Pharmacological Management of People Living with End-Stage Chronic Obstructive Pulmonary Disease

Supportive care and pharmacological treatment can improve the quality of life of people with end-stage chronic obstructive pulmonary disease (COPD) who cope on a daily basis with substantial physical, psychological, social and spiritual morbidity. Smoking cessation is the only intervention that reduces the rate of progression of COPD, but evidence-based drug treatments and non-pharmacological strategies can relieve symptoms and reduce the impact of exacerbations. People with severe COPD live with increasingly troublesome breathlessness and other symptoms such as fatigue, pain, sputum production and weight loss. As breathlessness increases, treatment is stepped up from short-acting to long-acting bronchodilators supplemented by non-pharmacological interventions such as pulmonary rehabilitation. Opiates relieve breathlessness, and referral to a multidisciplinary breathlessness service is an option for those with intractable symptoms. Other smoking-related conditions, such as coronary heart disease and lung cancer as well as depression and anxiety are common and should be treated with conventional pharmacotherapy. Acute exacerbations become more frequent and more severe as the disease reaches end-stage. Inhaled corticosteroids in combination with long-acting bronchodilators can reduce the frequency of exacerbations, and supported self-management aims to facilitate timely treatment of deterioration. Palliative care services have traditionally been predicated on identifying people with end-stage disease—a model that does not resonate with the unpredictable, relapsing trajectory of COPD. Approaches to care that promote a flexible approach to palliation alongside curative care could do much to improve the burden of living with severe COPD.