Balamugesh Thangakunam, Christian Medical College, Vellore, India.
8 May 2007
The article by Yohannes AM is worth commending (1). The need for sensitizing patients and physicians treating COPD, to consider palliative care services to improve the quality of life has been highlighted well. I would like to make few comments.
While discussing the use of long acting bronchodilators the authors have mentioned that those on tiotropium need close monitoring for adverse effects like urinary infection. We suppose this should read urinary retention, since tiotropium is frequently associated with urinary retention and not urinary infection (2).
In the section on oxygen therapy it is mentioned that the “long term benefits of oxygen therapy for COPD patients remain inconclusive” We would like to question the veracity of this statement. There are two landmark trials that showed improvement in survival with long term oxygen therapy for hypoxic COPD patients (3,4). The Global Initiative for chronic Obstructive Lung Diseases guidelines of 2006 also mention that oxygen therapy improves survival (www.goldcopd.com) There also have a beneficial impact on exercise capacity, lung mechanics, and mental state (5). Even short term use of ambulatory oxygen is associated with significant improvement in health related quality of life in COPD patients who do not fulfill criteria for long term oxygen therapy but demonstrate significant exertional desaturation (6). However caution needs to be exercised in selecting patients for long term oxygen therapy since too much oxygen will lead to carbon-di-oxide retention.
The role of inhaled glucocorticoids has not been discussed. Glucocorticoids have been proven to reduce the rate of decline in quality of life and reduce the frequency of exacerbations in patients with severe COPD (7).
There is no mention on the role of smoking cessation in this article. Smoking cessation is the single most effective and cost effective way to reduce exposure to COPD risk factors. It is recommended that all smokers with COPD should be should be offered the most intensive smoking cessation intervention feasible (www.goldcopd.com). However this may not be appropriate in a terminally ill COPD patient considering the nicotine withdrawal effects.
References
1. Yohannes AM. Palliative care provision for patients with chronic obstructive pulmonary disease. Health Qual Life Outcomes. 2007,5:17.
2. Kesten S, Jara M, Wentworth C, Lanes S. Pooled clinical trial analysis of tiotropium safety. Chest 2006,130:1695-703.
3. Report of the Medical Research Council Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981; i: 681–6.
4. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxaemic chronic obstructive lung disease – a clinical trial. Ann Intern Med 1980; 93: 391–8.
5. Tarpy SP, Celli BR. Long-term oxygen therapy. N Engl J Med 1995,333:710-4.
6. Eaton T, Garrett JE, Young P, Fergusson W, Kolbe J, Rudkin S, Whyte K. Ambulatory oxygen improves quality of life of COPD patients: a randomised controlled study. Eur Respir J 2002,20:306-12.
7. Yang Ia, Fong K, Sim E, Black P, Lasserson T. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2007,18(2):CD002991.
Palliative care for COPD patients
8 May 2007
The article by Yohannes AM is worth commending (1). The need for sensitizing patients and physicians treating COPD, to consider palliative care services to improve the quality of life has been highlighted well. I would like to make few comments.
While discussing the use of long acting bronchodilators the authors have mentioned that those on tiotropium need close monitoring for adverse effects like urinary infection. We suppose this should read urinary retention, since tiotropium is frequently associated with urinary retention and not urinary infection (2).
In the section on oxygen therapy it is mentioned that the “long term benefits of oxygen therapy for COPD patients remain inconclusive” We would like to question the veracity of this statement. There are two landmark trials that showed improvement in survival with long term oxygen therapy for hypoxic COPD patients (3,4). The Global Initiative for chronic Obstructive Lung Diseases guidelines of 2006 also mention that oxygen therapy improves survival (www.goldcopd.com) There also have a beneficial impact on exercise capacity, lung mechanics, and mental state (5). Even short term use of ambulatory oxygen is associated with significant improvement in health related quality of life in COPD patients who do not fulfill criteria for long term oxygen therapy but demonstrate significant exertional desaturation (6). However caution needs to be exercised in selecting patients for long term oxygen therapy since too much oxygen will lead to carbon-di-oxide retention.
The role of inhaled glucocorticoids has not been discussed. Glucocorticoids have been proven to reduce the rate of decline in quality of life and reduce the frequency of exacerbations in patients with severe COPD (7).
There is no mention on the role of smoking cessation in this article. Smoking cessation is the single most effective and cost effective way to reduce exposure to COPD risk factors. It is recommended that all smokers with COPD should be should be offered the most intensive smoking cessation intervention feasible (www.goldcopd.com). However this may not be appropriate in a terminally ill COPD patient considering the nicotine withdrawal effects.
References
1. Yohannes AM. Palliative care provision for patients with chronic obstructive pulmonary disease. Health Qual Life Outcomes. 2007,5:17.
2. Kesten S, Jara M, Wentworth C, Lanes S. Pooled clinical trial analysis of tiotropium safety. Chest 2006,130:1695-703.
3. Report of the Medical Research Council Working Party. Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema. Lancet 1981; i: 681–6.
4. Nocturnal Oxygen Therapy Trial Group. Continuous or nocturnal oxygen therapy in hypoxaemic chronic obstructive lung disease – a clinical trial. Ann Intern Med 1980; 93: 391–8.
5. Tarpy SP, Celli BR. Long-term oxygen therapy. N Engl J Med 1995,333:710-4.
6. Eaton T, Garrett JE, Young P, Fergusson W, Kolbe J, Rudkin S, Whyte K. Ambulatory oxygen improves quality of life of COPD patients: a randomised controlled study. Eur Respir J 2002,20:306-12.
7. Yang Ia, Fong K, Sim E, Black P, Lasserson T. Inhaled corticosteroids for stable chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2007,18(2):CD002991.
Competing interests
Nil