07.19.2024

Understanding Dyspnea in End-Stage COPD: Back to Basics

Chronic Obstructive Pulmonary Disease (COPD) is characterized by persistent respiratory symptoms with airflow limitation due to airway and/or alveoli abnormalities such as restriction, scarring, destruction of air sacs, and loss or elasticity of bronchioles. COPD is usually a progressive disease leading to increased morbidity and mortality.1,2

End-stage COPD is characterized as Stage 4 (very severe COPD) according to the Global Initiative for Obstructive Lung Disease (GOLD). There are four stages of lung disease (Stage 1-4) with each stage being defined by spirometry measurement of FEV1 (forced expiratory volume exhaled in 1 second). End-stage COPD is defined as a FEV1 of less than or equal to 30%.2 While this can be a helpful objective measurement of COPD, FEV1 cannot be reliably used as the only diagnostic test.

The Modified Medical Research Council (mMRC) Dyspnea Scale and the Clinical COPD Questionnaire (CCQ) are two self-reported questionnaires that help clinicians assess symptom severity. The mMRC is a self-reported dyspnea scale of perceived breathlessness, composed of 5 statements that are rated on a scale of 1-4 (higher being more severe). The CCQ is a self-reported health status score from 0-6 (higher being poorer control).3 These two scales can help define a symptom score and support COPD assessment and diagnostic indicators.

End-stage COPD is currently the third most prevalent primary diagnosis in hospice care.4 While this disease process can be complicated with multiple symptoms such as dyspnea, chronic cough, sputum production, acute exacerbation, and pain,5 this article focuses primarily on the assessment and management of dyspnea, the most common symptom of COPD and one of the key objectives in COPD symptom management.6

End-Stage COPD Etiology and Assessment

Dyspnea is defined as the subjective experience of breathing discomfort (breathlessness) in a patient to varying degrees leading to significant disability and a negative effect on quality of life.7,10 While the etiology of COPD can be multifactorial and complex, the feeling of breathlessness usually manifests as an awareness of a mismatch of respiratory supply-and-demand.11

Assessment of a patient with shortness of breath can be difficult. While there are multiple assessment tools that have been identified as appropriate in palliative care, it has been hard to link treatment recommendations to scale ratings for improved patient outcomes. According to the Pulmonary Perspective: A Review of Quality of Care Evaluation for the Palliation of Dyspnea, due to the complexity of dyspnea with multiple etiologies and treatment options, in order to operationalize its treatment, re-assessment should occur along with a well-documented management plan with routine follow-up.12 A few scales may be useful in reaching this goal:

  • Numerical Rating Scale (NRS)

For a patient that can self-report, the NRS may be used to assess responses to treatment during re-assessment.7 The scale asks patients to rate their breathing discomfort from 0 (“none”) to 10 (“unbearable”). These types of scales have been used successfully for pain assessment and are now widely used for patients with shortness of breath. They are easy to administer and understand and able to measure perceived changes in shortness of breath over time.12

  • Respiratory Distress Observation Scale (RDOS)

For patients who cannot self-report, the RDOS may be used. A RDOS score of less than 3 indicates respiratory comfort. An RDOS score greater than or equal to 3 signifies respiratory distress and need for palliation. Higher RDOS scores signify a worsening condition.13,14

Management of End-Stage COPD in Hospice

Non-Pharmacological Therapy

Dyspnea, or breathlessness, can be taxing on the whole person causing physical strain, emotional fear, biological restrictions, and psychological distress.21

This list of non-pharmacological measures can support a patient experiencing dyspnea: 21

  • Physical methods:
    • Positioning: Sit up and lean forward
    • Cool air and moving air (consider a fan)
    • Breathing training such as pursed lip breathing or diaphragmatic breathing
  • Emotional methods:
    • Counseling
    • Open environment
    • Relaxation
    • Distractions such as music or audio books

Pharmacological Therapy

The “Dyspnea Ladder” can help support a comprehensive approach to management of dyspnea in End-stage COPD.15

The following are medication options for dyspnea in COPD based on drug classification:

Bronchodilators17

For patients using handheld inhalers it is important to understand the limitations of these devices. A patient with end-stage COPD will have a weak inspiratory effort. In addition, the ability to hold their breath for 5-10 seconds, expel air, and breathe in slowly and deeply, will likely be impaired. The use of handheld inhalers is also variable based on education level, age, socioeconomic status, physical limitations, cognitive functioning, and chronic disease burden.17 Poor techniques in inhaler use can lead to decline in symptom control and possible dyspnea crisis. Such patients could benefit from nebulized medication.

