Is chronic breathlessness less recognised and treated compared with chronic pain? A case-based randomised controlled trial

Disability and long-term breathlessness: a cross-sectional, population study

INTRODUCTION

Disability, resulting from altered interactions between individuals and their environment, is a worldwide issue causing inequities and suffering. Many diseases associated with breathlessness cause disability but the relationship between disability and the severity of breathlessness itself is unknown.This study evaluated associations between disability using the WHO's Disability Assessment Schedule (WHODAS) 2.0 and levels of long-term breathlessness limiting exertion.

METHODS

This population-based, cross-sectional online survey (n=10 033) reflected the most recent national census (2016) by age, sex, state/territory of residence and rurality. Assessments included self-reported disability (WHODAS 2.0 12-item (range 12 (no disability) to 60 (most severe disability)) assessed in 6 domains) and long-term breathlessness limiting exertion (modified Medical Research Council (mMRC) breathlessness scale; 0-4 (4-most severe)). Days in the last month affected by breathlessness were reported.

RESULTS

Of respondents (52% women; mean age 45), mean total disability score was 20.9 (SD 9.5). 42% (n=4245) had mMRC >0 (mMRC1 31% (n=3139); mMRC2 8% (n=806); mMRC3,4 3% (n=300)). Every level of long-term breathlessness limiting exertion was associated with greater levels of disability (total p <0.001; each domain p <0.001). The most compromised domains were Mobility and Participation.In the last 30 days, people with severe breathlessness (mMRC 3-4): experienced disability (20 days); reduced activities/work (10 days); and completely forwent activities (another 5 days).

CONCLUSIONS

Disability should be in the definition of persistent breathlessness as it is systematically associated with long-term breathlessness limiting exertion in a grade-dependent, multidimensional manner. Disability should be assessed in people with long-term breathlessness to optimise their social well-being and health.

Breathlessness assessment, management and impact in the intensive care unit: a rapid review and narrative synthesis

BACKGROUND

Adults in the intensive care unit (ICU) commonly experience distressing symptoms and other concerns such as pain, delirium, and breathlessness. Breathlessness management is not supported by any ICU guidelines, unlike other symptoms.

AIM

To review the literature relating to (i) prevalence, intensity, assessment, and management of breathlessness in critically ill adults in the ICU receiving invasive and non-invasive mechanical ventilation (NIV) and high-flow oxygen therapy, (HFOT), (ii) the impact of breathlessness on ICU patients with regard to engagement with rehabilitation.

METHODS

A rapid review and narrative synthesis using the Cochrane Methods Group Recommendations was conducted and reported in accordance with PRISMA. All study designs investigating breathlessness in adult ICU patients receiving either invasive mechanical ventilation (IMV), NIV or HFOT were eligible. PubMed, MEDLINE, The Cochrane Library and CINAHL databased were searched from June 2013 to June 2023. Studies were quality appraised.

RESULTS

19 studies representing 2822 ICU patients were included (participants mean age 48 years to 71 years; proportion of males 43-100%). The weighted mean prevalence of breathlessness in ICU patients receiving IMV was 49% (range 34-66%). The proportion of patients receiving NIV self-reporting moderate to severe dyspnoea was 55% prior to initiation. Breathlessness assessment tools included visual analogue scale, (VAS), numerical rating scale, (NRS) and modified BORG scale, (mBORG). In patients receiving NIV the highest reported median (interquartile range [IQR]) VAS, NRS and mBORG scores were 6.2cm (0-10 cm), 5 (2-7) and 6 (2.3-7) respectively (moderate to severe breathlessness). In patients receiving either NIV or HFOT the highest reported median (IQR) VAS, NRS and mBORG scores were 3 cm (0-6 cm), 8 (5-10) and 4 (3-5) respectively.

CONCLUSION

Breathlessness in adults receiving IMV, NIV or HFOT in the ICU is prevalent and clinically important with median intensity ratings indicating the presence of moderate to severe symptoms.

Translation and Linguistic Validation of the Multidimensional Dyspnea Profile into Hindi in a Palliative Care Setting

Objectives

The Multidimensional Dyspnea Profile (MDP) comprehensively addresses dyspnea, incorporating both perceptual and affective components, and has proven effective in assessing breathlessness among patients with chronic lung conditions. Despite its validation in High-Income Countries, its applicability in Low/Middle-Income countries remains uncertain. Additionally, the MDP has not been translated into Hindi or validated in an Indian context. Our aim was to translate the MDP into Hindi and linguistically validate it for use in an Indian palliative care setting, with a high rate of illiteracy.

Materials and Methods

The comprehensibility and acceptability of the translated MDP in Hindi were assessed through in-depth interviews with seven Hindi-speaking patients with cancer. The study focused on tailoring the MDP in a socioeconomically disadvantaged population characterized by a high rate of illiteracy. The translation process involved forward and backward translations by independent certified translators, with input from in-country Indian palliative medicine physicians and healthcare personnel.

Results

The Hindi version of the MDP was adapted for use in an Indian context and in a population with a high rate of illiteracy, aligning with international guidelines for Patient-Reported Outcomes demonstrating relevance in a specific cultural and healthcare context. The MDP increased healthcare staff 's understanding of underlying causes of dyspnea in a socioeconomically disadvantaged population enrolled into palliative care and with a high rate of illiteracy.

Conclusion

The study underscores the importance of linguistic validation and cultural adaptation in ensuring the applicability of Patient-Reported Outcomes measures in diverse healthcare settings. Because the MDP can be perceived as time-consuming, selected parts of the instrument may be used as needed.

European Respiratory Society clinical practice guideline on symptom management for adults with serious respiratory illness

Respiratory symptoms are ubiquitous and impair health-related quality of life in people with respiratory disease. This European Respiratory Society (ERS) task force aimed to provide recommendations for symptomatic treatment in people with serious respiratory illness. The ERS task force comprised 16 members, including representatives of people with serious respiratory illness and informal caregivers. Seven questions were formulated, six in the PICO (Population, Intervention, Comparison, Outcome) format, which were addressed with full systematic reviews and evidence assessed using GRADE (Grading of Recommendations Assessment, Development and Evaluation). One question was addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. To treat symptoms in people with serious respiratory illness, the task force suggests the use of graded exercise therapy (conditional recommendation, low certainty of evidence); and suggests the use of a multicomponent services, handheld fan and breathing techniques (conditional recommendations, very low certainty of evidence). The task force suggests not to use opioids (conditional recommendation, very low certainty of evidence); and suggests either administering or not administering supplemental oxygen therapy (conditional recommendation, low certainty of evidence). The task force suggests that needs assessment tools may be used as part of a comprehensive needs assessment, but do not replace patient-centred care and shared decision making (conditional recommendation, low certainty of evidence). The low certainty of evidence, modest impact of interventions on patient-centred outcomes, and absence of effective strategies to ameliorate cough highlight the need for new approaches to reduce symptoms and enhance wellbeing for individuals who live with serious respiratory illness.

