It can help determine the severity of your COPD. With age, COPD will progress in severity, and the outlook tends to become poorer with passing years, especially in seniors. Exposure to air pollution and secondhand tobacco smoke can further damage your lungs and airways.
Smoking can also affect outlook. According to a study that looked at year-old Caucasian males, smoking reduced life expectancy for those with end-stage COPD by almost 6 years. You should make monitoring your lung symptoms and function a top priority.
Dealing with COPD can be challenging enough without feeling lonely and scared about this disease. Even if your caregiver and the people closest to you are supportive and encouraging, you may still benefit from spending time with others who have COPD. Hearing from someone going through the same situation may be helpful. Maintaining your quality of life is very important at this stage.
There are lifestyle steps you can take, such as checking air quality and practicing breathing exercises. However, when your COPD has progressed in severity, you may benefit from additional palliative or hospice care. Chronic obstructive pulmonary disease COPD is a group of progressive lung diseases. But that doesn't make it easy to quit. Our readers sent us their tips on how to quit…. Glucocorticoids are chemicals that can stop inflammation. These palliative care blogs can provide people with serious illnesses and their caregivers the answers they need.
Smoking is the leading cause of emphysema, a disease of the lungs that makes it hard to breathe. Learn more about how emphysema affects you and how…. Learn about the causes and symptoms of chronic bronchitis, how to get tested, and when to seek treatment. A cough that persists for eight or more weeks is known as a chronic cough, and it can occur along with a variety of other symptoms like shortness of….
Health Conditions Discover Plan Connect. Medically reviewed by Stacy Sampson, D. Signs and symptoms of end-stage COPD. Living with end-stage COPD. Diet and exercise. Prepare for the weather. Palliative care. Stages or grades of COPD. Coping with COPD. Read this next. Medically reviewed by Raj Dasgupta, MD. Long-acting bronchodilators are convenient and more effective at maintaining symptom relief than short-acting therapies. These drugs may help reduce inflammation from COPD and may reduce exacerbations.
They are never used as solo therapy for COPD and are always prescribed in conjunction with a long-acting bronchodilator, sometimes two, in people with more severe COPD, significant symptoms or repeated exacerbations.
They are used to treat asthma. Potential side effects of ICS include thrush, hoarse voice and bruising. This class of drug reduces inflammation and may increase airway relaxation.
PDE-4 inhibitors have more adverse effects than inhaled medications for COPD and aren't recommended for people who are underweight.
Caution is advised for use in people with depression. Most medications for COPD are delivered via inhalers. There are four main types of inhalers:. It is important that you work with your health care professional to find the right inhaler for you and to become comfortable with how it works.
If you don't like the one you're using, ask about switching. Many inhalers are very effective, but the key is to find one that works for you and that you can use properly. Things such as your age, eyesight and other medical conditions can all affect your ability to use the medicine. Remember: the medication only works if it gets into your lungs. Any kind of lung infection, including a cold, can lead to a COPD exacerbation. You can't prevent all such infections, but you can protect yourself against pneumococcal pneumonia and the flu with vaccines.
So make sure you get a flu vaccine every year. If you are 65 or older, or you have COPD, you should consider getting a pneumococcal polysaccharide pneumonia vaccine. There are other medications that were once frequently used to treat COPD but are now usually only prescribed in limited circumstances. These drugs include: systemic glucorticoids, which are sometimes used for short-term treatment of exacerbations; mucus-thinning agents, which may benefit people with certain COPD symptoms, but are not widely recommended; and antibiotic therapy, which may be used on a short-term basis to treat bacterial infections but is usually not needed long-term if your COPD is well-controlled.
The best way to prevent COPD is to never smoke or stop smoking and avoid secondhand smoke. Also avoid exposure to toxic fumes or gases in your home, environment and workplace.
Review the following Questions to Ask about COPD so you're prepared to discuss this important health issue with your health care professional. For information and support on COPD, please see the recommended organizations, books and Spanish-language resources listed below. Wabash Ave. MacArthur Blvd. The most lead-contaminated neighborhoods in cities are often the poorest and home to the highest percentage of nonwhite children.
Your Health. Your Wellness. Your Care. Real Women, Real Stories. Home copd. Medically Reviewed. Overview What Is It?
