Intended for healthcare professionals

Clinical Review

The management of chronic breathlessness in patients with advanced and terminal illness

BMJ 2015; 349 doi: (Published 02 January 2015) Cite this as: BMJ 2015;349:g7617

This article has a correction. Please see:

  1. Magnus P Ekström, postdoctoral research fellow12,
  2. Amy P Abernethy, professor3,
  3. David C Currow, professor2
  1. 1Department of Clinical Sciences, Division of Respiratory Medicine & Allergology, Lund University, Lund, Sweden
  2. 2Discipline of Palliative and Supportive Services, Flinders University, Adelaide, Australia
  3. 3Division of Medical Oncology, Department of Medicine, Duke University Medical Center, Durham, NC, USA
  1. Correspondence to: M P Ekström, The Respiratory Unit, Department of Medicine, Blekinge Hospital, Karlskrona, Sweden pmekstrom{at}

The bottom line

  • Breathlessness is the subjective sensation of discomfort with breathing

  • It is a common cause of major suffering in people with advanced and terminal disease

  • Breathlessness should be measured routinely in patients with advanced disease and can be reduced by appropriate treatment

  • The preferred treatments for refractory breathlessness are pulmonary rehabilitation and oral low dose opioids

  • Evidence for use of benzodiazepines and supplemental oxygen (in the absence of severe hypoxemia) is lacking or inconsistent and these interventions are not recommended for refractory breathlessness

  • Consider early referral to specialist care (including palliative care) if the cause remains unclear or if the response to treatment is insufficient

Breathlessness—the sensation of discomfort with breathing—is a major cause of impaired activity and suffering worldwide and is common among elderly people in the community and in people with advanced disease.1 w1 Proper evaluation and treatment of breathlessness is vital to improve patients’ quality of life.

Importantly, the sensation of breathlessness that persists despite disease specific treatment can be relieved for many people. This review focuses on the management of refractory breathlessness, defined as breathlessness at rest or on limited exertion that persists despite optimal treatment of the underlying conditions, in advanced chronic disease, or towards the end of life.2 w4

Sources and selection criteria

We searched Medline, the Cochrane Database of Systematic Reviews, reference lists of major reviews, guidelines and consensus documents, and personal records using the terms “dyspnea” and “breathlessness”. We focused on systematic reviews, meta-analyses, randomized controlled trials, and high quality observational studies in patients with advanced or terminal disease.

What is breathlessness?

Breathlessness is defined by the American Thoracic Society as the “subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity.”w1 According to the present neurophysiological model, breathlessness is the awareness of a mismatch between the ventilator drive (the need to …

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