Objective To evaluate the safety of benzodiazepines and opioids in patients with very severe chronic obstructive pulmonary disease (COPD).Design Population based longitudinal consecutive cohort ...study.Setting Centres prescribing long term oxygen therapy in Sweden.Patients 2249 patients starting long term oxygen therapy for COPD in Sweden between 2005 and 2009 in the national Swedevox Register.Main outcome measures Effects of benzodiazepines and opioids on rates of admission to hospital and mortality, adjusted for age, sex, arterial blood gases, body mass index (BMI), performance status, previous admissions, comorbidities, and concurrent drugs.Results 1681 (76%) patients were admitted to hospital, and 1129 (50%) died under observation. No patient was lost to follow-up. Benzodiazepines and opioids were not associated with increased admission: hazard ratio 0.98 (95% confidence interval, 0.87 to 1.10) and 0.98 (0.86 to 1.10), respectively. Benzodiazepines were associated with increased mortality (1.21, 1.05 to 1.39) with a dose response trend. Opioids also had a dose response relation with mortality: lower dose opioids (≤30 mg oral morphine equivalents a day) were not associated with increased mortality (1.03, 0.84 to 1.26) in contrast with higher dose opioids (1.21, 1.02 to 1.44). Concurrent benzodiazepines and opioids in lower doses were not associated with increased admissions (0.86, 0.53 to 1.42) or mortality (1.25, 0.78 to 1.99). Associations were not modified by being naive to the drugs or by hypercapnia.Conclusions Lower dose opioids are not associated with increased admissions or deaths in patients with COPD and might be safe for symptom reduction in severe respiratory disease.
Spirometry reference values differ by race/ethnicity, which is controversial. We evaluated the effect of race-specific references on prevalence of lung function impairment and its relation to ...breathlessness and mortality in the US population.
Population-based analysis of the National Health and Nutrition Examination Survey (NHANES) 2007-2012. Race/ethnicity was analyzed as black, white, or other. Reference values for forced expiratory volume in one second (FEV
) and forced vital capacity (FVC) were calculated for each person using the Global Lung Initiative (GLI)-2012 equations for (1) white; (2) black; and (3) other/mixed people. Outcomes were prevalence of lung function impairment (< lower limit of normal LLN), moderate/severe impairment (< 50%pred); exertional breathlessness; and mortality until 31 December, 2015.
We studied 14,123 people (50% female). Compared to those for white, black reference values identified markedly fewer cases of lung function impairment (FEV
) both in black people (9.3% vs. 36.9%) and other non-white (1.5% vs. 9.5%); and prevalence of moderate/severe impairment was approximately halved. Outcomes by impairment differed by reference used: white (best), other/mixed (intermediate), and black (worst outcomes). Black people with FEV
≥ LLN
but < LLN
had 48% increased rate of breathlessness and almost doubled mortality, compared to blacks ≥ LLN
. White references identified people with good outcomes similarly in black and white people. Findings were similar for FEV
and FVC.
Compared to using a common reference (for white) across the population, race-specific spirometry references did not improve prediction of breathlessness and prognosis, and may misclassify lung function as normal despite worse outcomes in black people.
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DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
The fact that we all need oxygen to survive might make the benefit of supplemental oxygen in hypoxemia seem obvious. It is not. Long-term oxygen therapy was the first treatment to improve prognosis ...in patients with chronic obstructive pulmonary disease (COPD) and chronic severe hypoxemia.
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However, the question of whether long-term oxygen therapy is beneficial in moderate hypoxemia has been floating in the air.
The literature on the efficacy of long-term oxygen therapy requires no librarian. The current indications for its use are based on two unblinded, randomized trials that were conducted in the 1970s and involved a total . . .
We read with great interest the observational, registry-based study of the association between an incident opioid prescription and risk of subsequent hospitalisation or death within 30 days in people ...aged 66 years or older in the community with a diagnosis of chronic obstructive pulmonary disease (COPD), published recently in the European Respiratory Journal 1. The study was carefully conducted and accounts for potential confounding factors for which data were available. However, as with all observational studies, there are issues that affect interpretation of the findings and their application to clinical practice.
Breathlessness is a common, distressing, and limiting symptom that many people avoid by reducing their activity. This review discusses exertional tests that can be used for uncovering and assessing ...breathlessness depending on the person's severity of illness, function, the setting, and aim of the assessment.