Dyspnoea relief as an inherent benefit of high flow nasal cannula therapy: A laboratory randomized trial in healthy humans

BACKGROUND AND OBJECTIVE

Persistent dyspnoea is a public health issue for which the therapeutic arsenal is limited. This study tested high-flow nasal cannula therapy (HFNT) as a means to alleviate experimental dyspnoea.

METHODS

Thirty-two healthy subjects underwent an experimental dyspnoea induced by thoracoabdominal elastic loading. HFNT was administered with alternately FiO2 of 100% (HFNT100) or 21% (HFNT21). The sensory (S-VAS) and affective (A-VAS) components of dyspnoea, transcutaneous CO2 pressure (PtcCO2 ), pulse-oximetry oxygen saturation (SpO2 ), heart rate, respiratory rate and skin galvanometry were monitored continuously. Three experimental sessions of 8 min were conducted: the first session consisted in familiarization with the experimental dyspnoea and the next two sessions tested the effects of HFNT100 and HFNT21 alternatively in a randomized order.

RESULTS

HFNT21 and HFNT100 significantly reduced dyspnoea, respectively of ∆A-VAS = 0.80 cm [-0.02-1.5]; p = 0.007 and ∆A-VAS = 1.00 cm [0.08-1.75]; p < 0.0001; ∆S-VAS = 0.70 cm [-0.15-1.98]), p < 0.0001 and ∆S-VAS = 0.70 cm [0.08-1.95]), p = 0.0002) with no significant difference between HFNT21 and HFNT100. HFNT did not significantly alter the respiratory rate or the heart rate, reduced PtcCO2 only on room air and GSR under both experimental conditions.

CONCLUSION

HFNT was associated with a statistically significant reduction in the intensity of the sensory and affective components of dyspnoea, independent of oxygen addition. This relief of laboratory dyspnoea could result from a reduction of afferent-reafferent mismatch.

Which breathlessness dimensions associate most strongly with fatigue?-The population-based VASCOL study of elderly men

BACKGROUND

Breathlessness and fatigue are common symptoms in older people. We aimed to evaluate how different breathlessness dimensions (overall intensity, unpleasantness, sensory descriptors, emotional responses) were associated with fatigue in elderly men.

METHODS

This was a cross-sectional analysis of the population-based VAScular disease and Chronic Obstructive Lung Disease (VASCOL) study of 73-year old men. Breathlessness dimensions were assessed using the Dyspnoea-12 (D-12), Multidimensional Dyspnoea Profile (MDP), and the modified Medical Research Council (mMRC) scale. Fatigue was assessed using the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) questionnaire. Clinically relevant fatigue was defined as FACIT-F≤ 30 units. Scores were compared standardized as z-scores and analysed using linear regression, adjusted for body mass index, smoking, depression, cancer, sleep apnoea, prior cardiac surgery, respiratory and cardiovascular disease.

RESULTS

Of 677 participants, 11.7% had clinically relevant fatigue. Higher breathlessness scores were associated with having worse fatigue; for D-12 total, -0.35 ([95% CI] -0.41 to -0.30) and for MDP A1, -0.24 (-0.30 to -0.18). Associations were similar across all the evaluated breathlessness dimensions even when adjusting for the potential confounders.

CONCLUSION

Breathlessness assessed using D-12 and MDP was associated with worse fatigue in elderly men, similarly across different breathlessness dimensions.

Should opioids be used for breathlessness and in whom? A PRO and CON debate of the evidence

Purpose of review

The net clinical benefit of opioids for chronic breathlessness has been challenged by recent randomized clinical trials. The purpose was to review and weigh the evidence for and against opioid treatment for chronic breathlessness in people with serious disease.

Recent findings

Evidence to date on the efficacy and safety of opioids for chronic breathlessness was reviewed. Findings supporting a benefit from opioids in meta-analyses of earlier, mostly smaller trials were not confirmed by recent larger trials. Evidence pertains mostly to people with chronic obstructive pulmonary disease but also to people with pulmonary fibrosis, heart failure, and advanced cancer. Taken together, there is no consistent evidence to generally recommend opioids for severe breathlessness or to identify people who are more likely to benefit. Opioid treatment may be tested in patients with intractable breathlessness and limited other treatment options, such as in end-of-life care. Knowledge gaps were identified and recommendations were made for future research.

Summary

Key Points Supportive findings of net benefit of opioids for chronic breathlessness in earlier trials have not been confirmed by recent larger randomized clinical trials. There is no evidence that the opioid treatment improves the person’s exercise capacity or quality of life, and it increases the risk of adverse events. Evidence to date does not support that opioids should generally be recommended for treating breathlessness. In people with intractable symptoms and short expected survival, with few or no treatment options, it may still be reasonable to try opioid treatment with the aim to alleviate severe breathlessness. Research is needed to explore the potential benefit of opioids in selected patient groups. Opioids cannot be generally recommended for treating breathlessness based on insufficient evidence for net clinical benefit.

Fixed-intensity exercise tests to measure exertional dyspnoea in chronic heart and lung populations: a systematic review

INTRODUCTION

Exertional dyspnoea is the primary diagnostic symptom for chronic cardiopulmonary disease populations. Whilst a number of exercise tests are used, there remains no gold standard clinical measure of exertional dyspnoea. The aim of this review was to comprehensively describe and evaluate all types of fixed-intensity exercise tests used to assess exertional dyspnoea in chronic cardiopulmonary populations and, where possible, report the reliability and responsiveness of the tests.

METHODS

A systematic search of five electronic databases identified papers that examined 1) fixed-intensity exercise tests and measured exertional dyspnoea, 2) chronic cardiopulmonary populations, 3) exertional dyspnoea reported at isotime or upon completion of fixed-duration exercise tests, and 4) published in English.

