Strategies to relieve dyspnoea in patients with advanced chronic respiratory diseases. A narrative review.

Background and objective: The management of symptoms in patients with advanced chronic respiratory diseases needs more attention. This review summarizes the latest evidence on interventions to relieve dyspnoea in these patients. Methods: We searched randomised controlled trials, observational studies, systematic reviews, and meta-analyses published between 1990 and 2019 in English in PubMed data base using the keywords. Dyspnoea, Breathlessness AND: pharmacological and non pharmacological therapy, oxygen, non invasive ventilation, pulmonary rehabilitation, alternative medicine, intensive care, palliative care, integrated care, self-management. Studies on drugs (e.g. bronchodilators) or interventions (e.g. lung volume reduction surgery, lung transplantation) to manage underlying conditions and complications, or tools for relief of associated symptoms such as pain, are not addressed. Results: Relief of dyspnoea has received relatively little attention in clinical practice and literature. Many pharmacological and non pharmacological therapies are available to relieve dyspnoea, and improve patients' quality of life. There is a need for greater knowledge of the benefits and risks of these tools by doctors, patients and families to avoid unnecessary fears which might reduce or delay the delivery of appropriate care. We need services for multidisciplinary care in early and late phases of diseases. Early integration of palliative care with respiratory, primary care, and rehabilitation services can help patients and caregivers. Conclusion: Relief of dyspnoea as well as of any distressing symptom is a human right and an ethical duty for doctors and caregivers who have many potential resources to achieve this. Keywords: COPD, Lung cancer, Interstitial lung diseases, Pulmonary rehabilitation, Non invasive ventilation, Opioids, Oxygen, High-flow nasal therapy, Palliative care, Integrated car

The clinical management in extremely severe COPD

SummaryChronic obstructive pulmonary disease (COPD) affects 6% of the general population and is the fourth-leading cause of death in the United States with severe and very severe disease accounting for 15% and 3% of physician diagnoses of COPD. Guidelines make few recommendations regarding providing the provision of care for the most severe stages of disease, namely Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages III and IV with chronic respiratory failure.The effectiveness of inhaled drug therapy in very severe patients has not been assessed yet. Health care systems in many countries include public funding of long-term oxygen therapy for eligible candidates. Currently, there is little evidence for the use of mechanical ventilatory support in the routine management of hypercapnic patients. Pulmonary rehabilitation should be considered as a significant component of therapy, even in the most severe patients. Although Lung Volume Reduction Surgery has been shown to improve mortality, exercise capacity, and quality of life in selected patients, this modality is associated with significant morbidity and an early mortality rate in the most severe patients. Despite significant progress over the past 25 years, both short- and long-term outcomes remain significantly inferior for lung transplantation relative to other “solid” organ recipients.Nutritional assessment and management is an important therapeutic option in patients with chronic respiratory diseases. Morphine may significantly reduce dyspnoea and does not significantly accelerate death. No consistent improvement in dyspnoea over placebo has been shown with anxiolytics. Supplemental oxygen during exercise reduces exertional breathlessness and improves exercise tolerance of the hypoxaemic patient. Non-invasive ventilation has been used as a palliative treatment to reduce dyspnoea.Hypoxaemic COPD patients, on long-term oxygen therapy, may show reduced health-related quality of life, cognitive function, and depression. Only a small proportion of patients with severe COPD discuss end-of-life issues with their physicians

The cruel journey through the COVID-19 INFERNO.

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End stage chronic obstructive pulmonary disease

