Mitigating the impact of breathlessness in Chronic Obstructive Pulmonary Disease: can a structured specialty palliative care intervention fill in the gap in our treatment algorithms?

Breathlessness is a distressing symptom, uniformly faced at some point in the disease process in all patients with Chronic Obstructive Pulmonary Disease (COPD). Despite maximal medical therapy and pulmonary rehabilitation, patients with COPD continue to experience refractory dyspnea, pain, poor appetite, limitations of physical activity, emotional distress, depression and overall poor health-related quality of life. Our current GOLD ABE pharmacologic treatment algorithm provides maximal disease specific therapy directed at optimization of physiologic airflow obstruction and exacerbation frequency, however leaving a gap in how best to approach the complex and multifactorial symptom of refractory breathlessness that occurs despite these pharmacologic interventions and pulmonary rehabilitation. The comprehensive and multidisciplinary approach of specialty palliative care may well fill this gap in our treatment algorithms. In this review, we will review the growing body of literature on the definitions and role of primary and specialty palliative care in the treatment of patients with COPD, review the components of a structured palliative care intervention in advanced lung disease, review the current pharmacologic and non-pharmacologic treatments for breathlessness, the identified barriers to palliative care intervention and consider the future direction of palliative care engagement in patients with COPD.