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Canadian Respiratory Journal
Volume 18, Issue 2, Pages 69-78
Special Article

Managing Dyspnea in Patients with Advanced Chronic Obstructive Pulmonary Disease: A Canadian Thoracic Society Clinical Practice Guideline

Darcy D Marciniuk,1 Donna Goodridge,1 Paul Hernandez,2 Graeme Rocker,2 Meyer Balter,3 Pat Bailey,4 Gordon Ford,5 Jean Bourbeau,6 Denis E O’Donnell,7 Francois Maltais,8 Richard A Mularski,9 Andrew J Cave,10 Irvin Mayers,10 Vicki Kennedy,11 Thomas K Oliver,12,13 Candice Brown,12 and Canadian Thoracic Society COPD Committee Dyspnea Expert Working Group

1University of Saskatchewan, Saskatoon, Saskatchewan, Canada
2Dalhousie University, Halifax, Nova Scotia, Canada
3University of Toronto, Toronto, Canada
4Laurentian University, Sudbury, Ontario, Canada
5University of Calgary, Calgary, Alberta, Canada
6McGill University, Montreal, Quebec, Canada
7Queen’s University, Kingston, Ontario, Canada
8Laval University, Laval, Quebec, Canada
9Kaiser Permanente Northwest, Oregon/Washington, USA
10University of Alberta, Edmonton, Alberta, Canada
11Saskatoon Health Region, Saskatoon, Saskatchewan, Canada
12Canadian Thoracic Society, Ottawa, Canada
13McMaster University, Hamilton, Ontario, Canada

Copyright © 2011 Canadian Thoracic Society. This open-access article is distributed under the terms of the Creative Commons Attribution Non-Commercial License (CC BY-NC) (, which permits reuse, distribution and reproduction of the article, provided that the original work is properly cited and the reuse is restricted to noncommercial purposes.


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, hand-held 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.