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Margaret L. Campbell
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WHAT DO «
J PALLIATIVE
I DO NOW• CARE
RESPIRATORY
SYMPTOMS
EDITED BY
Margaret L , Campbell
y
i
Respiratory
Symptoms
What Do I Do Now?: Palliative Care
S E R I E S E D I TO R
Margaret L. Campbell, PhD, RN, FPCN

Professor Emeritus, Wayne University College of Nursing,
Detroit, MI
OT H E R VO L U M E S IN T HE SE RIE S
Pediatric Palliative Care, Edited by Lindsay B. Ragsdale & Elissa G. Miller

Pain, Edited by Christopher M. Herndon
iii
Respiratory
Symptoms
Edited by
Margaret L. Campbell, PhD, RN, FPCN

Professor Emeritus, Wayne University College of Nursing,
Detroit, Michigan
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ISBN 978–0–19–009889–6
DOI: 10.1093/med/9780190098896.001.0001
This material is not intended to be, and should not be considered, a substitute for medical or other
professional advice. Treatment for the conditions described in this material is highly dependent on
the individual circumstances. And, while this material is designed to offer accurate information with
respect to the subject matter covered and to be current as of the time it was written, research and
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v
Contents
List of Contributors vii
Introduction xi
1. Dyspnea Assessment 1
2. Reducing Dyspnea by Optimizing Treatment of Chronic

Obstructive Pulmonary Disease 7
Miranda Wilhelm and Jennifer Arnoldi
3. Treating Chronic Breathlessness in Severe Chronic Obstructive

Pulmonary Disease 21
Lynn F. Reinke, Mary M. Roberts, and Tracy A. Smith
4. Dyspnea, Chronic Obstructive Pulmonary Disease, and

Pulmonary Rehabilitation 31
DorAnne Donesky and Julie Howard
5. Treating Episodic Breathlessness 39

Yvonne Eisenmann and Steffen Simon
6. Reducing Episodic Dyspnea in Heart Failure 49

Beth B. Fahlberg and Ann S. Laramee
7. Dyspnea in Pediatric Congenital Heart Disease 61

Jennifer Wright and Jessica L. Spruit
8. Treating Chronic Dyspnea in Patients with Lung Cancer 69

Elizabeth A. Higgins, Susan Ezemenari, and Julia Arana West
9. Treating Dyspnea Through Reducing Malignant Pleural

Effusion 77
Christine A. Crader
10. Treating Dyspnea in Lung Cancer with Noninvasive

Ventilation 87
Vittoria Comellini and Stefano Nava
11. Palliative Care for Infants with Bronchopulmonary

Dysplasia 95
Christine A. Fortney and Jodi A. Ulloa
vi
12. Reducing Dyspnea by Treating Ascites 101

Habib A. Khan
13. Panting for Breath in End-Stage Dementia 109

Hermien W. Goderie-Plomp, Carole Parsons, David R. Mehr,
and Jenny T. van der Steen
14. Last Days with Chronic Obstructive Pulmonary Disease 119

15. Withdrawal of Invasive Mechanical Ventilation 125

16. Palliative Sedation for Intractable Dyspnea 135

Patricia Bramati and Eduardo Bruera
17. Sialorrhea in Amyotrophic Lateral Sclerosis 145

Mark B. Bromberg
18. Death Rattle 153

Index 159
vi Contents
vi
Contributors
Jennifer Arnoldi, PharmD, BCPS Christine A. Crader, MD

Clinical Associate Professor Ascension Medical Group
Southern Illinois University Internal Medicine
Edwardsville (SIUE) School of Detroit, MI, USA
Pharmacy
DorAnne Donesky, PhD,
Edwardsville, IL, USA
ANP-BC, ACHPN, ATSF
Patricia Bramati, MD Professor, School of Nursing
The University of Texas MD Touro University of California
Anderson Cancer Center Vallejo, CA, USA
Houston, TX, USA
Yvonne Eisenmann, MD
Mark B. Bromberg, MD, PhD University of Cologne
Department of Neurology Faculty of Medicine and
University of Utah University Hospital
Salt Lake City, UT, USA Department of Palliative
Medicine
Eduardo Bruera, MD
Cologne, Germany
The University of Texas MD
Anderson Cancer Center Susan Ezemenari, MD
Houston, TX, USA Fellow, Palliative Medicine
Division of Internal Medicine,
Margaret L. Campbell, PhD,
Palliative Medicine and
RN, FPCN
Geriatrics
Wayne State University, College
Medical University of South
of Nursing
Carolina
Detroit, MI, USA
Charleston, SC, USA
Vittoria Comellini, MD
Beth B. Fahlberg, PhD, MN, RN
Respiratory and Critical Care Unit
University of Wisconsin
University Hospital St.
Madison, WI, USA
Orsola-Malpighi
Bologna, Italy
vi
Christine A. Fortney, PhD, RN Ann S. Laramee, MS, ANP-BC,

