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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
Patients with chronic lung disease have an increased minute ventilation at rest and during...


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 However, as the disease becomes further advanced, specific therapies should be superseded by supportive measures, such as supplemental oxygen and opioids.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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