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Opioids have a role in the treatment of severe dyspnoea, but careful monitoring of their effects is essential.
To understand, define, and treat dyspnoea is difficult. It is an underappreciated problem in respiratory medicine, cardiology, and palliative medicine, and it is often hard to know when to supplement the treatment of an underlying disease by pure palliation. In this issue of Thorax Jennings et al1 present a meta-analysis of randomised controlled trials of opioids as treatment for dyspnoea, which shows that opioids do reduce dyspnoea in a variety of settings, including chronic obstructive pulmonary disease (COPD) and cancer. What inferences for clinical practice in primary care, secondary care, or specialist palliative care can be drawn from this finding? And what impact ought it to have?
Dyspnoea is a perception, and perceptions are affected by more than physiological variables. Although simple statements such as “dyspnoea is an uncomfortable sensation of breathing”2 may suffice as a shorthand definition of dyspnoea, the American Thoracic Society has suggested the following broader description: “. . . dyspnoea is a term used to characterise a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social and environmental factors that may induce secondary physiological and behavioural responses”.3 It therefore follows that methods of treating dyspnoea could include reducing the metabolic demand for ventilation, increasing the efficiency of the respiratory system as a gas exchanger, decreasing central respiratory drive, or reducing the perception of dyspnoea. This itself could include diminishing or altering psychosocial factors as well as pharmacological treatment.
Opioid treatment for the relief of dyspnoea is thus only one of many treatments available, with other examples being supplemental oxygen,4 chest wall vibration,5 pulmonary rehabilitation including lifestyle modification, …
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