Assistant Professor ACNS-BC, CHFN, ACHPN,
The Ohio State University College FHFSA
of Nursing University of Vermont
Martha S. Pitzer Center for Medical Center
Women, Children and Youth Burlington, VT, USA
Columbus, OH, USA
David R. Mehr, MD, MS
Hermien W. Goderie-Plomp, Professor Emeritus
MD, MSc, MSc Department of Family and
Elderly Care and Palliative Care Community Medicine
Physician University of Missouri
De Zellingen, Rotterdam, The Columbia, MO, USA
Netherlands
Stefano Nava, MD
Lecturer in Palliative Care
Department of Specialistic,
Leiden University Medical Center
Diagnostic and Experimental
Leiden, The Netherlands
Medicine (DIMES), Alma
Elizabeth A. Higgins, MD Mater Studiorum University
Associate Professor of Internal of Bologna
Medicine Bologna, Italy
Division of Internal Medicine,
Carole Parsons, PhD,
Palliative Medicine and Geriatrics
MPharm, MPSNI
Medical University of South Carolina
Lecturer in Pharmacy Practice
Charleston, SC, USA
School of Pharmacy
Julie Howard, RRT, TTS, CCM Queen’s University Belfast
COPD Case Manager Belfast, UK
Adventist Health Rideout
Lynn F. Reinke, PhD, RN
Marysville, CA, USA
Claire Dumke Ryberg, RN
Habib A. Khan, MD Presidential Endowed Chair in
Johns Hopkins Medicine End-of-Life/Palliative Care
Department of Palliative Medicine University of Utah College of
Wayne State University Nursing
Baltimore, MD, USA Salt Lake City, UT, USA
viii Contributors
ix
Mary M. Roberts, MSN, RN Jodi A. Ulloa, DNP, APRN-CNP,

Department of Respiratory NNP-BC
and Sleep Medicine, Westmead Assistant Professor of Clinical
Hospital Practice
Ludwig Engel Centre for The Ohio State University College
Respiratory Research, Westmead of Nursing
Institute for Medical Research Martha S. Pitzer Center for
The University of Sydney at Women, Children and Youth
Westmead Hospital Columbus, OH, USA
Westmead, New South Wales,
Jenny T. van der Steen, MSc,
Australia
PhD, FGSA
Steffen Simon, MD Associate Professor
Department of Palliative Medicine Leiden University Medical Center,
University of Cologne Department of Public Health and
Faculty of Medicine and University Primary Care
Hospital Leiden, The Netherlands
Cologne, Germany Senior Researcher
Radboud University Medical
Tracy A. Smith, MD
Center, Department of Primary
Department of Respiratory and
and Community Care
Sleep Medicine, Westmead Hospital
Nijmegen, The Netherlands
The University of Sydney at
Westmead Hospital Julia Arana West, MD
Westmead, New South Wales, Fellow, Palliative Medicine
Australia Division of Internal Medicine,
Palliative Medicine and Geriatrics
Jessica L. Spruit, DNP, CPNP-AC
Attending Physician, Department
Pediatric Nurse Practitioner
of Emergency Medicine
Stepping Stones Pediatric Palliative
Medical University of South
Care Program
Carolina
University of Michigan
Charleston, SC, USA
Health System
Ann Arbor, MI, USA
Contributors ix
x
Miranda Wilhelm, PharmD Jennifer Wright, MS, CPNP

