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Dyspnea: John M. Luce, MD, discusses management of dyspnea in patients with far-advanced lung disease.
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Dyspnea: John M. Luce, MD, discusses management of dyspnea in patients with far-advanced lung disease.
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Upload Date:
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Language: EN.
Segment:0 .
>> I'm Joan Stephenson, editor of JAMA's Medical News and Perspectives section. Today I have the pleasure of speaking with Dr. John Luce about managing dyspnea in patients with far advanced lung disease. Dr. Luce, why don't you introduce yourself to our listeners? >> Yes. Hi. I'm John Luce. I'm an emeritus professor of Medicine and Anesthesia at the University of California San Francisco, and a member of the Division of Pulmonary and Critical Care Medicine at San Francisco General Hospital, where I've been practicing for over 30 years.
>> Dr. Luce, what is dyspnea and what types of patients are at risk for this problem? >> Dyspnea is shortness of breath. The American Thoracic Society, of which I'm a member, describes it as being a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. And then goes on to describe the fact that it probably has multiple causes. As far as patients who have dyspnea, most of them are those with heart and lung disease. From a standpoint of lung disease, it occurs most commonly in patients with interstitial fibrosis, lung cancer, cystic fibrosis, and especially chronic obstructive pulmonary disease (or COPD).
>> When should the transition from restorative to palliative treatment begin for patients with lung disease? >> Well, this is a very difficult issue because many patients who have lung disease and their physician alike would prefer to keep treating the patients from a restorative standpoint as long as they could as long as there's any hope of things being restored. So I think this is going to vary from patient to patient and doctor to doctor. But generally speaking, I think when a patient is short of breath or dyspneic at rest, there should be a transition from restorative to palliative treatment.
Now, again, one wouldn't think of an abrupt change but more of a transition. And this could be a gradual transition, of course. Most of the patients who are short of breath or dyspneic at rest, are going to be homebound by that point, although some may leave the home occasionally. And certainly, even before that time, advanced care planning, discussion of issues such as mechanical ventilation, further hospitalization and the like, those discussions should have been had. >> What factors should be considered when choosing a treatment to help reduce dyspnea in patients with far advanced lung disease?
>> Well, again, I think that the most important things would be, what is the cause of the dyspnea, both in terms of the underlying disease -- heart or lung disease, but we're focusing on lung disease. And secondly, how does the dyspnea occur physiologically? Most patients, it's assumed feel short of breath when the respiratory muscles and the brain sense that the work of breathing is excessive and that the challenges to breathe imposed upon the patient are excessive. So one should be thinking in terms of treatment, specific treatment, as to what is it that causes this.
In other words, is it caused by the fact that the patient -- for example, somebody with COPD -- has limitation of airflow obstruction, and can that be treated with drugs -- for example, bronchodilators or corticosteroids? Other patients will have shortness of breath because they have severe emphysema involving the upper lobes. And some of those patients can be improved upon by surgery. This, of course, would never be entertained at the end of life, but if the patient was early enough in the process, you could do something like that. >> How should clinicians approach terminal care for patients with dyspnea?
>> Well, again, this gets to the issue of the transition from restorative to end-of-life care. And I would say primarily that there are two things that we know that can be prescribed specifically that help patients with dyspnea. One of them is oxygen, which many patients respond to. Although there are patients who respond to compressed air, including that which is blown on their faces, so this may be not purely a physiological effect. And secondly would be opioids. Most of the patients who get sedatives for dyspnea do not benefit from them. And not everybody who gets opioids benefits from them.
But I think by and large, if there's any drug that's going to be effective other than oxygen, it's going to be some sort of opioid in these kinds of patients. >> Is there anything else you would like to tell our listeners about managing dyspnea in patients with far advanced lung disease? >> Well, again, I would emphasize this transition between restorative and end-of-life care that you've been focusing on in some of your questions. There are definitely patients who have far advanced lung disease, especially patients with COPD, who can benefit from restorative treatments that I've mentioned, for example, bronchodilators, steroids I've mentioned.
Surgery to resect emphysematous blebs in the lungs. There's also, for example, good evidence that pulmonary rehabilitation, which improves exercise tolerance and provides a forum in which patients can mingle with other patients and talk about end-of-life issues with the other patients and with their physicians, is highly beneficial to patients. So yes opioids and oxygen at the end of life, but before that, there are things that can be done in the late stage of the disease that still are basically restorative in intent but have palliative effect as well.
>> Thank you, Dr. Luce, for your insights into managing dyspnea in patients with far advanced lung disease. For additional information about this topic, JAMAevidence subscribers can consult Chapter 6, which is co-written by Dr. Luce, in Care at the Close of Life. This has been Joan Stephenson of JAMA talking with Dr. John Luce for JAMAevidence.
