A 72 year-old man with a history of very severe chronic obstructive pulmonary disease (COPD) has increasing dyspnea that initially occurred only with exertion but has become present at rest over the last few years. He has a chronic cough with scant sputum production, which has not changed. The patient has not recently required hospitalization or other acute treatment for COPD exacerbations. He uses supplemental oxygen continuously. Medications include tiotropium, fluticasone/salmeterol, and theophylline. He also uses an albuterol rescue inhaler occasionally, but it provides very little relief. He quit smoking 4 years ago.
Respiratory rate is 20/min and pulse is 94/min. SaO₂ is 92% on oxygen at 3 L/min. Physical examination shows cachexia and pursed lip breathing. There is decreased air entry bilaterally with no wheezes.
Chest x-ray reveals hyperinflation. Forced expiratory volume in 1 second (FEV₁) is 19% predicted, forced vital capacity (FVC) is 56% predicted, and FEV₁/FVC is 0.43.
Which of the following therapies should be considered in this patient?

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Quizplus · Accepted Answer

11ec193a_98eb_07f8_853d_5753f4f06470_MD0002_00 Dyspnea is a sensation of breathlessness that is common in patients with end-stage lung disease, particularly chronic obstructive pulmonary disease (COPD). It is associated with a lower quality of life and remains unrelieved in nearly half of COPD patients. Patients with advanced COPD should receive triple inhaler therapy (long-acting beta agonist, long-acting anticholinergic, and glucocorticoid). Supplemental oxygen is beneficial if hypoxemia is present. Theophylline may also be considered, but its use is complicated by adverse effects and drug interactions. Additional management options in some patients may include pulmonary rehabilitation and noninvasive positive pressure ventilation. Opioids are an effective therapy for the relief of dyspnea, although their exact mechanism of action is unknown. They are often underused by clinicians due to fear of causing respiratory depression, addiction, and dependence in patients. Societal and patient factors also play a role in their underuse. A systematic review and a randomized controlled trial support the effectiveness of oral or parenteral opiates in relieving the symptoms of dyspnea in patients with all types of end-stage lung disease (specifically in COPD) without significant respiratory depression. (Choices A and E) There is a high prevalence of comorbid anxiety and depression in COPD, and their presence can worsen the perception of dyspnea. However, neither alprazolam nor sertraline has been demonstrated to improve dyspnea. Alprazolam may be used as adjunctive therapy to opioids to relieve the anxiety associated with dyspnea. (Choices B and D) Azithromycin and roflumilast are therapies that have been shown to decrease COPD exacerbation risk in patients with frequent exacerbations. However, this patient has not had any recent episodes.. Educational objective: Dyspnea is a distressing symptom of end-stage chronic obstructive pulmonary disease and often remains undertreated. Opiates can blunt the uncomfortable sensation of dyspnea in patients with advanced lung disease. The concerns of potential respiratory depression with opiate use seem unwarranted. __________ References: Managing dyspnea in patients with advanced chronic obstructive pulmonary disease: a Canadian Thoracic Society clinical practice guideline. (http://www.ncbi.nlm.nih.gov/pubmed/21499589)

A 72 Year-Old Man with a History of Very Severe