It is possible, however, to have emphysema, bronchitis and asthma all at the same time. Diagnosis It is important that you get diagnosed as early in the disease as possible. These may include: Spirometry. This simple test uses a spirometer, which is a machine that checks how well your lungs function and displays the results on a graph.
It measures two things: Forced vital capacity FVC , how much air you can exhale after taking in a deep breath. Forced expiratory volume FEV1 , how much air you can exhale in one second. Your doctor will read the results, assess how well your lungs are working and determine if you have COPD.
Spirometry is used not only to confirm your diagnosis, but also to track the progression of your disease over time. Other pulmonary tests. You may undergo other pulmonary tests, including one that measures your lung volume, and oximetry, in which a small sensor is clipped to your finger to measure the oxygen level in your blood.
Your doctor may order an X-ray to examine your lungs. CT scan. Although not required for a diagnosis, your doctor may order a CT scan, particularly to see if you have emphysema. Arterial blood gases. This test measures the amount of oxygen and carbon dioxide in your blood, as well as the acidity pH of your blood. As your COPD worsens, carbon dioxide builds up because you have a hard time exhaling. Among them are: depression diabetes heart disease high blood pressure infections lung cancer osteoporosis Two of the most common comorbidities are depression, which affects up to 40 percent of those with COPD, and osteoporosis, which is significantly more common in those with COPD than in those without it.
Treatment The goals of treating COPD are to reduce your symptoms and risk of exacerbations, and improve your overall health and exercise tolerance. Nonmedical treatments Smoking cessation.
If you smoke, you must stop. Continuing to smoke will increase damage to your lungs and worsen your symptoms. Your best chance at success in quitting smoking is to enlist the help of your doctor and to find a support system, either in person, by phone or online. You may also need medication or a nicotine replacement product, like gum or a patch. You may experience some nicotine withdrawal symptoms, because nicotine can be quite addictive.
These include sleeplessness, irritability, dizziness, headaches, increased appetite and weight gain. Be patient; symptoms usually peak within two to three days and disappear between a few days to several weeks after quitting. Pulmonary rehabilitation. This includes exercises to strengthen the muscles that help you breathe your diaphragm , as well as regular exercise, such as walking. If there is no formal pulmonary rehabilitation program near you, you should try to walk at least 20 minutes a day or until you feel any breathlessness or other symptoms.
Studies find that pulmonary rehabilitation programs can improve your ability to exercise, reduce shortness of breath, improve your quality of life and reduce the amount of medical services you use. About a third of people with severe COPD aren't able to eat enough and develop malnutrition.
This may make your COPD worse and increase your risk of death. Talk to your doctor about whether you should take high-calorie nutritional supplements and, if needed, appetite stimulants. You also might consider: Eating small, frequent meals with high-protein foods that are easy to fix, such as hard-boiled eggs, peanut butter, chicken breasts, cubes of cheese, cottage cheese and yogurt. Resting before meals. Taking vitamins check with your doctor on the best options. The quality of life of COPD patients appears to be at least as poor, and indeed may be worse than that of patients with lung cancer Gore et al ; Edmonds et al There is a growing body of evidence that existing service provision is unable to meet these needs Heffner et al ; Claessens et al ; Jones et al ; Elkington et al ; Au et al The emphasis appears to be on reactive crisis intervention at the time of acute exacerbations, rather than continual supportive care Skilbeck et al In a recent statement, the American College of Chest Physicians support the position that good quality palliative and end of life care should become an integral part of cardiopulmonary medicine Selecky et al Barriers to the provision of good quality palliative care have been identified Varkey Some steps have been made to overcome these barriers and develop services.
End of life programmes and other political initiatives are in the process of being developed in many countries Byock et al ; NHS The aim of this review is to provide readers with an appraisal of recent developments in end of life care for COPD patients.
An evidence-based approach will be given to overcoming many of the barriers that currently hinder the practice of good quality EOL care.
This review is aimed at respiratory specialists, who have a key role in improving the quality of generalist palliative care received by patients with COPD. The search was extended by hand-searching recent journals and reference lists, and using internet search engines to help identify other pertinent literature. Over the last decade, several studies have attempted to identify the palliative care needs of patients with advanced COPD Claessens et al ; Edmonds et al ; Seamark et al ; Elkington et al Despite heterogeneity in terms of study populations and outcome measures, the consistent conclusion of all these studies is that patients with advanced COPD experience a poor quality of life.
