title: 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.
authors.affiliation: University of Saskatchewan, Saskatoon, Saskatchewan. ctsinfo@lung.ca
authors.forename: Darcy D
authors.initials: DD
authors.lastname: Marciniuk
authors.forename: Donna
authors.initials: D
authors.lastname: Goodridge
authors.forename: Paul
authors.initials: P
authors.lastname: Hernandez
authors.forename: Graeme
authors.initials: G
authors.lastname: Rocker
authors.forename: Meyer
authors.initials: M
authors.lastname: Balter
authors.forename: Pat
authors.initials: P
authors.lastname: Bailey
authors.forename: Gord
authors.initials: G
authors.lastname: Ford
authors.forename: Jean
authors.initials: J
authors.lastname: Bourbeau
authors.forename: Denis E
authors.initials: DE
authors.lastname: O'Donnell
authors.forename: Francois
authors.initials: F
authors.lastname: Maltais
authors.forename: Richard A
authors.initials: RA
authors.lastname: Mularski
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Cave
authors.forename: Irvin
authors.initials: I
authors.lastname: Mayers
authors.forename: Vicki
authors.initials: V
authors.lastname: Kennedy
authors.forename: Thomas K
authors.initials: TK
authors.lastname: Oliver
authors.forename: Candice
authors.initials: C
authors.lastname: Brown
mesh_terms: D000701:Analgesics, Opioid / Q000627:therapeutic use*; D002183:Canes; D004417:Dyspnea / Q000188:drug therapy / Q000209:etiology / Q000628:therapy*; D004599:Electric Stimulation Therapy; D006801:Humans; D010102:Oxygen Inhalation Therapy; D029424:Pulmonary Disease, Chronic Obstructive / Q000150:complications / Q000188:drug therapy / Q000628:therapy*
chemical_list: D000701:Analgesics, Opioid