• perception of asthma/breathlessness
• palliative care

To the editor,

Breathlessness is the most frequently reported symptom by patients with advanced chronic lung disease or chronic heart failure and has widespread consequences.1 Despite optimal treatment for the underlying disease, disabling breathlessness persists for many—recently named chronic breathlessness syndrome.2 Patients, and their families, may live with chronic breathlessness for years, with serious functional and social limitations, care dependency and anxiety.3 Clinical practice guidelines and policy statements now highlight pharmacological and non-pharmacological interventions for the palliative management of breathlessness as a cornerstone of care.4 5 Despite this, many clinicians still feel ill-equipped and under-resourced to manage breathlessness, which remains a neglected symptom.1 6

Although the evidence base for breathlessness interventions is growing, important questions concerning optimal palliative management of breathlessness remain.7 Studies of opioids are mostly small and of cross-over design. The most recent Cochrane review8 found a smaller effect size and lower precision than other authors, although a repeat analysis9 of the same studies accounting for the cross-over design of most showed a larger effect size with improved precision and benefit consistent with a clinically relevant improvement.10 Safety concerns appear unfounded with oral low-dose opioid. Indeed, national cohorts of oxygen-dependent COPD and advanced interstitial lung disease found no association with excess hospital admission or mortality.11 12 Another very large cohort of people with COPD showed a statistically significant, small absolute excess mortality but data regarding reason for prescribing (eg, pain or breathlessness) was not available making clinical interpretation difficult.13 A systematic review …