Skilbeck et al interviewed 63 patients who had been admitted to hospital with an exacerbation of COPD in the last six months. On a numerical rating scale of 0—, with 0 meaning poor and meaning excellent, the mean quality of life score was Poor quality of life correlated particularly strongly with a low level of social functioning.
Interestingly, the study also included 50 patients with inoperable non-small cell lung cancer and found, using a generic quality of life measure, a significantly worse quality of life in the COPD patients than in those with cancer. These data should, however, be interpreted with a degree of caution as the two study populations were atypical in sex distribution and disease severity Hill and Muers There are many factors contributing to the poor quality of life suffered by patient with COPD.
The symptom burden is considerable. Psychological morbidity is also high in COPD. Overall, there can be no doubt that the physical and psychological symptom burden from advanced COPD is at least as severe as that from other incurable diseases.
Indeed, in a recent systematic review, Solano et al found that breathlessness, fatigue and anxiety occur more commonly in COPD than in advanced cancer, heart disease or renal disease Table 1. Qualitative studies have an important role in identifying unmet social, education and communication needs. Patients in the late stages of COPD are often housebound, but receive little support from community services Gore et al ; Elkington et al , Care-givers also suffer and have great demands placed on them Guthrie et al ; Jones et al ; Seamark et al There is evidence that patients with COPD have greater information needs than in those with other advanced disease, such as cancer Curtis et al Patients with COPD tend to experience significant morbidity for longer than patients with lung cancer.
In addition, studies of existing services show they are more likely to be admitted to admitted to acute hospital, in particular to intensive care units, they are less likely to know that they are dying, and they are less likely to receive medication for symptom control Lynn et al ; Edmonds et al ; McKinley et al ; Au et al This occurs despite the fact that most COPD patients prefer treatment focussed on comfort rather than on prolonging life, and COPD patients are equally as likely as lung cancer patients to prefer not to be intubated or receive cardiopulmonary resuscitation Claessens et al Why, then, are there such considerable unmet palliative care needs in patients with advanced COPD?
In order to answer this question and focus future service development appropriately, it is important to establish the causes of the current suboptimal quality of care at the end of life. The disease trajectory in COPD is typically that of a slow decline, punctuated by dramatic exacerbations that often end in unexpected death Lunney et al ; Murray et al This contrasts with that of cancer, where there is often maintenance of good function until a short period of relatively predictable decline in the last weeks or months of life.
COPD is particularly unpredictable as it progresses at a highly variable rate. Exacerbations causing respiratory failure occur suddenly and unpredictably, and the outcome of those exacerbations is often determined by last-minute decisions regarding life support. Typical disease trajectories for progressive chronic illness.
This disease trajectory has two important implications. First, it causes significant prognostication difficulties. How can good EOL care be provided when it is not clear that the end of life is approaching? Until recently there has been little evidence-based information available to help determine the prognosis in advanced COPD.
Commonly used prognostic criteria, including measures of air-flow limitation such as FEV 1 , degree of hypoxia, complications such as cor-pulmonale and recent hospitalisation requiring ventilation, have all been found to be unreliable Fox et al ; Domingo-Salvany et al ; Nishimura et al ; Coventry et al Second, unexpected death at the time of an acute exacerbation generates significant communication challenges.
Another important barrier to end of life care is that misconceptions about both COPD and palliative care abound. It is sobering that patients and caregivers generally fail to appreciate that COPD is a life-threatening disease that results in an inexorable decline in health status and function Lynn et al Good EOL care is impossible without recognition that death may occur prematurely.
The appreciation amongst patients that COPD is often a self-inflicted disease lead some to believe that they are not eligible or deserving of measures to improve quality of life. The practice of palliative care is also misunderstood. Patients and professionals often still expect a dichotomous model of care moving from disease modification to palliation, when this has long been superseded by a mixed model of care combining both approaches.