Standardized exertional tests are useful to uncover 'hidden' breathlessness earlier in people who may have adapted their physical activity to limit their breathing discomfort. In 'more fit' ambulatory people and outpatients, cardiopulmonary exercise testing is the gold standard for assessing symptom severity, underlying conditions, and mechanisms and treatment effects. Among field tests, the 6-min walk test is not useful for assessing breathlessness. Instead, the 3-min step test and walk test are validated for measuring breathlessness change in chronic obstructive pulmonary disease. In people with more severe illness (who are most often not breathless at rest), reported tests include upper limb exercise or counting numbers aloud, but a valid and useful test for this population is lacking.
A framework for selecting the most appropriate test to assess breathlessness validly is proposed, and research needs are identified.
Breathlessness that persists despite treatment for the underlying conditions is debilitating. Identifying this discrete entity as a clinical syndrome should raise awareness amongst patients, ...clinicians, service providers, researchers and research funders.Using the Delphi method, questions and statements were generated
expert group consultations and one-to-one interviews (n=17). These were subsequently circulated in three survey rounds (n=34, n=25, n=31) to an extended international group from various settings (clinical and laboratory; hospital, hospice and community) and working within the basic sciences and clinical specialties. The
target agreement for each question was 70%. Findings were discussed at a multinational workshop.The agreed term, chronic breathlessness syndrome, was defined as breathlessness that persists despite optimal treatment of the underlying pathophysiology and that results in disability. A stated duration was not needed for "chronic". Key terms for French and German translation were also discussed and the need for further consensus recognised, especially with regard to cultural and linguistic interpretation.We propose criteria for chronic breathlessness syndrome. Recognition is an important first step to address the therapeutic nihilism that has pervaded this neglected symptom and could empower patients and caregivers, improve clinical care, focus research, and encourage wider uptake of available and emerging evidence-based interventions.
In 2023, the American Thoracic Society (ATS) changed its recommendations regarding the use of race and ethnicity in pulmonary function test evaluation. Previously, the race/ethnicity-specific Global ...Lung Function Initiative (GLI) reference values published in 2012 were a recommended standard to which observed spirometry values should be compared. This was based on the observations of differences in lung function after adjustment for age, sex, and height between groups on the basis of self-reported race/ethnicity. GLI data indicated that, on average, White individuals had the greatest FEV and FVC, followed by North East (NE) Asians and South East (SE) Asians, whereas Black individuals had the lowest values. Reference values for spirometry play an important role across respiratory and occupational medicine, including in diagnostics and treatment of diseases such as asthma, chronic obstructive pulmonary disease, cystic fibrosis, and interstitial lung disease, impacting clinical decisions. The uncertainties and limitations of reference values should always be recognized, and lung function results must be interpreted in the broader clinical context.
Breathlessness is common in the population, especially in women and associated with adverse health outcomes. Obesity (body mass index (BMI) >30 kg/m
) is rapidly increasing globally and its impact on ...breathlessness is unclear.
This population-based study aimed primarily to evaluate the association of current BMI and self-reported change in BMI since age 20 with breathlessness (modified Research Council score ≥1) in the middle-aged population. Secondary aims were to evaluate factors that contribute to breathlessness in obesity, including the interaction with spirometric lung volume and sex.
We included 13 437 individuals; mean age 57.5 years; 52.5% women; mean BMI 26.8 (SD 4.3); mean BMI increase since age 20 was 5.0 kg/m
; and 1283 (9.6%) reported breathlessness. Obesity was strongly associated with increased breathlessness, OR 3.54 (95% CI, 3.03 to 4.13) independent of age, sex, smoking, airflow obstruction, exercise level and the presence of comorbidities. The association between BMI and breathlessness was modified by lung volume; the increase in breathlessness prevalence with higher BMI was steeper for individuals with lower forced vital capacity (FVC). The higher breathlessness prevalence in obese women than men (27.4% vs 12.5%; p<0.001) was related to their lower FVC. Irrespective of current BMI and confounders, individuals who had increased in BMI since age 20 had more breathlessness.
Breathlessness is independently associated with obesity and with weight gain in adult life, and the association is stronger for individuals with lower lung volumes.
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