Breathlessness is quite ubiquitous in our community. It is a highly prevalent symptom affecting a wide range of people across the whole community [1]. The natural history of breathlessness is being understood far better now than ever before. Populations' rates of breathlessness independent of health service utilisation have been published, updating work initially done some 45 years ago [2]. The prevalence, incidence and severity are now beginning to be understood.
Many people will live with disabling breathlessness for many years, limiting even the most basic activities of daily living for all of that time. The intensity of that breathlessness worsens with time in some key illnesses and for many such people, no direct attempt is made to treat their breathlessness other than continued futile attempts to modify the underlying cause(s) of their symptom. The vast majority of people with progressive illness are likely to have breathlessness as their disease trajectory worsens nearing death, which is not well palliated even today [3].
In three of the articles in this edition on dyspnoea, strong parallels are drawn with pain – its aetiology, manifestations and aspects of its treatment [4–6]. Another strong parallel between pain and breathlessness is the therapeutic nihilism that pervades the treatment of breathlessness as it did 30 years ago in treating pain. A concept that this person has severe lung or heart disease generates an expectation shared between practitioner and patient that, of course, the person will be breathless. This situation is highly reminiscent of many people with cancer-associated pain three decades ago when there was a shared acceptance that the person would have to experience pain. This therapeutic nihilism comes from at least two sources as many:
- Patients believe that they are always going to be breathless and, given that they have heart or lung disease, it is inevitable that this breathlessness will be uncontrolled and worsen over time. Further, if there were lifestyle factors such as smoking that have contributed to the underlying pathology, there may be an added guilt as a person believes that they ‘deserve’ breathlessness and approach the symptom with a fatalistic resignation or view it as overwhelmingly inevitable.
- Doctors, nurses and allied health practitioners believe that severe breathlessness is an expected part of many illnesses.
In order to overcome such therapeutic nihilism, active steps need to be taken collaboratively with the community and health professionals.
Simultaneously, there has been significant progress in better understanding breathlessness, its manifestations and its consequences. This includes initiatives in the basic sciences, clinical practice (including both pharmacological and nonpharmacological interventions) and in population health. This progress is long overdue, but even with these advances, there is little uptake of new and emerging evidence into policy or practice. One truly spectacular step forward in this year has been the new statement from the American Thoracic Society on the treatment of breathlessness [7]. Most importantly, this has reframed the role of opioids into an essential part of the treatment of breathlessness for the first time by this peak clinical body. This statement appears at the same time of emerging evidence that opioids can be safely administered in the target patient population with benefit maintained over time [8].
Despite the accelerating advances in the science of breathlessness, there is still the intrinsic challenge of how to change attitudes, beliefs and behaviours. If there are barriers both for patients asking for help (because they believe breathlessness is either inevitable or, even in some cases, ‘deserved’) or practitioners (who believe that nothing can be done), then excellent science alone cannot relieve this source of suffering. As researchers and clinicians, we need to explore ways of actively ensuring that research is taken up into practice through clinical guidelines that have a specific program of dissemination and uptake and seek changes to registration of key medications that have been shown to be of benefit. Without such measures, the science that is advancing, step by step, will not have the desired benefit for the tens of millions of people who are breathless at rest or on minimal exertion chronically across our communities on a daily basis.
The real measure of success will be when patients (or their families) ask ‘What can be done about my breathlessness?’ and their doctor or nurse replies ‘Lots. Let's look at the things that will most benefit you.’
References
1 Bowden JA, To T, Abernethy AP, Currow DC. Predictors of chronic breathlessness: a large population study. BMC Public Health 2011; 11:33.
2 Hammond E. Some preliminary findings on physical complaints from a prospective study of 1,064,004 men and women. Am J Pub Health 1964; 54:11–23.
3 Currow DC, Smith J, Davidson PM,
et al. Do the trajectories of dyspnoea differ in prevalence and intensity by diagnosis at the end of life? A consecutive cohort study. J Pain Symptom Manage 2010; 39:680–690.
4 Abernethy AP, Kamal AH, Wheeler JL, Cox X. Management of dyspnea within a rapid learning healthcare model. Curr Opin Support Palliat Care 2011.
5 Davidson PM, Johnson MJ. Update on the role of palliative oxygen. Curr Opin Support Palliat Care 2011.
6 Williams M. Applicability and generalizability of palliative interventions for dyspnoea: one size fits all, some or none? Curr Opin Support Palliat Care 2011.
7 Mahler DA, Selecky PA, Harrod CG,
et al. American College of Chest Physicians consensus statement on the management of dyspnea in patients with advanced lung or heart disease. Chest 2010; 137:674–691.
8 Currow DC, McDonald C, Oaten S,
et al. Once-daily opioids for chronic dyspnoea: a dose increment and pharmacovigilance study. J Pain Symptom Manage (in press).
