Management of symptoms in adults with serious, long-term lung conditions
Understanding the professional guideline.
Content Table
Introduction
Who is this document for and what is it about?
This document explains the recommendations in the European Respiratory Society (ERS) clinical guidelines for symptom management for adults with serious, long-term lung conditions. It is for people with long-term lung conditions, their family or carers.
What are clinical guidelines?
Clinical guidelines are produced after a scientific process used to gather the latest evidence on a condition or symptom. Guidelines also take into account the opinions of experts and the priorities of patients and carers who have experience of a condition. Clinical guidelines are written for healthcare professionals. They use them as a best practice document on how to diagnose, manage and treat a condition.
What does this document include?
This document summarises the key points from the clinical guidelines on managing symptoms in adults who have serious, long-term lung conditions. It explains them in a way that is easier to understand for people who do not work in a medical field. It describes the recommendations for the treatment of symptoms of lung conditions in adults and includes information on the standards to aim for to ensure that care is effective.
It outlines the areas covered on the topic and specific recommendations from the guideline. The recommendations from this guideline are classed as “conditional” because there is a lack of evidence on the topic. This means that healthcare professionals may suggest different treatment options in discussion with individuals.
Conditional recommendations from the full guideline are shown in this document with this icon.
By providing this information in an accessible way, this document aims to help people with long-term lung conditions understand more about the standard of care they should receive. This can help them to feel informed when making decisions about their treatment options.
What is a serious, long-term lung condition?
The clinical guideline refers to “serious respiratory illness”. This describes serious, long-term lung conditions that have a negative impact on a person’s quality of life and their ability to carry out day-to-day tasks. Serious, long-term lung conditions include chronic obstructive pulmonary disease (COPD), asthma, interstitial lung disease (ILD), pulmonary hypertension, cystic fibrosis and bronchiectasis. Lung cancer was not included in this clinical guideline, as these symptom management guidelines are available elsewhere [1].
Serious, long-term lung conditions often have difficult and complex symptoms and treatments, and can cause stress to patients and caregivers. People with these conditions have a high risk of death or being admitted to hospital.
How are symptoms managed in serious, long-term lung conditions?

What is the role of needs assessment tools in people with serious, long-term lung conditions?
Needs assessment tools are used to identify and track symptoms and other unmet needs of people living with these conditions.
Needs assessment tools may be used as part of a broad check of a person’s needs. They should not replace patient-centred care and discussions with individuals and their families or carers.
Tools used include:
- the Needs Assessment Tool – Progressive Disease: Interstitial Lung Disease
- the Supportive Needs Approach for Patients (SNAP) for patients with COPD
- the Measure Yourself Medical Outcome Profile for people with acute exacerbations of bronchitis
- the Carer Support Needs Assessment Tool for carers of people with COPD
Using needs assessment tools may improve health-related quality of life by increasing the focus on individual needs and helping people to understand their own needs.
Should graded exercise therapy be used to reduce fatigue in people with serious, long-term lung conditions?
Graded exercise therapy is used to manage extreme tiredness, known as fatigue. First, a person’s current level of physical ability is looked at. Then, over time, the amount of time they spend exercising is increased. Graded exercise therapy is often provided as part of a pulmonary rehabilitation programme.
Graded exercise therapy should be used to reduce fatigue in people with serious long-term lung conditions.
Activities used in graded exercise therapy include:
- aerobic exercise, such as walking
- training focused on muscle strength (resistance training)
- water-based exercise
- Tai Chi, along with medical yoga
It is important to keep an open mind when considering graded exercise therapy. A doctor should discuss any concerns about exercise with each individual. Additional monitoring and supervision may be suitable for people with severe pulmonary hypertension or a history of irregular heartbeat (“arrhythmia”) or fainting during exercise.
Should increased airflow be used to reduce breathlessness in people serious, long-term lung conditions?
Breathlessness can be relieved by increasing the flow of air using a handheld or table fan, or using compressed air. The airflow is directed at the cheek, or inside the nose or mouth. Using a fan to increase airflow is simple to do, safe, and does not need much training. Fans are sometimes given out to people in breathlessness clinics.
Increased airflow should be used to reduce breathlessness in people with serious, long-term lung conditions.
Should breathing techniques be used to reduce symptoms in people with serious, long-term lung conditions?
Breathing techniques include any method of changing the pattern of breathing. They can be used during exercise or while resting, and can be done with or without equipment. Techniques include:
- yoga focusing on the breath (pranayama)
- breathing exercises, such as pursed-lip breathing or tummy breathing (“diaphragmatic breathing”)
- breathing a rectangle
- managing the timing of breathing with exercise
Breathing techniques should be used to reduce symptoms in people with serious, long-term lung conditions.
Breathing exercises and yoga were found to be safe and easy to do. Proper instruction on technique is important, and this can be done either in-person or through a video appointment. Breathing techniques can be combined with other treatments in an individualised treatment plan (for example, finding a comfortable position to ease breathlessness).
Should supplemental oxygen be used to reduce symptoms in people with serious, long-term lung conditions?
Supplemental oxygen therapy involves breathing in air that contains more oxygen than usual. The oxygen is usually given through nasal prongs connected to an oxygen machine or an oxygen cylinder. Smaller, portable machines and cylinders can also be used for short periods of time. While they are not suitable for everyone, they can provide some people with the ability to be physically active or fly on commercial airlines.
It is very important to follow fire safety precautions when using oxygen devices. These include keeping the room well ventilated, installing and maintaining fire alarms and smoke detectors, and keeping oxygen devices away from open flames or heat sources.
Some people who experience severe breathlessness have low blood oxygen. For these people, a trial of oxygen therapy may be suitable.
