title: Contemporary issues in refractory dyspnoea in advanced chronic obstructive pulmonary disease.
abstract: OBJECTIVE
  Relieving dyspnoea when chronic obstructive pulmonary disease (COPD) no longer responds to disease-modifying therapy is challenging, with limited evidence to provide guidance. This review highlights recent advances that further our understanding and management of refractory dyspnoea in COPD, focusing on interventions that are considered beyond the conventional treatment of airflow obstruction/hyperinflation.
  
  
  RESULTS
  Advances in functional brain imaging have improved our understanding of limbic system activation in dyspnoea, providing insight into potential for targeted treatments. Qualitative research is defining the complexities of the multidimensional aspects of dyspnoea, supporting the need to address dyspnoea-related affective distress in prospective outcomes-based research. Studies evaluating inhaled furosemide in exertional dyspnoea and palliative noninvasive ventilation in advanced disease support ongoing work in this area. In addition, recent advances in delivery of rapidly acting opioids offer intriguing potential for management of incidental dyspnoea in advanced disease.
  
  
  CONCLUSIONS
  Improved understanding of the nature of dyspnoea in advanced COPD, advances in symptom mapping and noninvasive ventilatory support along with the potential of novel treatments offer hope that we can improve the management of refractory dyspnoea in COPD. Where evidence is lacking, we outline options that merit further evaluation.
authors.affiliation: Division of Palliative Medicine, Canada bDivision of Respirology, QEII Health Science Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
authors.forename: Robert
authors.initials: R
authors.lastname: Horton
authors.forename: Graeme
authors.initials: G
authors.lastname: Rocker
mesh_terms: D000280:Administration, Inhalation; D000701:Analgesics, Opioid / Q000008:administration & dosage; D014151:Anti-Anxiety Agents / Q000627:therapeutic use; D004417:Dyspnea / Q000188:drug therapy / Q000503:physiopathology / Q000628:therapy*; D006801:Humans; D010102:Oxygen Inhalation Therapy; D010166:Palliative Care / Q000379:methods*; D011175:Positive-Pressure Respiration; D029424:Pulmonary Disease, Chronic Obstructive / Q000188:drug therapy / Q000503:physiopathology / Q000628:therapy*
chemical_list: D000701:Analgesics, Opioid; D014151:Anti-Anxiety Agents