RESULTS

Searches identified 8785 papers. 123 papers were included, covering exercise tests using a variety of fixed-intensity protocols. Three modes were identified, as follows: 1) cycling (n=87), 2) walking (n=31) and 3) other (step test (n=8) and arm exercise (n=2)). Most studies (98%) were performed on chronic respiratory disease patients. Nearly all studies (88%) used an incremental exercise test. 34% of studies used a fixed duration for the exercise test, with the remaining 66% using an exhaustion protocol recording exertional dyspnoea at isotime. Exertional dyspnoea was measured using the Borg scale (89%). 7% of studies reported reliability. Most studies (72%) examined the change in exertional dyspnoea in response to different interventions.

CONCLUSION

Considerable methodological variety of fixed-intensity exercise tests exists to assess exertional dyspnoea and most test protocols require incremental exercise tests. There does not appear to be a simple, universal test for measuring exertional dyspnoea in the clinical setting.

European Respiratory Society clinical practice guideline: palliative care for people with COPD or interstitial lung disease

There is increased awareness of palliative care needs in people with COPD or interstitial lung disease (ILD). This European Respiratory Society (ERS) task force aimed to provide recommendations for initiation and integration of palliative care into the respiratory care of adult people with COPD or ILD. The ERS task force consisted of 20 members, including representatives of people with COPD or ILD and informal caregivers. Eight questions were formulated, four in the Population, Intervention, Comparison, Outcome format. These were addressed with full systematic reviews and application of Grading of Recommendations Assessment, Development and Evaluation for assessing the evidence. Four additional questions were addressed narratively. An "evidence-to-decision" framework was used to formulate recommendations. The following definition of palliative care for people with COPD or ILD was agreed. A holistic and multidisciplinary person-centred approach aiming to control symptoms and improve quality of life of people with serious health-related suffering because of COPD or ILD, and to support their informal caregivers. Recommendations were made regarding people with COPD or ILD and their informal caregivers: to consider palliative care when physical, psychological, social or existential needs are identified through holistic needs assessment; to offer palliative care interventions, including support for informal caregivers, in accordance with such needs; to offer advance care planning in accordance with preferences; and to integrate palliative care into routine COPD and ILD care. Recommendations should be reconsidered as new evidence becomes available.

ERS International Congress 2022: highlights from the Respiratory Clinical Care and Physiology Assembly

It is a challenge to keep abreast of all the clinical and scientific advances in the field of respiratory medicine. This article contains an overview of the laboratory-based science, clinical trials and qualitative research that were presented during the 2022 European Respiratory Society International Congress within the sessions from the five groups of Assembly 1 (Respiratory Clinical Care and Physiology). Selected presentations are summarised from a wide range of topics: clinical problems, rehabilitation and chronic care, general practice and primary care, mobile/electronic health (m-health/e-health), clinical respiratory physiology, exercise and functional imaging.

Patient and physician factors associated with symptomatic undiagnosed asthma or COPD

BACKGROUND

It remains unclear why some symptomatic individuals with asthma or COPD remain undiagnosed. Here, we compare patient and physician characteristics between symptomatic individuals with obstructive lung disease (OLD) who are undiagnosed and individuals with physician-diagnosed OLD.

METHODS

Using random-digit dialling and population-based case finding, we recruited 451 participants with symptomatic undiagnosed OLD and 205 symptomatic control participants with physician-diagnosed OLD. Data on symptoms, quality of life and healthcare utilisation were analysed. We surveyed family physicians of participants in both groups to elucidate differences in physician practices that could contribute to undiagnosed OLD.

RESULTS

Participants with undiagnosed OLD had lower mean pre-bronchodilator forced expiratory volume in 1 s percentage predicted compared with those who were diagnosed (75.2% versus 80.8%; OR 0.975, 95% CI 0.963-0.987). They reported greater psychosocial impacts due to symptoms and worse energy and fatigue than those with diagnosed OLD. Undiagnosed OLD was more common in participants whose family physicians were practising for >15 years and in those whose physicians reported that they were likely to prescribe respiratory medications without doing spirometry. Undiagnosed OLD was more common among participants who had never undergone spirometry (OR 10.83, 95% CI 6.18-18.98) or who were never referred to a specialist (OR 5.92, 95% CI 3.58-9.77). Undiagnosed OLD was less common among participants who had required emergency department care (OR 0.44, 95% CI 0.20-0.97).

CONCLUSIONS

Individuals with symptomatic undiagnosed OLD have worse pre-bronchodilator lung function and present with greater psychosocial impacts on quality of life compared with their diagnosed counterparts. They were less likely to have received appropriate investigations and specialist referral for their respiratory symptoms.

Associations in Perceived Health and Persistent Breathlessness: A Cross-Sectional Study

Background

Persistent breathlessness is debilitating and increases in prevalence with advanced age and at end of life. This study aimed to evaluate any relationship between self-reported global impressions of change (GIC) in perceived health and breathlessness in older men.

Design

Cross-sectional study of 73-year-old Swedish men in the VAScular and Chronic Obstructive Lung disease study. A postal survey included items on perceived changes in health and breathlessness (GIC scales) and breathlessness (assessed using the modified Medical Research Council [mMRC] breathlessness scale, Dyspnea-12 and Multidimensional Dyspnea Scale) since age 65.

Results

Of 801 respondents, breathlessness (mMRC ≥2) was reported by 17.9%, worsening breathlessness by 29.1%, and worsening perceived health by 51.3%. Worsening breathlessness was strongly correlated with worsening perceived health (Pearson's correlation coefficient of 0.68 [p < 0.001] and Kendall's τ of 0.56 [p < 0.001]) and associated with more limited function (47.2% vs. 29.7%; p < 0.0001) and increased rates of anxiety/depression.

Conclusion

The strong correlation between perceived changes in health and persistent breathlessness helps delineate a more comprehensive picture of the challenges faced by older adults living with this disabling symptom.

'Involve me and I learn': an experiential teaching approach to improve dyspnea awareness in medical residents

BACKGROUND

Dyspnea is a frightening and debilitating experience. It attracts less attention than pain ('dyspnea invisibility'), possibly because of its non-universal nature. We tested the impact of self-induced experimental dyspnea on medical residents.

MATERIALS AND METHODS

During a teaching session following the principles of experiential learning, emergency medicine residents were taught about dyspnea theoretically, observed experimental dyspnea in their teacher, and personally experienced self-induced dyspnea. The corresponding psychophysiological reactions were described. Immediate and 1-year evaluations were conducted to assess course satisfaction (overall 0-20 grade) and the effect on the understanding of what dyspnea represents for patients.

