Non-pharmacological Relief of Symptoms in the Severe Chronic Obstructive Pulmonary Disease Patient

Non-pharmacological Relief of Symptoms in the Severe Chronic Obstructive Pulmonary Disease Patient

Michela DiGiorgio, Nicolino Ambrosino
European Respiratory Disease 2007 - Issue I
Published: October 2008
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With increasing severity of disease, drugs may not be enough to alleviate dyspnoea of patients with chronic obstructive pulmonary disease (COPD). Many therapeutic interventions relieve dyspnoea by addressing different mechanisms, namely by reducing ventilatory demand, reducing ventilatory impedance or improving ventilatory muscle function.
Exercise training may result in improvement in dyspnoea, exercise tolerance and health-related quality of life (HRQoL).

Some data suggest an adjunctive effect of upper arm and specific inspiratory muscle training.

Only a few small controlled studies of neuromuscular electrical lowvoltage stimulation in severe COPD patients have been reported.

Supplemental oxygen during exercise reduces exertional breathlessness and improves exercise tolerance of hypoxaemic COPD patients. Heliox breathing can improve high-intensity exercise endurance capacity. Non-invasive assisted ventilation delivered during exercise enhances exercise tolerance in COPD patients, but its role in exercise training is still being discussed.

Lung-volume reduction surgery (LVRS) has become accepted in selected patients with severe symptomatic emphysema. Lung transplantation is an option for a more limited number of patients. COPD affects 6% of the general population and is a leading cause of morbidity and mortality worldwide.1,2 The most severe cases, i.e. those with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages III and IV, may account for 4.5 and 0.4%, respectively, in males and 2.2 and 0.3% in females.3

Dyspnoea is the most common symptom of COPD patients. It worsens with the natural history of disease and leads patients to inactivity and related peripheral muscle deconditioning so that patients may show progressive difficulties in performing simple activities of daily living (ADL).4 With increasing severity of disease, drugs may not be enough to alleviate dyspnoea. Therefore, there is a growing interest in nonpharmacological tools in addition to drug therapy in patients with severe COPD.

Determinants of Dyspnoea in COPD
Dyspnoea is “a term used to characterize a subjective experience of breathing discomfort that consists of qualitatively distinct sensations that vary in intensity. The experience derives from interactions among multiple physiological, psychological, social and environmental factors, and may induce secondary physiological and behavioral responses”.5 Different pathophysiological factors may contribute to exercise dyspnoea in COPD patients. These include increased intrinsic mechanical loading of inspiratory muscles (i.e. the intrinsic positive end-expiratory pressure (PEEPi)), airflow limitation, inspiratory muscle weakness, increased ventilatory demand relative to capacity, gas exchange abnormalities, cardiovascular factors and peripheral muscle wasting.6,7 In COPD, exercise dyspnoea correlates with lung hyperinflation, as assessed by inspiratory capacity, which, in turn, results in severe neuromechanical dissociation.8

Mechanisms of dyspnoea relief include reduction of ventilatory demand, reduction of ventilatory impedance and improvement in ventilatory muscle function.9,10 The most effective treatments for dyspnoea in COPD are bronchodilators11 and LVRS12 to improve the mechanical impairment, and pulmonary rehabilitation to reduce ventilatory demand.13 These modalities are useful at all stages of the illness.14,15 In severe COPD patients, the symptomatic drug treatment of dyspnoea may be relatively ineffective and is often accompanied by significant adverse effects.1,2,5

Exercise
Mild to severe COPD patients may obtain improvement in dyspnoea, exercise tolerance and HRQoL as a result of exercise training programmes.13,16,17 Exercise training is associated with enhanced oxidative capacity and higher capillary density in the trained muscles.18,19 A slower, deeper breathing pattern may result in a reduction of the endexpiratory lung volume, an improvement in dead space to tidal-volume ratio, a lower ventilatory requirement for exercise and a reduction in dynamic hyperinflation.16,20,21 Exercise training counteracts the increased exercise-associated oxidative stress of COPD.22

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