Clinical Associate Professor Stepping Stones Pediatric
Southern Illinois University Palliative Care
Edwardsville (SIUE) School of Michigan Medicine
Pharmacy Ann Arbor, MI, USA
Edwardsville, IL, USA
x Contributors
xi
Introduction
In this volume, nearly all the chapters relate to the complex symptom
dyspnea across diagnoses, lifespan, and care settings. Other chapters relate
to oral and pharyngeal secretions. These topics are addressed from a pallia-
tive care context.
Dyspnea, also known as breathlessness, has been defined as a person’s
awareness of uncomfortable or distressing breathing. As this can only
be known by the person, the term “respiratory distress” is used as the
observed corollary relying on patient signs when the person is unable to
report dyspnea, such as infants, young children, and adults with cognitive
impairments, which may be acute or chronic.
Dyspnea develops when inspiratory effort, hypoxemia, and/ or
hypercarbia develops, which activates three redundant brain areas. In the
cerebral cortex, the dyspneic person has an awareness of the change in
breathing efficiency. The amygdala in the subcortical temporal lobe is ac-
tivated when there is a threat to survival and produces a fear response. The
pons in the brainstem reacts by activating compensatory accelerations of
heart and respiratory rates and recruiting accessory muscles.
Assessment of dyspnea relies on self-report from as simple as a yes-
or-no response to the query “Are you short of breath?” to more complex
numeric scales (0–10) or categorical scales (none, mild, moderate, or se-
vere). For patients unable to report dyspnea, observation scales such as the
Respiratory Distress Observation Scale may be used. High-risk patients
should be assessed at every clinical encounter.
Dyspnea is one of the most difficult symptoms to experience and is also
one of the most difficult to treat, as the evidence base for this symptom
lags behind other prevalent symptoms such as pain or nausea, to name
two. Dyspnea is prevalent in patients with cardiopulmonary disorders and
cancer, and it escalates as death approaches. The development of dyspnea in
chronic disease is a predictor of mortality.
Dyspnea may be acute when a reversible etiology presents such as pneu-
monia, pleural effusion, or ascites. It is chronic in an irreversible condition
xi
such as chronic obstructive pulmonary disease (COPD), advanced heart

failure, or congenital cardiac conditions. Episodic dyspnea may typify acute
exacerbations in chronic conditions such as heart failure.
Treating dyspnea relies on a hierarchy of responses, beginning with
treating underlying, reversible conditions such as infections, pleural
effusions, volume overload, or ascites. Nonpharmacological treatments
include pulmonary rehabilitation, noninvasive ventilation, balancing rest
with activity, and optimal positioning. Pharmacological treatments include
oxygen, bronchodilators, and opioids. In cases of refractory dyspnea, palli-
ative sedation may be indicated.
Patients receiving invasive mechanical ventilation for respiratory failure
may undergo ventilator withdrawal to afford a natural death. These patients
are at very high risk for developing respiratory distress, which warrants
careful attention to the processes to minimize distress.
Salivary secretions pose a significant problem for patients with bulbar-
onset amyotrophic lateral sclerosis characterized by difficulties swallowing.
Treatment begins with anticholinergic medications and may include botu-
linum toxin injections or irradiation of salivary glands.
Pharyngeal secretions, also known as death rattle, develops in about
half of dying patients in the last days of life. Controversies about whether
medications are indicated or effective make up the evidence base. Ethical
concerns about medicating the patient to assuage the listener have been
raised.
The contributors to this volume have addressed all the treatments cur-
rently known for dyspnea, respiratory distress, and secretions with a case
study approach.
xii Introduction
1 Dyspnea Assessment
Stella is a nursing home resident in the advanced

stage of Alzheimer’s disease. Her goals of care are
comfort-focused, with surrogate decisions previously
made to withhold tube feedings, intubation,
cardiopulmonary resuscitation, and hospitalization.
She sleeps most of the day and night and is
noncommunicative except for sounds of displeasure
such as when being bathed or turned. Stella is at high
risk for aspiration pneumonia; she is offered a soft,
easy-to-swallow diet with foods such as pudding,
scrambled eggs, oatmeal, and baby food.
On daily exam a change in her breathing is noted; it
is highly likely that Stella has developed pneumonia,
probably secondary to immobility or food or liquid
aspiration. The clinical team cannot elicit a dyspnea
assessment from Stella, and they know she is at risk
for respiratory distress.
What do I do now?
1
2
WHAT IS DYSPNEA?
Dyspnea is a person’s awareness of uncomfortable or distressing breathing

that can only be known by self-report. In symptom care a patient’s self-
report has long been held as the gold standard for assessment. In a palli-
ative care context dyspnea should be assessed at every patient encounter,
for example in the hospital whenever vital signs are obtained, or at every
outpatient clinic visit, or at every house call for home-bound patients.
Since dyspnea escalates as death nears, the frequency of assessment should
be increased. Several tools are available for measuring and trending dyspnea
that are appropriate in palliative care.
Unidimensional Assessment Tools

