Dyspnea is a common problem among patients with interstitial fibrosis,
lung cancer, cystic fibrosis, and chronic obstructive pulmonary disease. The
slow but steady progression of such diseases, often punctuated by acute exacerbations
or secondary illnesses, can lead to decision-making dilemmas among patients
and their caregivers, such as when to accept mechanical ventilation, when
to forgo aggressive therapies, and when to make formal end-of-life care plans.
Two cases, a 74-year-old woman with dyspnea secondary to emphysema and a 65-year-old
woman with recurrent lung cancer and severe exertional fatigue and dyspnea,
illustrate how dyspneic patients approaching the end of life can be evaluated
and treated. Four management strategies for dyspnea are discussed: reducing
ventilatory impedance, reducing ventilatory demand, improving respiratory
muscle function, and altering central perception. Physicians should encourage
end-stage lung disease patients and their families to discuss issues such
as hospitalization and mechanical ventilation, to prepare advance directives,
and to participate in a plan to manage their dyspnea.