402231
2. Pidgeon T et al. A survey of patients’ experience of pain and other symptoms while receiving care from palliative care services. BMJ Supportive & Palliative Care 2016;6:315-322. https://spcare.bmj.com/content/6/3/315
3. Simon ST et al. Benzodiazepines for the relief of breathlessness in advanced malignant and non-malignant diseases in adults. Cochrane Database Syst Rev. 2016;10:CD007354. https://www.ncbi.nlm.nih.gov/pubmed/27764523
4. Peoples AR et al. Buspirone for management of dyspnea in cancer patients receiving chemotherapy: a randomized placebo-controlled URCC CCOP study. Support Care Cancer. 2016;24(3):1339-47. https://www.ncbi.nlm.nih.gov/pubmed/26329396
5. Currow D et al. Sertraline In Symptomatic Chronic Breathlessness: A Double Blind, Randomised Trial. American Journal of Respiratory and Critical Care Medicine. 2018;197:A7730. https://www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2018.197.1_MeetingAbstracts.A7730
6. Vogelmeier CF et al. Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report. GOLD Executive Summary. AJRCCM. 2017;195(5). https://www.atsjournals.org/doi/abs/10.1164/rccm.201701-0218pp