Care at the Close of Life: Evidence and Experience
Stephen J. McPhee, Margaret A. Winker, Michael W. Rabow, Steven Z. Pantilat, Amy J. Markowitz
Part B Symptom Management
Chapter 6. Management of Dyspnea in Patients With Far-Advanced Lung Disease: “Once I Lose It, It’s Kind of Hard to Catch It…”
John M. Luce, MD, Judith A. Luce, MD
Impedance is resistance to air movement in the lungs. It increases in patients with COPD because...
Topics Discussed:
benzodiazepines, dyspnea, lung diseases, lung volume reduction, opioids, oxygen therapy, pulmonary rehabilitation, respiratory muscles
Excerpt:
"In general, the most effective way to reduce dyspnea is to treat
either the primary lung disease or the secondary illnesses responsible
for breathlessness. This principle is particularly relevant in the early
stages of lung disease, when various interventions are more likely
to be productive and preferred by the patient, as in the ambulatory
patient with COPD described here. However, as the disease becomes
further advanced, specific therapies should be superseded by supportive
measures, such as supplemental oxygen and opioids. The following
section outlines these measures using the pathophysiologic approach
developed by the American Thoracic Society.2Impedance is resistance to air movement in the lungs. It increases
in patients with COPD because their airways are narrowed and their
lung elastance is reduced and in patients with interstitial fibrosis
because their lung parenchyma is infiltrated. As described by the
American Thoracic Society,24 airways obstruction
in patients with COPD traditionally has been treated with smoking
cessation and pharmacologic therapy, which typically includes inhaled 
2-agonists,
inhaled anticholinergics, and inhaled and systemic corticosteroids.
Inhaled corticosteroids have been shown to reduce dyspnea when given
over the long term in patients with COPD.25 Furthermore,
treatment with systemic corticosteroids results in acute improvement
in clinical outcomes among patients hospitalized with COPD exacerbations.26 Nevertheless,
neither inhaled nor systemic corticosteroids have been demonstrated
to slow the rate of decline in patients' lung function,
and systemic corticosteroids in particular can cause mood changes,
muscle weakness, immunosuppression, osteoporosis, and other adverse
effects. In light of these effects, systemic corticosteroids should
be administered on a trial basis and should not be continued if
they burden patients more than they benefit them...."
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