RESULTS

Overall, 55 emergency medicine residents participated in the study (26 men, median age 26 years). They were moderately satisfied with previous dyspnea teaching (6 [5-7] on a 0-10 numerical rating scale [NRS]) and expressed a desire for an improvement in the teaching (8 [7-9]). Immediately after the course they reported improved understanding of patients' experience (7 [6-8]), which persisted at 1 year (8 [7-9], 28 respondents). Overall course grade was 17/20 [15-18], and there were significant correlations with experimental dyspnea ratings (intensity: r = 0.318 [0.001-0.576], p = 0.043; unpleasantness: r = 0.492 [0.208-0.699], p = 0.001). In multivariate analysis, the only factor independently associated with the overall course grade was 'experiential understanding' (the experimental dyspnea-related improvement in the understanding of dyspneic patients' experience). A separate similar experiment conducted in 50 respiratory medicine residents yielded identical results.

CONCLUSIONS

This study suggests that, in advanced medical residents, the personal discovery of dyspnea can have a positive impact on the understanding of what dyspnea represents for patients. This could help fight dyspnea invisibility.

Tests to uncover and assess breathlessness: a proposed framework

PURPOSE OF REVIEW

Breathlessness is a common, distressing, and limiting symptom that many people avoid by reducing their activity. This review discusses exertional tests that can be used for uncovering and assessing breathlessness depending on the person's severity of illness, function, the setting, and aim of the assessment.

RECENT FINDINGS

Standardized exertional tests are useful to uncover 'hidden' breathlessness earlier in people who may have adapted their physical activity to limit their breathing discomfort. In 'more fit' ambulatory people and outpatients, cardiopulmonary exercise testing is the gold standard for assessing symptom severity, underlying conditions, and mechanisms and treatment effects. Among field tests, the 6-min walk test is not useful for assessing breathlessness. Instead, the 3-min step test and walk test are validated for measuring breathlessness change in chronic obstructive pulmonary disease. In people with more severe illness (who are most often not breathless at rest), reported tests include upper limb exercise or counting numbers aloud, but a valid and useful test for this population is lacking.

SUMMARY

A framework for selecting the most appropriate test to assess breathlessness validly is proposed, and research needs are identified.

Real-world opioid prescription to patients with serious, non-malignant, respiratory illnesses and chronic breathlessness

BACKGROUND

Chronic breathlessness is a disabling symptom that is often under-recognised and challenging to treat despite optimal disease-directed therapy. Low-dose, oral opioids are recommended to relieve breathlessness, but little is known regarding long-term opioid prescription in this setting.

AIM

To investigate the long-term efficacy of, and side-effects from, opioids prescribed for chronic breathlessness to patients with advanced, non-malignant, respiratory diseases.

METHODS

A prospective cohort study of all patients managed by the advanced lung disease service, an integrated respiratory and palliative care service, at the Royal Melbourne Hospital from 1 April 2013 to 3 March 2020.

RESULTS

One hundred and nine patients were prescribed opioids for chronic breathlessness. The median length of opioid use was 9.8 (interquartile range (IQR) = 2.8-19.8) months. The most commonly prescribed initial regimen was an immediate-release preparation (i.e. Ordine) used as required (37; 33.9%). For long-term treatment, the most frequently prescribed regimen included an extended-release preparation with an as needed immediate-release (37; 33.9%). The median dose prescribed was 12 (IQR = 8-28) mg oral morphine equivalents/day. Seventy-one (65.1%) patients reported a subjective improvement in breathlessness. There was no significant change in the mean modified Medical Research Council dyspnoea score (P = 0.807) or lung function measurements (P = 0.086-0.727). There was no association between mortality and the median duration of opioid use (P = 0.201) or dose consumed (P = 0.130). No major adverse events were reported.

CONCLUSION

Within this integrated respiratory and palliative care service, patients with severe, non-malignant respiratory diseases safely used long-term, low-dose opioids for breathlessness with subjective benefits reported and no serious adverse events.

Lower workforce participation is associated with more severe persisting breathlessness

Background

Not being able to work has negative health, social and financial consequences. Persisting breathlessness is prevalent in working-aged people. Is it associated with lower workforce participation? This study, using the South Australian Health Omnibus, aimed to explore associations between paid workforce participation and persisting breathlessness intensity, and economic impacts on income in people of working age.

Methods

This cross-sectional study conducted face-to-face interviews with a random sample of adults in South Australia (n = 8916). Questions included key demographic data, workforce participation and the presence and intensity of persisting breathlessness. Data from working-aged respondents (20–65 years of age) were standardised to the census for regression analyses. Work was coded to paid full- or part-time work or ‘other’. Persisting breathlessness (more than three of the last six months) used the modified Medical Research Council breathlessness scale (aggregated to 0, 1, 2–4). Opportunity cost valuations compared annual income foregone by persisting breathlessness severity.

Results

Of people interviewed, 6,608 were working-aged (49.9% male; 67.5% had post-secondary qualifications; 70.9% were in paid full- or part-time work; and 1.7% had mMRC score 2–4). Workforce participation dropped in working aged people with increasing breathlessness: mMRC 0, 70.6%; mMRC 1, 51.7%; mMRC 2–4, 20.3%. In the regression model, people with the most severe breathlessness were much less likely to work (OR 0.14; 95% CI 0.09, 0.22). Annual income foregone by people with persisting breathlessness was AU$10.7 billion (AU$9.1b for full-time and AU$1.6b for part-time work; range AU$5.9b, AU$49.7b).

Conclusion

Worsening persisting breathlessness is associated with lower workforce participation with direct financial consequences, greatest for older males.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-022-01861-y.

