Palliative care of chronic progressive lung disease

Editor – We read with interest the review on palliative care for patients with chronic progressive lung disease (Clin Med February 2014 pp 79–82). The authors recommend opioids and benzodiazepines for the symptomatic management of breathlessness. However, although there is reasonable evidence to support the use of opioids in this scenario,^1,2 a recent systematic review concluded that ‘there is no evidence for a beneficial effect of benzodiazepines for the relief of breathlessness in patients with advanced cancer and COPD [chronic obstructive pulmonary disease]’.³ Moreover, TJR Harrison reported ‘no correlation between symptom relief and level of anxiety’ in his study of lorazepam for the management of breathlessness in patients with advanced cancer.⁴ In other words, there is no evidence to support the use of benzodiazepines to manage breathlessness, even in patients with co-existent anxiety.

Many physicians are wary of prescribing opioids and benzodiazepines in patients with chronic lung disease due to concerns about their safety.⁵ Recently, Ekström et al reported that the administration of low dose opioids (ie ≤30 mg oral morphine equivalence/day) to patients with ‘severe’ COPD was not associated with an increased risk of hospitalisation or death.⁶ However, higher doses of opioids did appear to lead to increased mortality. In contrast, Ekström et al reported that the administration of low (and high) dose benzodiazepines was associated with an increased risk of hospitalisation and death.⁶ Interestingly, the concurrent use of low dose opioids and low benzodiazepines did not appear to lead to increased hospitalisation or mortality.