Resource limitations are a significant impediment to the delivery of effective EOL care Traue and Ross Improving the palliation of COPD has significant implications for funding, manpower and education. Palliative care specialists are not always well informed about the management of non-malignant disease and respiratory specialists require training in the skills of palliation.
Finally, it is increasingly recognised that a lack of research evidence on end of life care is hindering service development Field and Cassel Research in this vulnerable patient group is beset by significant ethical and methodological challenges Lawton ; Addington-Hall ; Kendall et al These include difficulties in gaining informed consent, poor recruitment rates and high attrition rates.
Challenges caused by the unpredictable disease trajectory can be overcome with improved HCP prognostication and communication skills. Resource limitations can be compensated for by careful evidence-based service development, using existing resources to provide cost-effective interventions. Generalist palliative care education, advance care planning and service development must each be improved in order to enhance the quality of EOL care received by those with COPD.
The remainder of this review will provide an evidence-based analysis of aspects of each of these important topics. The end of life needs of patients with COPD are at least as great as, if not greater than, those suffering from advanced lung cancer.
Patients experience a prolonged deterioration with low quality of life, uncontrolled symptoms, psychological morbidity, social isolation, and unmet communication and information needs.
Prognostication difficulties, resource limitations and inadequate research evidence to support service development are the principle barriers to the provision of good end of life care. In landmark research, Steinhauser et al a , b used qualitative methods to generate descriptors of the components of end of life care considered most important by patients, carers and healthcare professionals, and subsequently tested these for generalizability in a national survey.
The greatest concern of patients and carers was to avoid dying in distress with uncontrolled symptoms. Why do patients with advanced COPD suffer from uncontrolled symptoms? Healthcare professionals may be hesitant about proactively managing symptoms, in part, due to concerns about adverse effects of pharmacological interventions, such as respiratory depression from opioids or anxiolytics. There may be an element of therapeutic nihilism, believing that symptoms such as fatigue cannot be ameliorated.
Good generalist palliative care education, providing an evidence-based approach to symptom management, is the key. Dyspnea is an almost universal symptom in advanced COPD, and it is one of the most significant contributors to the poor quality of life experienced by these patients Lynn et al ; Skilbeck et al ; Edmonds et al It can therefore be a consequence either of increased ventilatory demand, or impairment of the mechanical process of ventilation. Cognitive, emotional and behavioral factors contribute to the central perception of dyspnea.
The multidimensional pathophysiology of dyspnea gives scope to a wide range of potential palliative interventions. Interventions that reduce ventilatory demand include oxygen therapy and exercise training Swinburn et al Impairment of ventilation may be helped by breathing techniques that improve respiratory muscle function, and oxygen therapy which can reduce dynamic hyperinflation Somfay et al The central perception of dyspnea can be modified by pharmacological interventions such as opioids and anxiolytics, and by non-pharmacological measures such as education, psychological support and behavioral interventions.
Which of these approaches are of use in the last weeks and months of life? The use of long-term oxygen therapy LTOT , involving continuous use of oxygen for 15 or more hours each day is well established in severely hypoxic patients with COPD PaO 2 less than 7. As well as giving benefit in terms of survival, LTOT appears to enhance quality of life in severely hypoxic patients.
The two patient groups were well matched in all variables other than the greater degree of hypoxia in the LTOT group. From examination of all studies included in the original review and three studies published subsequently Lewis et al ; Nandi et al ; Stevenson and Calverley , it is clear that there are little data to support the use of SBOT at rest, including before or after exercise. SBOT during exercise does, however, appear to be of greater value.
It cannot, of course, be assumed that acute responders who gain benefit from oxygen in experimental conditions will also benefit when oxygen is used over a longer time period at home. Just four controlled studies have examined the effect of SBOT on breathlessness when used at home during activities of daily living.
Two studies, both included in our original review, examined quality of life in patients randomized to receive either home oxygen or air over a 12 week period. Eaton et al , using a study population with significant exercise desaturation and providing light oxygen cylinders, did find an improvement in quality of life in patients who had been receiving oxygen.
McDonald et al recruited patients who desaturated less on exercise and supplied heavier oxygen cylinders; they found no improvement in quality of life. In a more recent study, Eaton et al randomized 78 patients discharged after an acute exacerbation to cylinder oxygen, cylinder air or usual care. There were no significant differences between the groups in quality of life, breathlessness or acute healthcare utilization.