Relationship between Multimorbidity and Quality of Life in a Primary Care Setting: The Mediating Role of Dyspnea

Multimorbidity is known to impair Quality of Life (QoL) in patients in a primary setting. Poor QoL is associated with higher dyspnea perception. How multimorbidity and dyspnea perception are related to QoL needs clarification. The aim of the present study is to evaluate the mediating role of dyspnea perception in the relationship between multimorbidity and QoL in adults with and without airflow obstruction in a primary care setting. Seventeen general practitioners participated in the study: a total of 912 adult patients attending the practitioner’s surgery for a generic consultation completed a preliminary respiratory screening; 566 of them answered a respiratory questionnaire between January and June 2014, and 259 of the latter (148 M, aged 40–88) agreed to go through all the of procedures including spirometry, the IMCA and QoL (SF-36 through Physical Health “PCS” and Mental Health components) questionnaires, evaluation of comorbidities and the mMRC Dyspnea Scale. For screening purpose, a cut-off of FEV₁/FVC < 70% was considered a marker of airflow obstruction (AO). Of the sample, 25% showed airflow obstruction (AO). No significant difference in mMRC score regarding the number of comorbidities and the PCS was found between subjects with and without AO. Multimorbidity and PCS were inversely related in subjects with (p < 0.001) and without AO (p < 0.001); mMRC and PCS were inversely related in subjects with (p = 0.001) and without AO (p < 0.001). A mediation analysis showed that the relation between number of comorbidities and PCS was totally mediated by mMRC in subjects with AO and partially in subjects without AO. We conclude that the effect of multimorbidity on PCS is totally mediated by mMRC only in AO. Detecting and monitoring mMRC in a primary care setting may be a useful indicator for evaluating a patient’s global health.

Health service utilisation associated with chronic breathlessness: random population sample

BACKGROUND

Most health service utilisation studies are of people with specific diagnoses or demographic characteristics, and rarely of specific chronic symptoms. The aim of this study was to establish whether population-level health service utilisation increases in people with chronic breathlessness.

METHODS

A cross-sectional analysis was carried out of the South Australian Health Omnibus Survey 2017, a multi-stage, clustered area, systematic sampling survey of adults where questions are administered face-to-face in respondents' homes. Self-report of health service utilisation in the previous 3 months (medical consultations, emergency department, hospital admission), chronic breathlessness (severity, duration, modified Medical Research Council (mMRC) breathlessness scale) and demographic data were used to predict self-reported health service utilisation.

RESULTS

A total of 2898 people were included (49.0% male; median age 48.0 years (IQR 32.0-63.0); 64.1% educated beyond school; 55.4% in work; 73.5% had outpatient contact; 6.3% had a hospital admission in the previous 3 months). Chronic breathlessness (mMRC ≥1) was reported by 8.8% of respondents. In bivariable analyses, people with greater contact with health services were older, and a higher proportion were overweight/obese and had more severe chronic breathlessness. In multivariable analyses, chronic breathlessness and older age were positively associated with outpatient care and inpatient care, and people with chronic breathlessness were hospitalised for longer (incidence rate ratio 2.5; 95% CI 1.4-4.5).

CONCLUSION

There is a significant association between worse chronic breathlessness and increased health service utilisation. There is a need for greater understanding of factors that initiate contact with health services.

How to Assess Breathlessness in Chronic Obstructive Pulmonary Disease

Activity-related breathlessness is the most problematic symptom of chronic obstructive pulmonary disease (COPD), arising from complex interactions between peripheral pathophysiology (both pulmonary and non-pulmonary) and central perceptual processing. To capture information on the breathlessness experienced by people with COPD, many different instruments exist, which vary in applicability depending on the purpose and context of assessment. We reviewed common breathlessness assessment instruments, providing recommendations around how to assess the severity of, or change in, breathlessness in people with COPD in daily life or in response to exercise provocation. A summary of 14 instruments for the assessment of breathlessness severity in daily life is presented, with 11/14 (79%) instruments having established minimal clinically importance differences (MCIDs) to assess and interpret breathlessness change. Instruments varied in their scope of assessment (functional impact of breathlessness or the severity of breathlessness during different activities, focal periods, or alongside other common COPD symptoms), dimensions of breathlessness assessed (uni-/multidimensional), rating scale properties and intended method of administration (self-administered versus interviewer led). Assessing breathlessness in response to an acute exercise provocation overcomes some limitations of daily life assessment, such as recall bias and lack of standardized exertional stimulus. To assess the severity of breathlessness in response to an acute exercise provocation, unidimensional or multidimensional instruments are available. Borg's 0-10 category rating scale is the most widely used instrument and has estimates for a MCID during exercise. When assessing the severity of breathlessness during exercise, measures should be taken at a standardized submaximal point, whether during laboratory-based tests like cardiopulmonary exercise testing or field-based tests, such as the 3-min constant rate stair stepping or shuttle walking tests. Recommendations are provided around which instruments to use for breathlessness assessment in daily life and in relation to exertion in people with COPD.

The breathing brain: The potential of neural oscillations for the understanding of respiratory perception in health and disease

Dyspnea or breathlessness is a symptom occurring in multiple acute and chronic illnesses, however, the understanding of the neural mechanisms underlying its subjective experience is limited. In this topical review, we propose neural oscillatory dynamics and cross-frequency coupling as viable candidates for a neural mechanism underlying respiratory perception, and a technique warranting more attention in respiration research. With the evidence for the potential of neural oscillations in the study of normal and disordered breathing coming from disparate research fields with a limited history of interdisciplinary collaboration, the main objective of the review was to converge the existing research and suggest future directions. The existing findings show that distinct limbic and cortical activations, as measured by hemodynamic responses, underlie dyspnea, however, the time-scale of these activations is not well understood. The recent findings of oscillatory neural activity coupled with the respiratory rhythm could provide the solution to this problem, however, more research with a focus on dyspnea is needed. We also touch on the findings of distinct spectral patterns underlying the changes in breathing due to experimental manipulations, meditation and disease. Subsequently, we suggest general research directions and specific research designs to supplement the current knowledge using neural oscillation techniques. We argue for the benefits of interdisciplinary collaboration and the converging of neuroimaging and behavioral methods to best explain the emergence of the subjective and aversive individual experience of dyspnea.

Referral criteria to palliative care for patients with respiratory disease: a systematic review

BACKGROUND

Advanced non-malignant respiratory diseases are associated with significant patient morbidity, yet access to palliative care occurs late, if at all.

AIM

To examine referral criteria for palliative care among patients with advanced non-malignant respiratory disease, with a view to developing a standardised set of referral criteria.

DESIGN

Systematic review of all studies reporting on referral criteria to palliative care in advanced non-malignant respiratory disease, with a focus on chronic obstructive pulmonary disease and interstitial lung disease.

DATA SOURCES

A systematic review conducted and reported according to the Preferred Reporting Items for Systematic Reviews and Meta Analyses guideline was undertaken using electronic databases (Ovid, MEDLINE, Ovid Embase, and PubMed).

