Commentary

Breathlessness is a common and distressing symptom for people with advanced illness. The review by Bausewein et al of non-pharmacological interventions is an important adjunct to reviews of pharmacological management of breathlessness.1 Although a rigorous assessment was done, the limited number of studies, variable quality, and heterogeneity of interventions and outcomes made this a challenging synthesis. The multidimensional aspects of breathlessness in advanced disease are represented in the breadth of non-pharmacological interventions included in the review. Studies that were of sufficient quality to provide recommendations for practice included only patients with COPD and cannot be assumed to apply to the wider review population of patients with malignant and non-malignant conditions.

The effect of individual study quality on practice implications has to be tempered against the real world constraints of different practice settings, resource limitations, variable costs, and patient preferences. For example, studies of chest-wall vibration were done in the laboratory, making translation to practice unclear. Breathing retraining was graded as medium quality, but the different breathing strategies used in the 3 studies limit any specific direction for practice. In contrast, walking aids, which were shown to clearly benefit patients with COPD, can be used in many practice environments. Neuroelectrical muscle stimulation of leg muscles is another well-tolerated intervention with potential for wider use. Despite having only low-quality evidence, some interventions are worth considering for use in practice. The crossover RCT of a hand-held fan showed significant improvement in breathlessness in a mixed population of patients with cardiopulmonary disease and is a practical, economical approach.2

The review by Bausewein et al highlights the need for high-quality research that reflects the realities of people with advanced diseases that cause breathlessness and those who care for them.