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Ideas whose times have come

Currow, David Ca; Abernethy, Amy Pa,b

Current Opinion in Supportive and Palliative Care: June 2009 - Volume 3 - Issue 2 - p 91–92
doi: 10.1097/SPC.0b013e32832b25e5
Respiratory problems: Edited by David C. Currow and Amy P. Abernethy

aDepartment of Palliative and Supportive Services, Flinders University, Bedford Park, South Australia, Australia

bDepartment of Medicine, Division of Medical Oncology, Duke University Medical Centre, Durham, North Carolina, USA

Correspondence to Professor David C. Currow, Flinders University, 700 Goodwood Road, Daw Park, SA 5041, Australia Tel: +61 8 8275 1871; fax: +61 8 8374 4018; e-mail:

In the 19th century Victor Hugo wrote ‘greater than the tread of mighty armies is an idea whose time has come’. One has the sense of inexorable progress from this line. To invert this, ‘… the times can stop a great idea’.

The burden of breathlessness is not new, and a century ago there were already established attempts to relieve the sensation of dyspnoea. The need for symptomatic treatment at this time was clear – there were few things to modify the underlying causes of breathlessness across the population. Today, despite advances unparalleled in human history, especially in the past 50 years, for many people there will be a point in the disease trajectory when – alone or together with disease modifying treatment – the focus becomes symptomatic control of breathlessness.

This volume of Current Opinion in Supportive and Palliative Care is an opportunity to revisit how advances are made in clinical medicine. There are two examples in this volume that deserve careful reflection as improvement in the symptomatic control of refractory dyspnoea is considered. Both were ideas well before the time at which clinical care could implement them in a systematic way into routine clinical practice: the use of opioids for the relief of breathlessness [1] and the use of lung volume reduction surgery [2]. Both were considered and implemented before a substantial hiatus in the use of these interventions, and then subsequent cautious but meticulous reintroduction into clinical practice – great ideas before their time.

First, opioids were noted in the 19th century to help relieve dyspnoea and were probably relatively widely used for this indication [3]. The relationship between opioids and brainstem-mediated respiratory depression was demonstrated by the 1950s. At this time, the use of opioids for dyspnoea rapidly fell into disrepute given that toxicity could be caused in people whose respiratory function was already compromised. Indeed, it could be argued that the pursuit of symptomatic benefit broadly across clinical care at this time, particularly in medicine, ceased to be a focus until almost two decades later, given the rapid advances in many clinical disciplines in which genuine improvements in clinical care and clinical outcomes were being generated.

Likewise, the concept that reducing the volume of redundant bullae in emphysematous lungs surgically in order to improve function of less damaged lung was first proposed and trialled half a century ago [2]. Again, unacceptable postoperative mortality saw this approach to the symptomatic management of dyspnoea plunge into disrepute together with the potential of improving exercise tolerance and perhaps even survival. Improvements in care during and after surgery allowed this technique to be revisited almost 30 years after such an intervention was first attempted. The intervening years had improved every aspect of the care that needed to be offered in this setting.

Both of these approaches to improving the management of dyspnoea have, with the fullness of time, been shown to have a role to play. They both reflect the time taken to translate a sound and useful theory into practice that can predictably deliver a net clinical benefit to people by understanding the science and ensuring that the intervention is directed to people who will derive the most benefit from it.

The focus has been on dyspnoea as a unified symptom rather than a heterogeneous group of sensations characterized by both the intensity and the unpleasantness of the sensation [4]. Both of these interventions have real but quantified limitations that can allow practitioners to have conversations with patients informed by a growing body of evidence. This volume of Current Opinions demonstrates that many important steps forward have been taken in trying to identify subgroups of people who would benefit most from these interventions.

Patients rarely have a single mechanism contributing to their breathlessness in the setting of supportive and palliative care. The future of dyspnoea research must be to:

  1. better understand the components of the subjective sensation of dyspnoea and the unique descriptors for each component;
  2. match these descriptors with specific underlying pathophysiologies; and
  3. establish whether the combination of descriptor and pathophysiology can lead to symptomatic interventions that are more targeted and therefore deliver more predictable benefit [4,5].

What other ideas in the symptomatic control of breathlessness have been discarded because their time had not come? This is a population with little respiratory reserve in whom clinical trials can only be conducted with extreme care. Potential benefits must be carefully balanced against any toxicity, including irreversible harm and mortality.

Given the continuing poor control of this symptom around the world, every opportunity must still be taken to find ways to relieve this most primal of fears – an inability to take one's next breath, creating the overwhelming sense of ultimate doom.

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1 Currow DC, Ward AM, Abernethy AP. Advances in the pharmacological management of breathlessness. Curr Opin Support Pall Care 2009.
2 Shah AA, D'Amico TA. Lung volume reduction surgery for the management of refractory dyspnea in chronic obstructive pulmonary disease. Curr Opin Support Pall Care 2009.
3 Kallet RH. The role of inhaled opioids and furosemide for the treatment of dyspnea. Respir Care 2007; 52:900–910.
4 Williams MT, Cafarella P, Olds T, et al. The language of breathlessness differentiates between patients with chronic obstructive pulmonary disease and age-matched adults. Chest 2008; 134:489–496.
5 Garrard A, Williams MT. The language of breathlessness: a systematic review. Internet J Allied Health Sci Pract 2008; 6:1–14.
© 2009 Lippincott Williams & Wilkins, Inc.