RESULTS

Searches yielded 2052 unique titles, which were screened for eligibility resulting in 62 studies addressing referral criteria to palliative care in advanced non-malignant respiratory disease. Of 18 categories put forward for referral to palliative care, the most commonly discussed factors were hospital use (69% of papers), indicators of poor respiratory status (47%), physical and emotional symptoms (37%), functional decline (29%), need for advanced respiratory therapies (27%), and disease progression (26%).

CONCLUSION

Clinicians consider referral to specialist palliative care for a wide range of disease- and needs-based criteria. Our findings highlight the need to standardise palliative care access by developing consensus referral criteria for patients with advanced non-malignant respiratory illnesses.

Indications and patterns of use of benzodiazepines and opioids in severe interstitial lung disease: a population-based longitudinal study

Background

Despite evidence that opioids might relieve chronic breathlessness, physicians may still be reluctant to prescribe them due to safety concerns. By contrast, benzodiazepine (BDZ) prescribing often seeks to reduce chronic breathlessness despite no evidence of net benefit. Prescribing patterns and indications for these medications in severe interstitial lung disease (ILD) are unknown. Here, our objective was to evaluate the indications, medications and temporal patterns of BDZ and opioid prescriptions in people with oxygen-dependent ILD.

Methods

This was an observational, population-based, longitudinal study of adults starting long-term oxygen therapy (LTOT) for ILD between 2005 and 2014 in the Swedish National Registry for Respiratory Failure (Swedevox). People dispensed BDZs (n=2000) and opioids (n=2000) from 6 months before start of LTOT throughout follow-up (first of death or study end) were analysed.

Results

Of 1635 included patients, 651 (39.8%) received BDZs and 710 (43.4%) received opioids during the study period; 373 (22.8%) patients received both. The most frequently prescribed BDZs and opioids were oxazepam (85.6%) and oxycodone (28.7%), respectively. Indications for breathlessness were uncommon for BDZs (1.4%) and opioids (6.4%). During the last year of life, opioid indications for breathlessness increased from 2.5% (12-10 months before death) to 10.2% in the last 3 months of life (p=0.048).

Conclusions

In oxygen-dependent ILD, opioids are rarely prescribed for breathlessness even in the last months of life, when chronic breathlessness often increases in prevalence and intensity.

How Physicians in South India Recognize, Assess, and Manage People with Chronic Breathlessness Syndrome: A Thematic Analysis

OBJECTIVES

Chronic breathlessness syndrome has been defined to help clinicians actively seek, and patients legitimately present with, persistent breathlessness, and to drive services and research. However, views from low- to middle-income countries were not included. We aimed to explore the views of hospital physicians regarding chronic breathlessness syndrome, its recognition and management.

METHODS

This was a secondary analysis of qualitative data collected during a service development project. Three focus groups of physicians caring for patients with chronic breathlessness in a single tertiary hospital in South India were conducted in English, audio-recorded, transcribed, and subjected to thematic analysis.

RESULTS

Fifteen physicians from oncology, palliative care, cardiology, and respiratory specialties participated. Three major themes (impact, invisibility, and purpose) were generated. Findings mirrored those in high-income countries. Chronic breathlessness, as defined, was seen as prevalent, with a major impact on patients, families, and physicians. Nonpalliative care physicians described therapeutic helplessness with poor awareness and/or ability to manage breathlessness accompanied by active avoidance. This helplessness, a perceived lack of assessment tools and lack of access to palliative care contributed to the "invisibility" of chronic breathlessness. Most participants agreed with the name of chronic breathlessness syndrome. All agreed that systematic identification would foster education regarding assessment and management and support service development and research.

CONCLUSIONS

Chronic breathlessness syndrome is recognized in South India but, as in higher-income countries, risks being invisible due to the lack of awareness of therapeutic interventions. A named and defined syndrome was seen as a way to improve identification and management.

No gender-related bias in COPD diagnosis and treatment in Sweden: a randomised, controlled, case-based trial

Introduction

COPD is a major cause of morbidity and mortality. The prevalence, morbidity and mortality of COPD among females have increased. Previous studies indicate a possible gender bias in the diagnosis and management of COPD. The present study aims to determine if there is gender bias in the management of COPD in Sweden.

Methods

This was a double-blind, randomised (1:1), controlled, parallel-group, web-based trial using the hypothetical case scenario of a former smoker (40 pack-years and quit smoking 3 years ago) who was male or female. The participants were blind to the randomisation and the purpose of the trial. The case progressively revealed more information with associated questions on how the physician would manage the patient. Study participants chose from a list of tests and treatments at each step of the case scenario.

Results

In total, 134 physicians were randomised to a male (n=62) or a female (n=72) case. There was no difference in initial diagnosis (61 (98%) male cases and 70 (97%) female cases diagnosed with COPD) and planned diagnostic procedures between the male and female cases. Spirometry was chosen by all the physicians as one of the requested diagnostic tests. The management of the hypothetical COPD case did not differ by sex of the responding physician.

Conclusion

In Sweden, diagnosis and management of a hypothetical patient with COPD did not differ by the gender of the patient or physician.

No gender-related bias in COPD managementhttps://bit.ly/3gTsWoG

Quality of Life Changes With Duration of Chronic Breathlessness: A Random Sample of Community-Dwelling People

INTRODUCTION

Chronic breathlessness is associated with poorer quality of life (QoL). This population study aimed to define dimensions of QoL and duration and dominant causes of breathlessness that most diminished QoL.

METHODS

This cross-sectional, population-based, and randomized survey of adults (n = 2977) in South Australia collected data on demographics, modified Medical Research Council (mMRC) breathlessness, and QoL (EuroQoL five-dimension five-level [EQ-5D-5L] measure; Short Form 12 quality-of-life measure). Data weighted to the census were analyzed for relationships between EQ-5D-5L and its dimensions with mMRC. Regression models controlled for age, sex, education, rurality, and body mass index.

RESULTS

About 2883 responses were analyzed: 49% were males; mean age was 48 years (SD 19). As mMRC worsened, EQ-5D-5L and its dimensions worsened. More severe chronic breathlessness was iteratively associated with lower mobility, daily activities, and worse pain/discomfort. For self-care and anxiety/depression, impairment was only with the most severe breathlessness. Respondents who had chronic breathlessness for two to six years had the worst QoL scores. People who attributed their breathlessness to cardiac failure had poorer QoL. Respondents who reported a cardiac cause for their breathlessness had worse mobility, poorer usual activities, and more pain than the other causes. The regression analyses showed that worse chronic breathlessness was associated with worsening QoL in each dimension of EQ-5D-5L, with the exception of the self-care, which only worsened with the most severe breathlessness.