Many patients with chronic obstructive pulmonary disease (COPD) die each year as those with lung cancer but current guidelines make few recommendations on the care for the most severe patients i.e. those with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages III and IV with chronic respiratory failure. Only smoking cessation and long term oxygen therapy (LTOT) improve survival in COPD. Although non invasive positive pressure ventilation (NPPV) may have an adjunctive role in the management of chronic respiratory insufficiency there is little evidence for its use in the routine management of stable hypercapnic COPD patients. At difference, several prospective, randomised, controlled studies, systematic reviews and meta-analyses show good level of evidence for clinical efficacy of NPPV in the treatment of acute on chronic respiratory failure due to acute exacerbations of COPD. NPPV is also alternative to invasive ventilation for symptom relief in end stage COPD. Surgical interventions for end stage COPD like bullectomy, different modalities of lung volume reduction surgery and lung transplantation are likely to be of value to only a small percentage of patients. Nevertheless, there are specific indications, which, when added to pulmonary rehabilitation will further advance exercise capacity and quality of life. As in other chronic diseases when severity of disease increases along the natural history, therapy aimed to prolong life becomes less and less important in comparison to palliative therapy aimed to relieve symptoms. The most effective treatments for dyspnoea are bronchodilators, although also opiates may improve dyspnoea. Supplemental oxygen reduce exertional breathlessness and improve exercise tolerance in hypoxaemic COPD patients. There are difficulties in treating with antidepressant the frail and elderly COPD patients. Good clinical care can prevent or alleviate suffering by assessing symptoms and providing psychological and social support to the patients and their families

Kliniczne postępowanie w bardzo ciężkiej postaci POChP

Przewlekła obturacyjna choroba płuc (POChP) dotyka 6% ogólnej populacji i jest na czwartym miejscu w Stanach Zjednoczonych pod względem przyczyny zgonów. Ciężką i bardzo ciężką postać choroby lekarze rozpoznają u odpowiednio 15% i 3% chorych na POChP. Wytyczne wprowadzają pewne zalecenia dotyczące opieki nad chorymi w najcięższych stadiach choroby, czyli - według GOLD - w POChP stopnia III i IV, z przewlekłą niewydolnością oddechową. Skuteczność stosowania wziewnych leków u bardzo ciężko chorych nie została jeszcze opisana. Systemy opieki zdrowotnej w wielu krajach refundują długotrwałą tlenoterapię u odpowiednio dobranych kandydatów. Obecnie niewiele dowodów przemawia za rutynowym stosowaniem mechanicznej wentylacji u pacjentów z hiperkapnią. Rehabilitację płucną powinno się uważać za istotny element leczenia również najciężej chorych. Jakkolwiek są dowody, że operacyjne zmniejszenie objętości płuc u wybranych chorych obniża śmiertelność oraz poprawia wydolność w czasie ćwiczeń i jakość życia, metoda ta wiąże się ze znaczną chorobowością i śmiertelnością pooperacyjną u pacjentów w najcięższych stadiach choroby. Mimo znacznego rozwoju w ciągu ostatnich 25 lat zarówno krótko-, jak i długoterminowe rezultaty przeszczepiania płuc są znacznie gorsze w porównaniu z odbiorcami innych miąższowych narządów. Ocena odżywienia i właściwa dieta są istotną składową opieki u pacjentów z przewlekłymi chorobami układu oddechowego. Morfina może natomiast znacznie zmniejszyć duszność, nie przyspieszając przy tym zgonu. Nie udowodniono znaczącej poprawy duszności u chorych otrzymujących leki anksjolityczne w porównaniu z placebo. Uzupełniające podawanie tlenu podczas wysiłku zmniejsza duszność wysiłkową i zwiększa tolerancję wysiłku u hipoksemicznych chorych. Nieinwazyjną wentylację stosuje się w czasie opieki paliatywnej w celu zmniejszenia duszności. Hipoksemiczni chorzy na POChP, wymagający długotrwałej tlenoterapii, mogą wykazywać zmniejszoną jakość życia związaną ze stanem zdrowia, pogorszenie funkcji poznawczych oraz depresję. Tylko niewielki odsetek chorych na ciężką postać POChP omawia ze swoim lekarzem zagadnienia związane z końcem życia

Manual Massage Therapy for Patients with COPD: A Scoping Review.