Nonoyama et al , in an interesting study incorporating multiple N-of-1 RCTs for each of 27 patients, also found no evidence to support the use of long-term ambulatory oxygen therapy for patients who do not qualify for LTOT.
Importantly, no studies have been able to find factors that can predict which patients are likely to experience symptom relief from supplemental oxygen. Furthermore, Eaton et al found that an acute response to oxygen did not predict those that would benefit when using longer-term oxygen. Response to oxygen does not correlate with the extent of dyspnea at rest, level of hypoxemia at rest, degree of desaturation on exercise, or any tests of lung function. The response to oxygen is extremely variable between individuals, although more reproducible on an individual level Waterhouse and Howard The only way to select the patients who will benefit from oxygen therapy is to undertake an individual clinical assessment.
At its most rigorous, the undertaking an N-of-1 RCT has been described and recommended Bruera et al ; Uronis et al The burdens of oxygen therapy are considerable Spathis et al A degree of psychological dependence is inevitable, and some patients become acutely anxious during even a short interruption in oxygen supply.
Cumbersome, heavy equipment may restrict movement and activities within the home and limit excursions outside. Use of an oxygen mask may impair communication between a patient and family. Some patients feel a sense of social stigma and embarrassment, which may further hinder interaction and lead to isolation.
Other issues include its combustibility, its considerable cost being, and the uncomfortable drying of airways including the nasal mucosa. Overall, therefore, there is little evidence to support the use of oxygen in palliating dyspnea. Although single assessment studies appear to show benefit from oxygen during exercise, these findings are not reproduced when oxygen is used longer-term during activities of daily living. Despite this lack of evidence of benefit, breathless patients approaching the end of life are often commenced on oxygen.
Given the negative aspects of oxygen therapy, it is likely that during end of life care, the burdens of oxygen therapy may well outweigh the benefits in a significant proportion of patients. Withdrawal of oxygen therapy is, of course, not easy. It can cause distress, feelings of abandonment and fear that life may be shortened. Through careful and sensitive communication, patients may be helped to understand the lack of evidence for benefit from SOBT, the inevitable development of psychological dependence, the burdens of oxygen therapy and the lack of selection criteria to determine who may benefit.
With individual clinical assessment, the few individuals who may benefit from SBOT can be identified. There is good evidence that exercise is one of the most successful non-pharmacological approaches to managing breathlessness. Reconditioning is central to the benefit provided by pulmonary rehabilitation programs Lacasse et al In the end of life phase capacity for exercise reduces, and the four most common approaches are use of a fan, energy conserving measures, breathing techniques and relaxation strategies.
The flow of cool air through the nose, mouth or over the cheek can reduce the perception of dyspnea Schwartzstein et al ; Liss and Grant It is believed that stimulation of nasal or pharyngeal mucosal receptors or facial receptors in the region of the trigeminal nerve leads to afferent information being projected to the sensory cortex where it alters the central perception of dyspnea.
There is extensive anecdotal evidence that patients find benefit from use of a fan, or from standing by an open window. Even with end-stage disease, patients find a small hand-held fan easy to use. It is a cheap piece of equipment that, unlike use of oxygen does not draw untoward attention to its user, and has no adverse effects.
Interestingly, Booth et al , in a study of cancer patients who were breathless at rest, found that both cylinder air and cylinder oxygen improve breathlessness, without there being a statistically significant difference between them. It may be that some of the benefit that patients perceive from oxygen may simply be due to it being a flow of cool gas. There is, to date, only a small amount of research evidence examining the use of a fan Booth et al ; further studies are known to be underway.
Energy conservation techniques reduce dyspnea by reducing demand for ventilation. A variety of recommendations have been published that help patients to complete activities of daily living with less effort Carrieri-Kohlman and Stulbarg Possible techniques include sitting where possible, avoiding bending by arranging equipment closely and sliding or pushing items instead of lifting.
