COPD Dyspnea, Asthma, Morphine and Other Opiate Treatments: A Case Presentation.

Chronic obstructive pulmonary disease (COPD) dyspnea can be a debilitating symptom.  What is dyspnea you ask?  The American Thoracic society defines dyspnea as
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 factor and may induce secondary physiological and behavioral responses
I have had several brief episodes of dyspnea in my life, usually related to a  viral illness.  But I  know I can't even begin to know what severe dyspnea feels like.  I do, however, see it every day as a hospitalist.  Usually my patients have end stage COPD, mostly a disease of smoking.  COPD patients  usually have significant air trapping in the lungs and have difficulty finding enough energy for their next breath.

I have a hard time watching a conscious COPD patient struggling to get their next breath.  Short of intubation or biPAP therapy, there isn't a lot of other mechanical interventions we as doctors can do to alleviate COPD dyspnea.  Once the lung tissue has died, it cannot be replaced.

In addition to the dead lung tissue for folks living with emphysema, severe asthmatics battle airway spasm and congestion that prevents inhalation of oxygen and exhalation of carbon dioxide.  As the airways contract, the asthma related dyspnea gets worse and is eventually followed by respiratory arrest.

How do we treat the problem?  We use bronchodilators.  These are  medications that counteract the spasm of the airways.  These medications include the short acting albuterol and Xopenex.  We also use the longer acting bronchodilator formulations such as Serevent (salmeterol) or Advair (combination inhaled steroid fluticasone and  salmeterol)  and the long acting formoterol or Symbicort (combination inhaled steroid budesonide  and formoterol).

Sometimes we also add a short acting anticholinergic bronchodilator such as ipratropium bromide (Atrovent).  It's used in  combination with nebulized  albuterol (Duoneb) or in combination with inhaler form (Combivent).  Sometimes we'll use the long acting anticholinergic once a day bronchodilator tiotropium bromide (Spiriva) instead.

For acute severe attacks in hospitalized patients, we will also use intravenous steroids (such as solumedrol) in very high doses (125mg IV q 6 hours) and taper the dosing from there, eventually discharging the patient on a two week prednisone taper (usually starting at 40 mg a day).  Some patients with asthma or COPD require chronic maintenance doses of steroids which themselves can come with chronic side effects, which can be as unbearable as the asthma dyspnea we are trying to treat.  Other medications are available as well (such as the leukotriene receptor antagonist Singulair) in the treatment of asthma.

Asthma or COPD related dyspnea can be a very difficult symptom to treat.  Even in patients who aren't hypoxemic, the subjective nature of dyspnea varies from mild and acute to severe and chronic.  We often use inhaled morphine in patients on hospice or end of life cares.  It can be a very effective method to control the agonizing drowning sensations of asthma or COPD related dyspnea.

Breathin' Stephen is a blogger, a patient with severe refractory asthma since birth, a retired respiratory therapist and a marathoner.  A marathoner?  That's incredible.  Instead of rolling over and accepting a disability check with a bold sense of entitled anger, he decided to take control of his life.  I encourage all of you who feel like you got the short end of the stick in life to go read about the power of perspective in your daily life choices.

Will you roll over and die?  Or will you turn your disability into ability.  Stephen has taken his asthma management one step further by initiating Methadone, an opiate used as the treatment of choice for heroin addicts in remission, to control his severe asthma dyspnea.  Stephen is correct in his assertion that many physicians are weary of using narcotics to treat dyspnea.  The drugs can induce respiratory depression and death if not monitored carefully.  In fact, the FDA has recently suggested that physicians be required to undergo additional certification to earn prescribing privileges for class 2 narcotics.  

Would I recommend class II opiates such as Methadone for most patients with asthma dyspnea?  Of course not.   Would some patients benefit with better COPD or asthma dyspnea control?  Yes they would.   However, in this litigious society we practice in, I think most physicians might think twice about  the  off label use of drugs, especially opiates, when doctors are being charged with homicide for their  unorthodox use.  

Would I prescribe opiates for use in asthma dyspnea?  Not in a million years.  Not as long as doctors are charged with homicide for off label use of medications. Would I take a class the certify myself?  Perhaps I would.  But I would use that class as a basis for telling patients opiates are not indicated for migraine headaches, opiates are not indicated for their irritable bowel pain and opiates do not have an FDA indication for asthma dyspnea.  

Perhaps the unintended consequences of health care reform such as  this FDA action  will limit patient access to pain medications and increase the burden of suffering by patients all across this country, including those experiencing severe refractory asthma dyspnea.  I recommend you go check out Breathin' Stephen and see what an inspiration he is to patients who chose to turn disabled into abled and his inspiration to help others achieve their dreams.

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