End-stage COPD

1
End-stage COPD

• Treatment of breathlessness
• End of life care.

2
Treatment of breathlessness in end-stage disease

• Nebulisers in COPD
• Oxygen
• Pulmonary rehabilitation
• Opiates
• (Benzodiazepines)

3
COPD - nebulisers

• Distressing breathlessness despite maximal
  inhalers
• able to use it
• assess one or more (over a trial period)
• reduction in symptoms
• increase in ability to do ADL
• increase exercise capacity
• improvement in lung function (not necessary)

4
Oxygen for breathlessness in COPD

• LTOT - given for prognostic benefit
• no evidence on SOB in studies in 1981,1980
• Ambulatory oxygen
• mild hypoxaemia and exercise desaturation
• prescribed if improvement in dyspnoea or exercise
  capacity
• new formal assessment procedure.

5
Oxygen for breathlessness

• Short burst - episodes of severe SOB not relieved
  by other treatments and improvement in SOB
  documented
• high cost, relatively unknown benefit
• Oxygen in palliative care - lung cancer - not
  clear that it relieves dyspnoea in patients who
  are not hypoxaemic.

6
Oxygen for breathlessness -the evidence - 1

• Evidence in palliative care that both oxygen and
  air (in a cylinder) are better than no treatment
  for breathlessness.
• Small study of 14 patients with hypoxia and
  advanced cancer in 1993 suggests they could tell
  the difference!

7
Oxygen for breathlessness - the evidence - 2

• RCT 51 patients 4l/min air or oxygen, blinded,
  improved symptomatically with both treatments, no
  difference in symptoms, despite improved sats on
  oxygen (17 patients hypoxic)
• RCT 33 cancer patients with dyspnoea SaO2 gt90, 6
  minute walk, oxygen or air at 5l/min, no change
  in dyspnoea, fatigue or distance walked.

8
Oxygen for breathlessness - 3

• Systematic review in 2004 - low grade evidence
  that oxygen and airflow improve dyspnoea in some
  patients with advanced disease at rest.
• Expert working group of Scientific Committee of
  the Association of Palliative Medicine published
  report in 2004 - unsure of benefit - use as part
  of treatment plan and assess patient benefit
  individually
• Breathlessness complex symptom

9
Pulmonary rehabilitation (COPD)

• MRC dyspnoea grade 3 or above (stops for breath
  at own pace)
• Programme of physical training, disease
  education, nutritional, psychological and
  behavioural intervention.
• Effect on exercise capacity, dyspnoea and health
  related QoL significantly greater than the effect
  of bronchodilator drugs

10
Opiates

• Systematic review in 2002 - 18 RCT (1CCF, others
  COPD, cancer, interstitial) dyspnoea any cause -
  significant positive effect of opiates on
  sensation of breathlessness - oral and parenteral
  more than nebulised.
• Studies small
• No problems with resp depression.

11
Opiates - 2

• BMJ 2003
• RCT 48 patients, 42 COPD, 34 home oxygen,
  recruited from respiratory/cardiac/palliative
  care OPD
• 4 days oral sustained release morphine 20mg with
  laxatives as necessary.
• Morphine superior to placebo
• No respiratory depression.

12
Benzodiazepines

• Used widely in palliative care
• Fail to work in 4 trials out of 5
• No recent RCT
• 18 pink puffers crossover trial of diazepam 25mg
  in 1981 no effect on breathlessness, reduced
  exercise tolerance, caused drowsiness.

13
End of life care

• Problem is when to start it.
• Illness trajectories and palliative care
• Scott A Murray, Marilyn Kendall, Kirsty Boyd and
  Aziz Sheikh
• BMJ 2005, 330 1007-1011

14
Illness trajectories - 1
15
Illness trajectories - 2
16
Illness trajectories - 3
17
Prognosis

• Question people want answered is what is going
  to happen?
• Cannot give a precise answer (!), but illness
  trajectory helps.