There are no controlled studies evaluating such techniques; observational studies have described patient experiences Brown et al Breathing techniques improve the mechanical efficiency of respiration. The aim of these techniques is to reduce respiratory rate and prolong expiration, while using a gently leaning forward posture that improves the mechanical efficiency of the diaphragm. Several studies confirm the benefit of pursed-lips breathing on dyspnea Tiep et al ; Breslin Several step-by-step exercises to alter breathing rhythm have been published Gallo-Silver and Pollack Counting during the respiratory cycle has been advocated, such as a count of 4 during inhalation, of 7 during exhalation and a count to 2 before recommencing inhalation.
Such breathing patterns need practice until they become unconscious and automatic. It is hard to learn such techniques close to the end of life, and is therefore important to teach patients early. Relaxation techniques and training in anxiety reduction are particularly important with advanced disease. Anxiety increases breathlessness, which in turn contributes to the anxiety, leading to a deteriorating vicious circle Bailey Various methods have been described, and techniques should be tailored and adapted for each individual.
Methods include progressive muscular relaxation with systematic tensing and relaxing of all muscle groups, visualization and guided imagery, self-hypnosis and distraction by music Walker ; Carrieri-Kohlman Renfroe found that taught relaxation techniques in ten COPD patients reduced anxiety more than in a control group that were told to relax without specific instructions.
However, benefits were not maintained after the study, a finding confirmed in other studies Gift et al Again this supports the view that such techniques should be continually practiced and should be taught well before the end of life phase in order to be of use when need arises.
The use of pharmacological measures to palliate breathlessness is important in the final weeks and months of life, in conjunction with continued use of the non-pharmacological techniques described above. Their use is, however, often hindered by controversy, mainly in relation to safety concerns. A recent and commendable review in this journal has examined this topic in detail with reference to COPD patients Uronis et al Therefore, only a summary of the most relevant evidence will be given here, with focus on issues of safety.
There is consistent evidence that opioids reduce the sensation of breathlessness. Jennings et al undertook a meta-analysis of all data prior to and found a highly statistically significant effect of oral and parenteral opioids on breathlessness and a trend towards improved exercise tolerance.
There was no evidence of benefit from nebulized opioids. Thirteen of the eighteen included studies involved patients with COPD. There was more nausea, vomiting, dizziness, drowsiness and constipation in patients taking opioids compare to placebo. No deaths in any of the studies were attributed to opioids. Out of four studies that measured arterial blood gas tensions, in one study there was a statistically significant rise in pCO 2 in patients on dihydrocodeine.
However, in no instance did the Pa CO2 rise above 5. Amongst the nine studies that measured oxygen saturation, none reported a significant change in patients on opioids. There is no evidence to date that the doses of opioids used to palliate breathlessness causes clinically detectable respiratory depression or increased mortality Mazzocato et al ; Jennings et al Why, then, is this beneficial therapy so commonly withheld on grounds of safety? The answer lies in the form of a deep societal misconception.
The idea that opioids may kill when used for symptom control entered UK society in when Dr Bodkin Adams used the doctrine of double effect DDE as defense when accused of murdering an elderly lady from whose will he was to benefit. Since then this defense has been reused to the extent that unintended death from opioids used for symptom control has now become the classic example of DDE in clinical practice George and Regnard This misconception seems to be entrenched, even in the face of lack of evidence.
Interestingly, when opioids are given after withdrawing ventilator support in intensive care patients they not only do not hasten death, but may even enable breathing to continue longer after ventilator withdrawal Chan et al Public and healthcare professional suspicion of opioids will continue until there is good evidence for lack of harm, not simply lack of evidence of harm.
A safety study using parenteral opioids for pain in cancer patients has been recently published, showing no evidence for respiratory depression Estfan et al A large safety study in COPD patients is urgently needed as, to date, no studies have been sufficiently powered to detect rare but serious adverse effects Currow et al In the meantime a pragmatic approach is needed.
Opioids should be started at a low dose and titrated up carefully, with appropriate monitoring Mashford et al ; National Institute of Clinical Excellence ; Selecky et al Education of healthcare professionals would facilitate the appropriate use of morphine; for example, it would help prescribers to know that 1.
Clear protocols need to be developed so that patients are not denied this potentially important treatment. There is almost no evidence to support the use of any other non-specific pharmacological agents in the palliation of dyspnea. Other than opioids, the most commonly used drugs are anxiolytics.
