Prevalence and Pharmacologic Treatment of Breathlessness in Severe Chronic Obstructive Pulmonary Disease

University dissertation from Lund University, Faculty of Medicine

Abstract: BackgroundChronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. Chronic breathlessness is a feared and distressing symptom with significant impact on daily life. Little is known of the prevalence of breathlessness at the end of life in severe COPD. International guidelines support the use of opioids to treat breathlessness, but it is unknown how commonly opioids are prescribed for the indication of breathlessness. Supplemental oxygen therapy is commonly prescribed, but data is conflicting on its efficacy in treating breathlessness. Knowledge of physician ability to identify chronic breathlessness and readiness to treat breathlessness with opioids is limited.Aims• To evaluate the prevalence of symptoms and their management at the end of life in patients with oxygen-dependent COPD in Sweden, compared to those with cancer (Study I).• To quantify the reported indications for opioid prescriptions in oxygen-dependent COPD in Sweden (Study II).• To investigate the efficacy of supplemental oxygen therapy for breathlessness in COPD patients with no or mild hypoxemia (Study III).• To assess potential recognition and treatment of chronic breathlessness as compared to chronic pain by physicians in Sweden, using a case-based survey (Study IV).Study DesignNationwide register-based cohort study of patients with oxygen-dependent COPD recorded in the Swedevox register linked with the Swedish Register of Palliative Care (Study I) and with the Swedish Prescribed Drug Register (Study II). Cochrane systematic review and meta-analysis of the efficacy of supplemental oxygen therapy for breathlessness (Study III). Randomized, controlled, double-blind, parallel-group, web-based trial of Swedish physicians treating a hypothetical patient with COPD and severe breathlessness versus a patient with severe pain (Study IV).Results and conclusionsAt the end of life, breathlessness was three times more common in patients with COPD than in those with cancer (Study I). Opioids were commonly prescribed for pain in oxygen-dependent COPD patients but rarely to treat breathlessness, which represented 2% of the stated indications (Study II). Supplemental oxygen therapy modestly reduced breathlessness during exercise in COPD with no or mild hypoxemia, but there was no evidence of an effect in daily life or on quality of life (Study III). In a case presentation of a COPD patient, severe chronic breathlessness was less likely to be identified by physicians as requiring symptomatic treatment and also less likely to be treated with opioids as compared to a patient with chronic pain (Study IV).