Background and objectives: Manual massage therapy is a therapeutic option for the treatment of several pathological conditions affecting the musculoskeletal system. It has been pointed out that massage might be beneficial for COPD patients thanks to therapeutic effects primarily related to hyperemia, increased both skin temperature and blood flow, and activation of the lymphatic system. The present study reports current evidence on the systemic effects of manual massage in patients with COPD. Materials and Methods: A scoping review was conducted on five major databases. The search went through all databases since their inception until December 2018. Results: Seventy-eight citations were retrieved; after the selection process was completed, seven articles were considered eligible. In patients receiving manual massage, improvements were observed in FEV1, dyspnea perception, and in the 6-minute walking test. Conclusions: To date the use of the manual massage in patients with COPD is not supported by substantial evidence in the literature: indeed, it is proposed as a therapeutic option in association with other interventions such as physical exercise

Physical activity in patients with chronic obstructive pulmonary disease on long-term oxygen therapy: a cross-sectional study

Background and aim: There are few studies evaluating physical activity (PA) in patients with chronic obstructive pulmonary disease (COPD) on long-term oxygen therapy (LTOT). Aim: To assess PA in hypoxemic COPD patients on LTOT. Methods: In this cross-sectional study, we compared lung function, arterial blood gases, respiratory and peripheral muscle strength, 6-min walking distance (6MWD), daily energy expenditure and steps, and health-related quality of life (HRQL) in COPD patients on LTOT (LTOT group) versus two groups of control patients not needing LTOT: with (HYPOX) and without (COPD) exercise-induced desaturations. Results: Groups did not differ as regards demographics, anthropometrics, peripheral or respiratory muscle strength. Compared to the other groups, LTOT patients had more severe airway obstruction and lung hyperinflation, greater number and severity of comorbidities, shorter 6MWD, as well as lower mean SpO2 during 6MWD and worse quality of life. LTOT patients had a lower daily energy expenditure, shorter time spent > 3.0 METs and longer sedentary time compared to the COPD group, and less daily steps compared to the other groups. No significant difference in any parameter of PA was found between COPD and HYPOX. In LTOT patients, daily steps showed a strong correlation with 6MWD, and a moderate correlation with airway obstruction, level of oxygenation, comorbidities and quality of life but not with peripheral and respiratory muscle strength. In COPD and HYPOX patients, daily steps were strongly correlated with 6MWD and level of oxygenation as assessed by PaO2/FiO2. There was no significant correlation between mean SpO2 and 6MWD in any group. Conclusion: COPD patients on LTOT perform less physical activity than patients not needing LTOT, both with and without exercise-induced desaturations. Patients with exercise-induced desaturations do not perform less physical activity than those without

COPD patients' pre-flight check: A narrative review

For most of the people with stable and well-controlled chronic obstructive pulmonary disease (COPD), air travel is safe and comfortable, but the flight environment may pose clinical challenges. This narrative review aims to update the requirements for allowance to fly of people with COPD without chronic respiratory failure. A literature review was performed on platforms: Pubmed, Scopus and Ovid, for citations in English from 2000 to 2021. The following key words were used: COPD AND: air-travel, in-flight hypoxemia, fitness to air travel. Official regulatory documents and guidelines were also examined. Current air travel statements recommend supplemental oxygen when in flight arterial oxygen tension (PaO2) is expected to fall below 6.6 or 7.3 kPa. Several lung function variables, prediction equations and algorithms have been proposed to estimate in-flight PaO2, the need for in-flight supplemental oxygen, and to select individuals needing more advanced pre-flight testing, such as the hypoxia-altitude simulation test. Exercise induced desaturation and aerobic capacity correlate significantly with in-flight PaO2. COPD patients with late intensification of disease, new changes in medications, recent acute exacerbation/ hospitalization or anticipated emotional and physical stress during the proposed air-travel should be carefully evaluated by the caring family or specialist physician

Hemoptysis due to a large endobronchial mass successful regression after the use of high flow nasal cannula

In recent years, high flow nasal cannula is being increasingly used. Most studies showed positive results when used in hypoxaemic respiratory failure. Its use in a patient with a large endobronchial mass has not yet being described. We report a patient who presented with hemoptysis and hypoxaemic respiratory failure second to a large mass obstructing the right main bronchus. High flow oxygen via nasal cannula was initiated with a quick improvement of the hemoptysis and the oxygen saturation. Thus, allowing the patient to be rapidly stabilized