However, there was no clear evidence that oxygen therapy reduced symptoms. Side-effects of oxygen therapy included airway dryness, irritation and nosebleeds. There were some reports of falls caused by tripping over oxygen tubing. Although the side-effects are small, and easily managed, they can limit physical and social activities in some people and may increase the burden for individuals and caregivers.
The decision to start supplemental oxygen therapy should be considered carefully with a physician and carers. Stopping smoking is vital, and people should be offered support to do so. The equipment and oxygen levels should be tailored to individual needs. The supplemental oxygen therapy should be stopped if a person does not perceive any benefit from it.
This recommendation applies only to the use of oxygen for symptom relief. It is important to note that some people will be prescribed long-term oxygen therapy because they have low blood oxygen levels at rest. For these people the oxygen therapy has important benefits (e.g. living longer) regardless of whether it relieves symptoms.
The current evidence base is limited and there is a need for high quality clinical trials to test the effect of oxygen on breathlessness in daily life across different lung conditions.
Should opioids be used to reduce symptoms in people with serious, long-term lung conditions?
Opioids are strong painkillers. They are used in small doses to reduce feelings of breathlessness.
Opioids should not be used for the treatment of breathlessness in people with serious, long-term lung conditions.
There was no clear evidence that opioids reduced breathlessness. The certainty of evidence (the extent to which we can be confident that what the research tells us about a particular treatment is accurate) was very low. People with serious, long-term lung conditions, caregivers and clinicians also reported concerns about the safety of opioids. Concerns include the risks of effects on a person’s breathing, using the medicine incorrectly or becoming dependent or addicted to it, along with stigma and the association of opioids with death and dying. Taking opioids can affect a person’s quality of life, for example, not being able to drive.
If opioid treatment is chosen, it is important to be sure that all illnesses contributing to the breathlessness have been treated. Individuals, caregivers and health professionals should receive education and support about safe opioid use, and about other self-management approaches.
Should a multicomponent service be used to reduce symptoms in patients with serious, long-term lung conditions?
Multicomponent services provide people with more than one option to help with symptoms. At least one of these will be a non-drug treatment, such as breathing or relaxation techniques. A team of specialists provide care, either at home or in a clinic.
A multicomponent service should be used to reduce symptoms in people with serious, long-term lung conditions.
People receiving multicomponent care are at low risk of any side-effects. Services are relatively low cost to run, although this varies with different healthcare systems. More research is needed into how these services could be provided in community settings, known as primary care.
When should treatment start?
There is not very much evidence about the timing or order of treatments to manage symptoms in people with serious, long-term lung conditions. A detailed check of needs should be the first step in developing a treatment plan specific to each person.
Each person will have an individual range of needs and may find some treatments better than others, depending on different stages of illness. Simple steps, like increased airflow or breathing exercises, can be started earlier in the course of their condition. More complex options, such as multicomponent services, may be more suitable for people who have more symptoms, or who need more support with managing symptoms. Regular checks are important.
What research needs to be done in the future?
The task force found that more research is needed into new ways of managing symptoms, including breathlessness, fatigue and cough, in people with serious, long-term lung conditions.
- There was very little evidence supporting the use of any treatments for cough.
- Discussions with people living with lung conditions and caregivers showed that clinical trials of treatments for extreme tiredness and cough are needed.
- More studies are needed in people with breathlessness at rest, and those in end-of-life palliative care.
- Studies should include people with a variety of serious, long-term lung conditions (most are currently done in patients with COPD). They should include a range of people from different groups, including people in low and middle-income countries.
- It is important to understand the experiences and views of people with serious, long-term lung conditions, as well as those of the people who care for them, regarding their symptoms.
- Studies are needed that look at the effectiveness of using digital technologies that can support delivery of symptom management care remotely, without having to attend a clinic in person.
- It is important to look at how research findings can be put into everyday practice.
Further reading
This guideline was produced by the European Respiratory Society and the European Lung Foundation. You can find out more about these organisations and access the full professional guideline using the links below:
Full clinical guideline – published in the European Respiratory Journal in 2024:
Further resources for patients and carers:
About ERS
The European Respiratory Society (ERS) is an international organisation that brings together physicians, healthcare professionals, scientists and other experts working in respiratory medicine. It is one of the leading medical organisations in the respiratory field, with a growing membership representing over 140 countries. The ERS mission is to promote lung health in order to alleviate suffering from disease and drive standards for respiratory medicine globally. Science, education and advocacy are at the core of everything it does. ERS is involved in promoting scientific research and providing access to high-quality educational resources. It also plays a key role in advocacy – raising awareness of lung disease amongst the public and politicians. www.ersnet.org
About ELF
The European Lung Foundation (ELF) was founded by ERS to bring together patients and the public with professionals. ELF produces public versions of ERS guidelines to summarise the recommendations made to healthcare professionals in Europe, in a simple format for all to understand. These documents do not contain detailed information on each condition and should be used in conjunction with other patient information and discussions with your doctor. More information on lung conditions can be found on the ELF website: www.europeanlung.org
References
[1] Hui D, Maddocks M, Johnson MJ, et al. Management of breathlessness in patients with cancer: ESMO Clinical Practice Guidelines. ESMO Open 2020; 5: e001038.
Glossary
Exacerbation: a noticeable worsening of a condition.
Randomised controlled trial: a study in which a number of similar people are randomly assigned to two (or more) groups to test a specific drug or treatment. One group (the experimental group) has the treatment being tested, the other (the comparison or control group) has an alternative treatment, a dummy treatment (placebo) or no treatment at all. The groups are studied to see how effective the treatments are. Outcomes are measured at specific times and any difference in response between the groups is assessed statistically.
Usual care: the routine care received by patients with a particular condition. It is often used as a comparator group in a controlled trial. The care the patients in this group receive is not changed and should not be influenced by the research being done.