Responding to a symptom assessment requires several cognitive steps on
the patient’s part: (1) ascertain their sensation, (2) pay attention to the
clinician’s assessment instructions, (3) formulate a response, (4) commu-
nicate that response in some fashion, and (5) recall their previous report if
trending is requested. When a patient is feeling poorly or is fatigued, these
steps may pose difficulty and simpler tools are indicated.
The simplest measure is to ask for a “yes” or “no” response to the query
“Are you short of breath?” or, in the case of the mechanically ventilated
patient, “Are you getting enough air?” Knowing the presence or absence of
dyspnea is helpful, but its intensity cannot be assessed with this approach.
A more complex tool is a numeric rating scale, usually anchored at 0 for no
dyspnea and 10 for the worst possible dyspnea. Patients may need guidance
on how to use numbers to characterize their symptom intensity. A variation
to using numbers is to ask for a categorical ranking (none, mild, moderate,
severe). Some patients may find these categorical rankings easier to under-
stand and relate to their experience than a numeric rating.
Another variation that can be used to rate intensity is a visual analog
scale, typically a 100-mm scale anchored at 0 and 100, with tick marks
at every 10 points (Figure 1.1). The patient points to a line on the scale
representing their experience and the clinician can convert that to a nu-
meric score; this approach is useful in the critical care setting with patients
who are mechanically ventilated and nonverbal. A vertical scale was pre-
ferred by patients with chronic obstructive pulmonary disease (COPD).1
2 WHAT DO I DO NOW? Respiratory Symptoms

3
Worst distress 100
No distress 0
FIGURE 1.1. Visual analog scale for dyspnea
Multidimensional Assessment Tools

Dyspnea is a multidimensional symptom with physical and affective attributes
that are not captured by the unidimensional tools just described. These scales
may be applied by patients with intact cognition who may be receiving palliative
care concurrently with disease treatment. The Dyspnea-122 is a multidimen-
sional scale composed of 12 descriptors that are scored on a four-item scale with
the points summed to produce a total dyspnea score (Table 1.1). Subscales for
physical and affective domains can be derived. The focal point for this assessment
is “these days,” which captures the average experience of a chronic symptom.
The Multidimensional Profile (MDP)3 comprises 11 numeric rating
scales (0–10) of different sensory and affective breathlessness sensations and
a “forced choice” item requiring respondents to select which of five sensory
qualities best describes their breathlessness. Individual item ratings are re-
ported, and subdomain scores can be calculated. Where a single score is
sought by users, the MDP-A1 item (0–10 rating of breathlessness unpleas-
antness) was recommended by the developers; a total summed score of all
items is not recommended for the MDP. The user specifies the focal event
Dyspnea Assessment 3
4
TABLE 1.1. The Dyspnea-12

Item None Mild Moderate Severe
1. My breath does not go in all the way.
2. My breathing requires more work.
3. I feel short of breath.
4. I have difficulty catching my breath.
5. I cannot get enough air.
6. My breathing is uncomfortable.
7. My breathing is exhausting.
8. My breathing makes me feel depressed.
9. My breathing makes me feel miserable.
10. My breathing is distressing.
11. My breathing makes me agitated.
12. My breathing is irritating.
Reprinted with permission from J. Yorke.
(e.g., “after you climb three flights of stairs,” “last minute of breathing on the
mouthpiece”) or timepoint (e.g., “right now”) for the MDP, and can choose
to use only one or a few of the instrument scales, depending on the clinical
purpose of assessment. Permission for use must be obtained from the author.
The Modified Medical Research Council (MMRC) dyspnea scale4
stratifies dyspnea into one of four scores relative to function, with 0 signi-
fying dyspnea only with strenuous exercise and 4 representing too dyspneic
to leave the house or dress. The MMRC dyspnea scale is best used to estab-
lish baseline functional impairment related to respiratory disease.
Observation Scale
Patients who are unable to provide a symptom report but can experience the
symptom are vulnerable to over-or under-treatment. Respiratory distress
is the observed corollary to reported dyspnea relying on patient signs. The
Respiratory Distress Observation Scale5 was developed for patients with ad-
vanced disease who are unable to self-report (Table 1.2). Eight variables are

