Role of Palliative Care in Chronic Obstructive Pulmonary Disease

Chronic Obstructive Pulmonary Disease

COPD is a common disease characterized by progressive airflow limitation and tissue destruction due to chronic inflammation from prolonged exposure to gases and noxious particles like cigarette smoking. It causes narrowing of the airway and decreased lung recoil presenting with classic symptoms of cough, dyspnea and sputum production which may eventually lead to respiratory failure.

Role Of Palliative Care in COPD Patients

COPD is the third most common cause of morbidity and mortality worldwide so providing palliative care for symptom management and improving the quality of life is of at most importance.

Symptom Management in COPD

The most important aspect is to acknowledge the fear and panic of the patient associated with acute exacerbation of COPD. As palliative care physicians we can educate the patient regarding the non-pharmacological methods to minimize the symptom burden of acute exacerbation of COPD. Few of the effective non-pharmacological methods in COPD are as follows:

1. Smoking Cessation
2. Pulmonary Rehabilitation
3. Long term oxygen therapy
4. Non-invasive positive pressure ventilation (NIV)
5. Lung volume reduction surgery
6. Reassurance, Explanation and Positing
7. Stay calm and remove anxiety
8. Activity pacing
9. Acceptance of the situation and positive thinking
10. Table fan at bedside
11. Distraction techniques
12. Relaxation techniques and psychosocial support

Role Of Pulmonary Rehabilitation in COPD

Palliative care physicians can emphasize and encourage the role of pulmonary rehabilitation for the patient and their families usually by involving interdisciplinary team of specialists with a goal of achieving and maintaining maximum level of independence and functioning in the community. Chest physiotherapist play an integral part in giving the techniques aimed to reduce the work of breathing and improving disabilities. The goals of pulmonary rehabilitation is to reduce dyspnoea, increase muscle endurance, improve the respiratory and peripheral muscle strength, ensure long term commitment to exercises , to remove fear and anxiety, to improve the nutritional status and health status of COPD patients. The Pulmonary Rehabilitation program includes:

• Breathing Retraining
• Diaphragmatic breathing and Segmental breathing improve pulmonary function parameters
• Pursed lip breathing reduces dyspnoea and work of breathing
• Chest physiotherapy
• Chest wall and intrapulmonary percussive vibration and mechanical insufflations-exsufflation devices for patients who have difficulty in mobilizing secretions

Pharmacological Methods

• 0 or 1 moderate exacerbations/year (not leading to hospital admissions) Bronchodilator/Long acting bronchodilator + Long acting Muscuranic agonist(LABA+LAMA)
• >2 moderate exacerbations or >1 leading to hospitalization – LABA+LAMA (consider LABA+LAMA+ICS if blood esinophil count >300)
• Low dose opioids

Opioids In COPD Patients

Opioids acts on the central receptors in the right posterior cingulated gyrus by decreasing the metabolic rate, ventilator requirements and causes vasodilation improving the cardiac function. It blunts the medullary response to hypercarbia or hypoxia, alters the neurotransmission within the medullary respiratory centre and blunts the afferent transmission from pulmonary mechanoreceptors to the central nervous system thereby causing cortical sedation leading to suppression of respiratory awareness, provides adequate analgesia leading to reduced pain induced respiratory drive and has anxiolytic effects in patients with COPD. In a review article published in 2019, there was 52% reduction in dyspnoea when opioids was used along with inhalers as adjuvant therapy improving the overall quality of life in patient with COPD

Patient Education in COPD

To slow the progression or to prevent acute exacerbation of COPD, patient should be educated on the following:

1. Smoking Cessation
2. Avoidance of second hand smoking
3. To reduce exposure to inorganic substances like asbestos,chromium,silica,carbon dust and organic substances like bird droppings,thermophilic fungi and bacterial species.
4. To reinforce the use of Inhalers – Bronchodilators and Corticosteroids
5. Good follow-ups and adherence to treatment plan
6. Chest physiotherapy and pulmonary rehabilitation
7. To get Annual influenza vaccination PCV13 and PPSV23 atleast 1 year apart for patients aged 65 years or above and PPSV23 under 65 years with co morbidities

Case Scenario

83-year-old female, known hypertensive presented to Palliative Medicine department at AIIMS, New Delhi with shortness of breath and dry cough in the past 1 week associated with chest tightness and difficulty in sleeping at night. Breathlessness was acute in onset and gradually progressing in nature (MMRC Grade 4) associated with noisy breathing. She also complains of chest pain while coughing and gasping for breath during night time while lying supine in the bed. She recalls multiple admissions in the past during winter months for acute exacerbation of COPD in the same ward for which medications and inhalers were prescribed. She admits that she is not on regular follow up with the pulmonary department and not compliant with taking her medication/inhalers on time.

Breathing training during pulmonary rehabilitation program

 

 

 

 

 

 

 

Take Home Message

Chronic obstructive pulmonary disease management requires interdisciplinary team approach consisting of pulmonologist, respiratory therapist/physiotherapist and palliative care. It requires comprehensive patient-centred treatment plans to maintain regular follow ups and good adherence to treatment plans to achieve optimum healthcare outcome. Patient needs to be reinforced to quit smoking and avoid exposure to harmful gases/noxious chemicals. Pulmonary rehabilitation plays a vital role in improving the quality of life, breathlessness and exercise capacity in COPD patients. Opioids like morphine can be given in low dose for reduction in dyspnoea when used along with inhalers as adjuvant therapy improving the overall quality of life in patient with COPD.

 

Note: This article is a republication from the December edition of the Indian Association of Palliative Care‘s free monthly e-newsletter.