CONCLUSIONS

This is the first study to report on chronic breathlessness and impairment across dimensions of QoL and differences by its duration. Mobility, usual activity, and pain drive these reductions.

Unanswered questions and future direction in the management of terminal breathlessness in patients with cancer

Breathlessness is among the most common and deteriorating symptoms in patients with advanced cancer, which may worsen towards the end of life. Breathlessness in patients with estimated life expectancy of weeks to days has unique clinical features: it tends to worsen rapidly over days to hours as death approaches often despite current symptom control measures. Breathlessness in patients during the last weeks to days of life can be called ‘terminal breathlessness’. While evidence has accumulated for the management of breathlessness in patients with cancer who are not dying, such evidence may not be fully applied to terminal breathlessness. Only a few studies have investigated the best practice of terminal breathlessness in patients with cancer. In this paper, we summarise the current evidence for the management of terminal breathlessness, and propose future directions of clinical research.

Standardized measurement of breathlessness during exercise

PURPOSE OF REVIEW

Exertional breathlessness is common and pervasive across various chronic disease populations. To accurately assess response to intervention and optimize clinical (symptom) management, detailed assessment of exertional breathlessness is imperative. This review provides an update on current approaches to assess exertional breathlessness and presents the need for individualized assessment of breathlessness standardized for the level of exertion.

RECENT FINDINGS

Breathlessness assessment tools commonly invite people to recall their breathlessness while at rest with reference to activities of daily living. To directly quantify breathlessness, however, requires assessment of the dimensions of breathlessness (e.g., sensory intensity, quality, and unpleasantness) in response to a standardized exercise stimulus. Different exercise stimuli (e.g., self-paced, incremental, and constant work rate exercise tests) have been used to elicit a breathlessness response. Self-paced (e.g., 6-min walk test) and incremental exercise tests assess exercise tolerance or endurance, and are not recommended for assessment of exertional breathlessness. Constant work rate tests, however, including recently validated 3-min constant-rate stair stepping and walking tests, standardize the exercise stimulus to enable the breathlessness response to be directly quantified and monitored over time.

SUMMARY

To adequately guide symptom management and assess intervention efficacy, clinicians and researchers should assess breathlessness with multidimensional assessment tools in response to a standardized and individualized exercise stimulus.

Activities Forgone because of Chronic Breathlessness: A Cross-Sectional Population Prevalence Study

Background: Chronic breathlessness is a prevalent disabling syndrome affecting many people for years. Identifying the impact of chronic breathlessness on people's activities in the general population is pivotal for designing symptom management strategies.

Objective: This study aimed to evaluate the association between chronic breathlessness and activities respondents identify can no longer be undertaken (“activities forgone”).

Design: This population-based cross-sectional online survey used a market research company's database of 30,000 registrants for each sex, generating the planned sample size—3000 adults reflecting Australia's 2016 Census by sex, age group, state of residence, and rurality.

Setting/Subjects: The population of focus (n = 583) reported a modified Medical Research Council (mMRC) breathlessness scale ≥1 and experienced this breathlessness for ≥3 months.

Measurements: Activities forgone were categorized by mMRC using coding derived from the Dyspnea Management Questionnaire domains. Activities were classified as “higher/lower intensity” using Human Energy Expenditure scale.

Results: Respondents were male 50.3%; median age 50.0 (IQR 29.0); with 66% living in metropolitan areas; reporting 1749 activities forgone. For people with mMRC 1 (n = 533), 35% had not given up any activity, decreasing to 9% for mMRC 2 (n = 38) and 3% for mMRC 3–4 (n = 12). Intense sport (e.g., jogging and bike riding) was the top activity forgone: 42% (mMRC 1), 32% (mMRC 2), and 36% (mMRC 3–4). For respondents with mMRC 3–4, the next most prevalent activities forgone were “sexual activities” (14%), “lower intensity sports” (11%), and “other activities” (11%).

Conclusions: People progressively reduce a wide range of activities because of their chronic breathlessness.

"So, I try not to go …" Acute-On-Chronic Breathlessness and Presentation to the Emergency Department: In-depth Interviews With Patients, Carers, and Clinicians

CONTEXT

People with acute-on-chronic breathlessness due to cardiorespiratory conditions frequently present to the emergency department (ED) causing burden for the person concerned, their care takers, and emergency services.

OBJECTIVE

To understand the reasons for ED presentation for acute-on-chronic breathlessness and how optimal care might avoid presentations.

METHODS

Qualitative in-depth linked interviews were conducted as part of a mixed-methods study. Transcripts of audio-recordings were subjected to thematic analysis. Consenting patients presenting to a single tertiary hospital ED with acute-on-chronic breathlessness able to be interviewed were eligible. Patient-participants (n = 18) were purposively sampled for maximum variation. Patient-participant-nominated carers (n = 9) and clinicians (n = 8) were recruited.

RESULTS

Theme 1: "The context for the decision to present to the ED" is the experience of acute-on-chronic breathlessness, in which a person faces an existential crisis not knowing where the next breath is coming from, and previous help-seeking experiences. Theme 2 ("Reasons for presentation"): Some were reluctant to seek help until crisis when family carers were often involved in the decision to present. Others had previous poor experiences of help-seeking for breathlessness in the community and turned to the ED by default. Some had supportive primary clinicians and presented to the ED either on their clinician's recommendation or because their clinician was unavailable.

CONCLUSIONS

The decision to present to the ED is made in the context of serious crisis and previous experiences. Discussion of the reason for presentation may enable better management of chronic breathlessness and reduce the need for future emergency presentation.

Nurses' knowledge of law at the end of life and implications for practice: A qualitative study

BACKGROUND

Some patients do not receive adequate pain and symptom relief at the end of life, causing distress to patients, families and healthcare professionals. It is unclear whether undertreatment of symptoms occurs, in part, because of nurses' concerns about legal and/or disciplinary repercussions if the patient dies after medication is administered.

AIM

The aim was to explore nurses' experiences and knowledge of the law relating to the provision of end-of-life pain and symptom relief.

DESIGN

Semi-structured interviews with nurses were assessed using a six-stage hybrid thematic analysis technique.

SETTING/PARTICIPANTS

Four face-to-face and 21 telephone interviews were conducted with nurses who routinely prescribed and/or administered pain and symptom relief to patients approaching the end of their lives in Queensland and New South Wales, Australia.