5
TABLE 1.2. Respiratory Distress Observation Scale
Variable 0 points 1 point 2 points Total
Heart rate per minute <90 beats 90–109 beats ≥110 beats
Respiratory rate per ≤18 breaths 19–30 breaths >30 breaths

minute
Restlessness: None Occasional, Frequent

non-purposeful slight movements
movements movements
Accessory muscle None Slight rise Pronounced

use: rise in clavicle rise
during inspiration
Paradoxical breathing None Present

pattern
Grunting at end- None Present

expiration: guttural
sound
Nasal flaring: None Present

involuntary
movement of nares
Look of fear None Eyes wide

open, facial
muscles
tense, brow
furrowed,
mouth open
Source: m.campbell@wayne.edu
scored from 0 to 2 points and the points are summed to yield a total inten-
sity score ranging from 0 to 16. Reliability and validity have been established
across diagnoses and settings of care; intensity cut-points are 0–2 =no distress,
3 =mild distress, 4–6 =moderate distress, and 7 and higher =severe distress.6,7
SUMMARY
Several unidimensional and multidimensional scales and an observation

scale were described as suitable for assessment in patients receiving palliative
Dyspnea Assessment 5
6
care. Selection of the optimal tool will depend on the patient’s cognitive
abilities, which are influenced by disease trajectory, fatigue, sedation, me-
chanical ventilation, and underlying conditions such as dementia.
Stella has a heart rate of 108 and respiratory rate of 22. She has slight
restlessness and a slight rise in the clavicle, signifying accessory muscle use.
There is no apparent paradoxical breathing, nor grunting, nor nasal flaring
or a fearful facial expression. Thus, her RDOS score is 4, signifying mod-
erate distress. The nurses elevated the head of her bed, placed a fan blowing
on her cheek, and began immediate-release morphine elixir at 5 mg every
4 hours. Subsequent RDOS scores decreased to 2 or 3 with this regimen.
KEY POINTS TO REMEMBER
• Assessment is critical to optimizing treatment.

• Patient abilities will inform selection of an assessment tool
or scale.
• Self-reported dyspnea presence and intensity is the gold
standard.
• Respiratory distress signs are indicated for those who cannot
report their experience.
References
1. Gift A. Validation of a vertical visual analogue scale as a measure of clinical
dyspnea. Rehab Nurs. 1989;14:323–325.
2. Yorke J, Moosavi SH, Shuldham C, Jones PW. Quantification of dyspnoea
using descriptors: development and initial testing of the Dyspnoea-12. Thorax.
2010;65(1):21–26.
3. Banzett RB, O’Donnell CR, Guilfoyle TE, et al. Multidimensional Dyspnea
Profile: an instrument for clinical and laboratory research. Eur Respir J.
2015;45(6):1681–1691.
4. Mahler DA, Wells CK. Evaluation of clinical methods for rating dyspnea. Chest.
1988;93(3):580–586.
5. Campbell ML, Templin T, Walch J. A Respiratory Distress Observation Scale for
patients unable to self-report dyspnea. J Palliat Med. 2010;13(3):285–290.
6. Campbell ML. Psychometric testing of a respiratory distress observation scale. J
Palliat Med. 2008;11(1):44–50.
7. Campbell ML, Kero KK, Templin TN. Mild, moderate, and severe intensity cut-points
for the Respiratory Distress Observation Scale. Heart Lung. 2017;46(1):14–17.

