Nursing Care of Dyspnea: The 6th Vital Sign in Individuals with ...

Nursing Best Practice GuidelineAntibioticsRam, Joppi and Barnes (2004), in a systematic review, indicate that acute bacterial exacerbations of COPDare common, costly and difficult to manage. A number of researchers link AECOPD to bacterial infectionby pathogens such as Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa andM. catarrhalis. These bacteria may be associated with increased sputum volume and purulence (Blanchard,2002; Eller, Ede, Schaberg, Niederman, Mauch & Lode, 1998; Grossman, 1998; Murphy, Sethi & Niederman, 2000; Ram et al.,2004). However, the use of antibiotics is often prescribed to alleviate and to treat the cough and increasepurulent sputum production that leads to increase breathlessness (Calverley & Walker, 2003). In theseinstances, the use of antibiotics is controversial (Adams, Melo, Luther, & Anzueto, 2000; Anthonisen, Manfreda,Warren, Hershfield, Harding, & Nelson, 1987; Dewan, Rafique, Kanwar, Satpathy, Ryschon, Tillotson, et al., 2000; Grossman,1997; 1998; Murphy et al., 2000; Nicotra, Rivera & Awe, 1982; Niederman, 1997; Ram et al., 2004; Wilson, 1998). Ram andcolleagues (2004) suggest there is increased recognition that exacerbations may be due to viral infectionsof the upper respiratory tract or may be non-infective, so that antibiotic treatment is not always warranted.Anthonisen et al. (1987) found statistically significant advantages of antibiotic therapy for exacerbationscompared to placebo and suggest that antibiotic use is favourable where increased dyspnea, sputumproduction or increased purulence of sputum is present in more severe exacerbations. A meta-analysis bySaint, Bent, Vittinghoff & Grady (1995) attempted to estimate the effectiveness of antibiotics in treatingAECOPD and demonstrated benefits from antibiotic therapy. Adams et al. (2000) assessed predictivefactors of relapse for patients with AECOPD and the findings suggest that patients treated with antibioticshad significantly lower relapse rates than those who did not receive antibiotics.Psychotropic DrugsRipamonti (1999) suggests that although benzodiazepines are commonly used in the symptomatictreatment of cancer-related dyspnea, no clinical controlled trials have been performed in cancer patients.Buspirone, a nonbenzodiazeoine anxiolytic and a serotonin agonist has been demonstrated to be effectivein relieving dyspnea in patients with anxiety disorders and obstructive lung disease when given at doses of15-45 mg/day (Craven & Sutherland, 1991). Ripamonti (1999) suggests that chlorpromazine (Chlorpromanyl) issignificantly more effective than placebo in reducing dyspnea in patients with COPD.OpioidsCurrently available evidence does not support the clinical use of nebulized opioids; however, someclinicians utilize opioids to treat the symptom of dyspnea in end-stage COPD. Controlled clinical trials onthe symptomatic effect of nebulized opioids in COPD have been carried out and the use is controversial(Ripamonti, 1999; Zebraski, Kochenasti & Raffa, 2000). Moreover, Zebraski et al. (2000) suggest that the effect ofnebulized morphine sulfate in COPD patients has not always been robust nor always reproducible.Foral, Malesker, Huerta and Hilleman (2004) examined the literature related to the use of nebulized opioidsin COPD. They suggest that the evidence in the literature that suppots the use of nebulized opioids islacking and studies varied considerably in dose, opioid used, administration schedule and methodology.Moreover, they mentioned that as stated in the the Global Initiative for Lung Disease guidelines, opioid use iscontraindicated in COPD management due to the potential respiratory depression and worsening hypercapnia.37