RESULTS

While many nurses had no personal experiences with legal or professional repercussions after a patient had died, the fear of hastening death and being held accountable was frequently discussed and regarded as relevant to the provision of inadequate pain and symptom relief. Concerns included potential civil or criminal liability and losing one's job, registration or reputation. Two-thirds of participants believed that pain relief was sometimes withheld because of these legal concerns. Less than half of the interviewed nurses demonstrated knowledge of the doctrine of double effect, the legal protection for health professionals who provide end-of-life pain and symptom relief.

CONCLUSION

Education is urgently required to strengthen nurses' knowledge of the legal protections supporting the provision of appropriate palliative medication, thereby improving their clinical practice with end-of-life patients.

Breathlessness, Anxiety, Depression, and Function-The BAD-F Study: A Cross-Sectional and Population Prevalence Study in Adults

CONTEXT

Breathlessness is associated with depression, but its relationship to anxiety or impaired function is less clear.

OBJECTIVES

This study evaluated associations between chronic breathlessness and anxiety, depression, and functional status in the general population.

METHODS

This cross-sectional study of consenting adults (18 years and older) used an online survey. Quota sampling (n = 3000) was used reflecting the 2016 national census for sex, age, and place of residence. Other data included Four-Item Patient Health Questionnaire for depression and anxiety, the modified Medical Research Council (mMRC) Breathlessness Scale, and the Australia-modified Karnofsky Performance Scale. Multinomial logistic regression assessed predictors.

RESULTS

About 2977 respondents had all relevant scores (female 51.2%; median age 45.0 [range 18-92]). Prevalence of breathlessness (mMRC ≥2) was 2.4%, anxiety 6.0%, depression 2.7%, coexisting anxiety/depression 6.1%, and poorer functional status (Australia-modified Karnofsky Performance Scale ≤60) 1.6%. In multinomial regression, depression, anxiety, and coexisting anxiety/depression were predicted by younger age, longer duration of breathlessness, and poorer functional status. The highest proportions of people with breathlessness were found in the coexisting anxiety/depression group (10.6%) and depression only group (8.8%). Poorest function was in the coexisting anxiety/depression group with 11.6%. The relationship between poorer functional status and coexisting anxiety/depression was significant (odds ratio 0.90; 95% CI 0.89, 0.92). Adjusted odds ratio for breathlessness and depression only was 3.0 (95% CI 1.2, 7.8).

CONCLUSION

Clinically important breathlessness (mMRC ≥2) was associated with depression, anxiety, and coexisting anxiety/depression. Poorer function that is associated with psychological morbidity in the general population requires further research.

No excess harms from sustained-release morphine: a randomised placebo-controlled trial in chronic breathlessness

Objectives

We aimed to identify and evaluate: (1) treatment-emergent adverse events (TEAE (worse or new since baseline)) and the subgroup of severe TEAEs in a placebo-controlled 7-day randomised trial of regular, low-dose, sustained-release oral morphine for chronic breathlessness and (2) clinical characteristics associated with TEAE.

Methods

Safety analysis of trial data. Adults with chronic breathlessness (modified Medical Research Council breathlessness score ≥2) due to heart or lung disease, or cancer, not on regular opioids were eligible. Symptoms associated with opioids (TEAE of special interest) were systematically sought using Common Terminology Criteria for Adverse Events (CTCAE) grading. Other harms could be reported at any time. The relationship between characteristics and presence of ≥1 TEAE of special interest was explored using univariable logistic regression analyses.

Results

1449/5624 (26%) Adverse Events from 279 participants were TEAE of which 150/1449 (10%) were severe (CTCAE grades 3–5). 1086/5624 (75%) were events of special interest of which 41/1086 (4%) were severe. Compared with placebo, morphine was not associated with more TEAE or severe TEAE of special interest (TEAE: OR 0.53, 95% CI 0.21 to 1.38, p=0.20; severe TEAE: OR 0.96, 95% CI 0.27 to 3.41, p=0.95) nor with CTCAE severity grade (χ2=4.39, p=0.50). Among the 26/150 (17%) with severe TEAEs, study withdrawal was more common in the morphine arm (18/26 (69%) morphine arm; 8/26 (30%) placebo arm). None of the severe TEAEs was a respiratory harm.

Conclusions

Severe morphine-associated toxicity was uncommon and not associated with study arm. Clinical consequences were minor and self-limiting.

Trial registration number

ACTRN126000806268.

Prevalence and management of chronic breathlessness in COPD in a tertiary care center

Background

Breathlessness is the prominent symptom of chronic obstructive pulmonary disease (COPD). Despite optimal therapeutic management including pharmacological and non-pharmacological interventions, many COPD patients exhibit significant breathlessness. Chronic breathlessness is defined as breathlessness that persists despite optimal treatment of the underlying disease. Because of the major disability related to chronic breathlessness, symptomatic treatments including opioids have been recommended by several authors. The prevalence of chronic breathlessness in COPD and its management in routine clinical practice have been poorly investigated. Our aim was to examine prevalence, associated characteristics and management of chronic breathlessness in patients with COPD recruited in a real-life tertiary hospital-based cohort.

Methods

A prospective study was conducted among 120 consecutive COPD patients recruited, in stable condition, at Nancy University Hospital, France. In parallel, 88 pulmonologists of the same geographical region were asked to respond to an on-line questionnaire on breathlessness management.

Results

Sixty four (53%) patients had severe breathlessness (modified Medical Research Council scale≥3), despite optimal inhaled medications for 94% of them; 40% had undergone pulmonary rehabilitation within the past 2 years. The severity of breathlessness increased with increasing airflow limitation. Breathlessness was associated with increased symptoms of anxiety, depression and with osteoporosis. No relation was found with other symptoms, exacerbation rate, or cardiovascular comorbidities. Among the patients with chronic breathlessness and Hospitalized Anxiety and/or Depression score > 10, only 25% were treated with antidepressant or anxiolytic. Among the pulmonologists 46 (52%) answered to the questionnaire and expressed a high willingness to prescribe opioids forchronic breathlessness, which contrasted with the finding that none of these patients received such treatments against breathlessness.

Conclusion

Treatment approaches to breathlessness and associated psychological distress are insufficient in COPD. This study highlights underuse of pulmonary rehabilitation and symptomatic treatment for breathlessness.

Electronic supplementary material

The online version of this article (10.1186/s12890-019-0851-5) contains supplementary material, which is available to authorized users.