Management of dyspnea in severe chronic obstructive pulmonary disease

Progression of chronic obstructive pulmonary disease (COPD) is frequently associated with increasing dyspnea; indeed, patients with serve COPD constitute the largest group of patients with chronic respiratory insufficiency. The sensation of dyspnea in these patients is mostly related to increased work of breathing, a consequence of an increased resistive load, of hyperinflation, and of the deleterious effect of intrinsic positive end-expiratory pressure (PEEP). Once optimal medical treatment has been provided, pharmacological treatments of dyspnea exist (beta 2-agonists, methylxanthines, opiates) but seldom suffice. Nonpharmacological complementary treatments must be envisioned. Patients with serve hyperinflation should be screened as possible candidates for lung reduction surgery. Pulmonary rehabilitation - including chest therapy, patient education, exercise training - has been established as effective on quality of life (QoL) and dyspnea. Noninvasive positive pressure devices may be effective for symptomatic treatment of severe dyspnea: continuous positive airway pressure (CPAP) counteracts the deleterious effect of PEEP in patients with serve hyperinflation; intermittent positive pressure breathing (IPPB) may decrease dyspnea and discomfort during nebulized therapy ; finally noninvasive positive pressure (IPPB) may decrease dyspnea and discomfort during nebulized therapy: finally noninvasive positive pressure ventilation (NIPPV) has been shown to be effective on the sensation of dyspnea and QoL in COPD with serve hypercapnia. (C) U.S. Cancer Pain Relief Committee, 2000.