Only one controlled study has examined the effect of benzodiazepines on breathlessness in COPD; there was no significant benefit from alprazolam, and of concern, there was a trend for deterioration in blood gases in the active arm Man et al The anxiolytic, buspirone is of potential interest as it is a respiratory stimulant. Fatigue is an important and common symptom in COPD. Overall, however, there is consistent evidence that fatigue is the second most prevalent symptom in COPD after breathlessness.
There is also little doubt that it has a profoundly negative impact on quality of life Small and Lamb ; Theander and Unosson ; Katsura et al Fatigue in other chronic, progressive diseases, such as cancer and multiple sclerosis has been the subject of increasing interest in recent years with extensive research into its prevalence, etiology and management Vogelzang et al ; Ahlberg et al ; NCCN This is in marked contrast to the situation in COPD.
Despite its significant prevalence and negative impact on quality of life, the topic of fatigue in COPD has been relatively neglected.
There have, to date, been very few studies investigating interventions that may help COPD-related fatigue. The only intervention that has been found to give any benefit is pulmonary rehabilitation. Exercise and reconditioning are rarely feasible options in very advanced disease.
The key to improving fatigue in end of care is to improve as much as is possible the underlying causes of the symptom. Fatigue is inextricably linked to three other common symptoms in COPD, dyspnea, depression and insomnia Woo ; Reishtein Although there is no research evidence to support this, it is intuitively likely that managing these symptoms may improve fatigue.
In particular, non-pharmacological measures such as energy conservation and relaxation techniques may have an important role Theander and Unosson Future research examining fatigue in COPD is urgently needed. It is important that the profile of this hitherto neglected symptom is raised. There is some evidence that central nervous system stimulants, such as methylphenidate and modafinil, may have a role in ameliorating fatigue related to cancer and chronic neurological conditions Rammohan et al ; Bruera et al It may be worth investigating the role of such drugs in advanced COPD where exercise and rehabilitation are no longer an option.
Pain is another common but neglected symptom in COPD. Several studies have examined the prevalence of pain in advanced COPD. Despite the wide range of documented prevalence caused by considerable study heterogeneity, there can be no doubt that pain is a significant problem in patients with advanced COPD.
Surprisingly, there have been no studies investigating the management of pain in COPD. Pain is usually felt in the chest, and may have a musculoskeletal or pleuropulmonary origin Leach Why is pain such a problem in COPD? In a large retrospective cohort study, Au et al found that patients who died within six months from COPD were significantly less likely to be given strong opioids for symptom control than patients with lung cancer.
A strong possibility is that analgesics are withheld because of concerns about adverse effects, in particular respiratory depression and bronchospasm due to opioids and NSAIDs respectively. The presence of pain should be taken as seriously in COPD as in any other condition. The World Health Organization guidelines for the use of analgesic drugs Figure 3 provide a useful framework for all chronic pain not just for cancer pain WHO ; Leach As discussed above, there is no evidence that clinically significant respiratory depression occurs with use of opioids for symptom control.
Care should of course be taken, commencing on low doses with judicious upward titration. McKeever et al in a recently published study that analyzed data from over 13, individuals from the Third National Health and Nutrition Examination Survey in the USA, found a significant dose-response relationship between paracetamol and the prevalence of COPD, which was not found with aspirin and ibuprofen.
Furthermore, paracetamol use was inversely associated with FEV 1 , whereas regular ibuprofen use was associated with a non-linear improvement in FEV 1. It is hypothesized that regular paracetamol use depletes levels of the antioxidant, glutathione, in lung tissue, leading increased lung tissue damage. Ibuprofen may improve lung function through its anti-inflammatory effect.
Even in asthma, ibuprofen does not appear to cause harm in population terms Lesko In a large study, children with asthma were randomly assigned to receive paracetamol or ibuprofen for a febrile illness Lesko et al Those on ibuprofen had significantly less asthma morbidity. These interesting findings are consistent with those of several other studies and deserve further investigation Konstan et al ; Shaheen et al ; Shaheen et al Overall, existing evidence suggests that paracetamol and NSAIDs should be used with equal care in COPD patients, but that for use in pain at the end of life, benefit from both ibuprofen and paracetamol is likely to outweigh any harm.
0コメント