Chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) have slowly progressive airway obstruction. The course of the disease is punctuated by exacerbations due to pulmonary infection, heart failure, and poor compliance with prescribed therapy. (3°) COPD generally affects middle-aged and older patients. They present with dyspnoea, exercise intolerance, cough, and sputum production. Physical examination reveals lung overinflation, prominent use of accessory muscles to augment respiration, diminished breath sounds, and diffuse wheezing. Blood gases usually reveal some degree of resting hypoxaemia that may worsen during sleep or exercise. Initial pharmacological management usually starts with inhaled b-adrenergic agents. Continued symptoms are treated with anticholinergic medications. An insufficient response is often managed by a trial of theophylline. Poorly controlled symptoms may require oral corticosteroids. (3°> As with asthma, pharmacological treatments for COPD can cause psychiatric symptoms. Patients with COPD must stop smoking. Respiratory function (as measured by pulmonary functions) declines faster in smokers who develop COPD than non-smokers who develop COPD.

The chronic hypoxia caused by COPD compromises cognition and mood, which, in turn, can produce delirium, mood lability, mood disorders, and restriction in daily activities. There is considerable evidence that supplemental oxygen improves cognitive function and quality of life, even when medication management no longer improves these measures/3!' Unfortunately, mood improvement with supplemental oxygen has not been conclusively demonstrated. The benefits of supplemental oxygen have a psychological cost; oxygen use is a social embarrassment and can elicit feelings of helplessness and hopelessness.

Panic attacks are reported in 38 per cent of patients with COPD.(3 33) Benzodiazepines, which are highly effective for controlling panic attacks, have limited usefulness in patients with COPD because they can suppress the respiratory pacemaker. Carbon dioxide, which is panicogenic when rebreathed, likely plays a role in promoting panic attacks (because carbon dioxide levels increase with the progression of COPD). Antidepressants are useful in patients with COPD who develop panic attacks. Low-dose neuroleptic medications (e.g. 2 mg perphenazine orally two to three times daily) are also sometimes used for severe fear and panic, especially in intensive care unit settings (that is to say, when weaning the patient from a respirator). High-potency neuroleptics such as haloperidol and risperidone can also be useful. Neuroleptics do not directly suppress respiration, though caution must be exercised so that the sedation induced by neuroleptics—potentially combined with other sedating agents—does not reduce respiratory effort beyond that required to maintain adequate oxygenation.

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