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Determining Prognosis: Patients with End-Stage Lung Disease (Reading & Sharing)

Disabling Dyspnea & Respiratory Distress

Defined by:

  • Dyspnea at rest or with minimal exertion
  • Dyspnea poorly responsive or unresponsive to bronchodilator therapy
  • Dyspnea results in other debilitating symptoms such as decreased functional activity, fatigue, and cough
  • FEV-1< 30% predicted post-bronchodilator, if available

Measures of total lung capacity and maximal work capacity that specifically predict a poor prognosis in end stage lung diseases, and a poor total lung capacity may be represented by the criterion of disabling dyspnea at rest of with minimal exertion, a postbronchodilator FEV-1 value less than 30% of that predicted reflects unresponsiveness or poor responsiveness to bronchodilators, and a highly impaired maximal work capacity may be manifested by decreased functional activity and fatigue. Studies suggested that patients with higher degrees of subjective dyspnea, regardless of pulmonary function studies, had significantly shorter survival times than patients who were less symptomatic.

Progression in pulmonary disease as manifested by multiple hospitalizations, emergency department visits, or doctor’s office visits, as patients with COPD worsen.

  • Generally develop more frequent episodes of acute bronchitis and pneumonia
  • Cor pulmonale
    • The development of pulmonary hypertension resulting in failure of the right side of the heart
    • is associated with increased mortality in patients with COPD

Other indicators of poor prognosis:

  • Body weight less or equal 90% of ideal body weight, or less or equal to 10% loss of weight
  • Resting tachycardia>100/min
  • Abnormal blood gases, if available, PO2 less and equal to 55 mm Hg or O2 sat reading less or equal to 88%, PCO2 greater or equal to 50 mm Hg
  • Continuous oxygen therapy.

When the patient with end-stage lung disease reaches the active dying phase, treatment goals shift from a supportive-prolonged-palliative plan to primarily palliative interventions. However, continuation of bronchodilators, steroids, and oxygen may reduce symptom distress. Thus, the primary focus shifts from treating the disease process to treating distressing symptoms.

Suplemental oxygen is beneficial in reducing dyspnea caused by hypoxemia. A fan directed at the patient’s face may be another useful strategy, although little evidence supports routine use. Opioids, most commonly morphine or fentanyl, are the mainstay of pharmacological management of dyspnea and effectiveness has been demonstrated in humerous clinical trials. The constipating effect of opioids never abates and patients receiving opioids must be on an aggressive bowel regimen using medications such as senna and docusate. fear and anxiety are components of respiratory distress experienced by the dying patient. The addition of a benzodiazepine to the opioid regimen has been successful in patients with advanced COPD.

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