Abbreviations: MDI=Metered Dose Inhaler; DPI=Dry Powder Inhaler; SMI=Soft Mist Inhaler

  • Inhaled Beta2 Agonists16,8 are medications that work by opening airways and relaxing smooth muscles:
    • Short-acting
      • Albuterol MDI and solution for nebulization (ProAir®, Ventolin®)
      • Levalbuterol MDI and solution for nebulization (Xopenex®)
    • Long-acting
      • Salmeterol DPI (Serevent® Diskus)
      • Indacaterol DPI (Arcapta® Neohaler)
      • Olodaterol SMI (Striverdi® Respimat)
      • Formoterol solution for nebulization (Foradil®)
      • Arformoterol solution for nebulization (Brovana®)
  • Inhaled Antimuscarinics (i.e., anticholinergics) are medications that work by reducing contraction of the airways’ smooth muscle and reducing hyperinflation:
    • Short-acting
      • Ipratropium MDI and solution for nebulization (Atrovent®)
    • Long-acting
      • Tiotropium DPI (Spiriva® Handihaler) and SMI (Spiriva® Respimat )
      • Umeclidinium DPI (Incruse® Ellipta)
      • Aclidinium DPI (Tudorza® Pressair )
      • Glycopyrrolate DPI (Seebri® Neohaler)
  • Inhaled Combination Beta2 Agonist/Antimuscarinic Products
    • Short-acting
      • Albuterol/ipratropium solution for nebulization (Duoneb®) and SMI (Combivent® Respimat)
    • Long-acting
      • Vilanterol/umeclidinium DPI (Anoro® Ellipta)
      • Formoterol/glycopyrrolate MDI (Bevespi® Aerosphere)
      • Olodaterol/tiotropium (SMI Stiolto® Respimat)
      • Indacaterol/glycopyrrolate DPI (Utibron® Neoinhaler)

Oxygen Therapy

There has been debate on the benefit of oxygen therapy in COPD due to the concept that the correction of hypoxia will decrease respiratory drive leading to worsening hypercapnia, an elevated carbon dioxide level in the blood. However, current practice supports use of oxygen as a comfort measure in hypoxic end-stage COPD. The titration of oxygen to achieve saturation between 88%-92% is deemed safe and appropriate and can be used without concern.9

The goal of oxygen therapy for patients at end of life is a focus on symptom control rather than on saturation numbers, specifically as a patient continues to decline. Oxygen delivery in the home may be limited to a nasal cannula with maximum flow rates between 8-10 l/m.6 Patient comfort and symptom management should be regularly assessed.

Opioids15,18

Opioids are commonly used for pain in advanced disease and are also recommended for dyspneic patients. For dyspnea that persists despite specific therapy, or when no specific therapy is warranted, opioids have been demonstrated to provide significant relief. Doses for the opioid-naïve should start low with gradual titration for symptom control.

Examples of initial dosing for intermittent dyspnea include:

  • Hydrocodone/acetaminophen (APAP) 5mg/325mg: Give one tablet by mouth every 4 hours as needed (up to 3gm APAP a day)
  • Hydromorphone 1mg/ml solution: Give 0.5ml (0.5mg) by mouth every 4 hours as needed
  • Morphine 20mg/ml solution: Give 0.125 to 0.25ml (2.5 to 5 mg) by mouth every 3 hours as needed
  • Oxycodone 20mg/ml solution: Give 0.125ml (2.5mg) by mouth every 3 hours as needed
  • Morphine long acting 15 mg tablets: Give 1 tablet my mouth every 12 hours

Clinical Considerations:

  • Consider weaker opioids (e.g., hydrocodone/acetaminophen) for mild dyspnea and stronger opioids (e.g., hydromorphone, morphine, oxycodone) for more severe symptoms.
  • Titrate opioid therapy until symptoms are relieved.
  • Monitor respiratory rate.

Anxiolytics

While anxiolytic therapy hasn’t shown a direct correlation with treating dyspnea, it is widely known that dyspnea can cause anxiety which can cause more dyspnea. It’s important that anxiety be assessed and managed accordingly.19

Benzodiazepines may be used as a second line of treatment or in combination with opioids. Start with a low dose, titrating accordingly for symptom control.20 Lorazepam oral concentrate is commonly used with initial dosing at 0.5mg PO/SL/IM/IV every 4 to 6 hours as needed.

Abbreviations: PO=by mouth, SL=sublingual, IM=intramuscular, IV=intravenous)

Dyspnea Crisis18

A dyspnea crisis can be defined as a sustained and severe breathlessness that overwhelms a patient and caregiver. It can be managed by first preparing the patient and caregiver to expect episodes to take place near the end of life in patients with COPD. Managing a dyspnea crisis may involve aggressive medication management and oxygen therapy. In severe cases, palliative sedation may be warranted which is outside the scope of this article.

Resources on Palliative Sedation:

Summary

End-stage COPD with the primary symptom of dyspnea is complex in both approach and management. It is important to regularly reassess symptoms and adjust therapies to optimally support. Patient goals should also be reviewed frequently and discussed when there is a change in patient status.

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References

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