2 Reducing Dyspnea by
Optimizing Treatment
of Chronic Obstructive
Pulmonary Disease
Miranda Wilhelm and Jennifer Arnoldi
JW, a 75-year old female, presents to the primary

care clinic with a chief complaint of “This inhaler is
not working.” The patient reports shortness of breath
with activities of daily living but has not experienced
an exacerbation or hospitalization or used an oral
corticosteroid related to chronic obstructive pulmonary
disease (COPD) for the last year. Relevant medical
history includes 60 pack-year history of smoking
cigarettes (1 pack per day for 60 years; quit “cold turkey”
approximately 1 year ago), COPD for 5 years, osteoporosis
for 10 years, hypertension for 20 years, and rheumatoid
arthritis for 33 years. Current medications include
tiotropium HandiHaler, albuterol hydrofluoroalkane
(HFA), salmeterol Diskus (recently added), alendronate,
lisinopril/hydrochlorothiazide, methotrexate and
hydroxychloroquine. Recent records indicate that her
forced expiratory volume in 1 second (FEV1) is 45% of
predicted and her COPD AssessmentTest (CAT) score is 18.
What do I do now?
7
8
T he Global Initiative for Chronic Obstructive Lung Disease (GOLD)

guidelines are updated and published on an annual basis. It is
recommended that all healthcare providers incorporate this evidence-based
guideline into their practice for the prevention, diagnosis, and treatment
of COPD. Currently, the GOLD guidelines recommend short- acting
bronchodilators, either a short-acting beta agonist (SABA) or a short-acting
muscarinic antagonist (SAMA), for relief of acute symptoms in all patients.
First-line maintenance pharmacotherapy includes the use of a long-acting
bronchodilator such as a long-acting beta agonist (LABA) or a long-acting
muscarinic antagonist (LAMA). Inhaled corticosteroids are considered the
last option to reduce exacerbations (Table 2.1). It is important to continue
these therapies through the end of life to manage symptoms and to maxi-
mize quality of life by minimizing dyspnea.
Selection of therapy for COPD should consider not only the patient’s
disease characteristics such as symptoms, exacerbation history, and future
risks, but also their physical capabilities, cognitive function, and other
comorbidities. The patient’s previous experience with inhalation devices,
their preferences, and insurance coverage of medication therapy should also
be considered.
For established regimens, the patient’s adherence and their inhaler tech-
nique should be assessed. If the patient is not using the inhaler as prescribed
or their technique is poor, this could reduce the actual and perceived effi-
cacy of the medication. Therefore, selecting the device can be just as impor-
tant as selecting the appropriate class of medications to use in COPD. Four
inhalation devices—metered-dose inhalers (MDIs), dry powder inhalers
(DPIs), soft mist inhalers (SMIs), and nebulizers—are used in COPD phar-
macotherapy. Table 2.2 lists their advantages and disadvantages.
INHALATION DEVICES
MDIs
MDIs consist of a canister, a metering chamber, and an actuator with a
mouthpiece (Figure 2.1). The canister contains a solution of the medica-
tion and a propellant. Shaking the device disperses the propellant into the
medication solution, creating the pressure needed for aerosolization. As the
canister is depressed, the patient must be ready to inhale the dose. Thus,

9
TABLE 2.1. Inhaled Medications Commonly Used to Treat COPD
Pharmacological Generic drug Brand drug name Inhalation type

class name
Beta2-agonists, Albuterol Generics (various) MDI, nebulization
short-acting solution
(SABA)
ProAir RespiClick DPI
(Teva)
ProAir Digihaler DPI

(Teva)
ProAir HFA (Teva) MDI
Proventil HFA MDI

(Merck)
Ventolin HFA MDI

(GlaxoSmithKline)
Levalbuterol Generics (various) Nebulization

solution
Xopenex HFA MDI

(Sunovion)
Beta2-agonists, Arformoterol Brovana Nebulization

long-acting (Sunovion) solution
(LABA)
Formoterol Perforomist Nebulization
(Mylan) solution
Indacaterol Arcapta Neohaler DPI, capsule-based

(Sunovion) dosage form
Olodaterol Striverdi Respimat SMI

(Boehringer
Ingelheim)
Salmeterol Serevent Diskus DPI

(GlaxoSmithKline)
Anticholinergics, Ipratropium Generics (various) Nebulization

short-acting solution
(SAMA)
Atrovent HFA MDI
(Boehringer
Ingelheim)
(continued)
Optimizing COPD Treatment 9

10
Table 2.1. Continued

class name
Anticholinergics, Aclidinium Tudorza Pressair DPI
long-acting (Circassia)
(LAMA)
Glycopyrrolate Seebri Neohaler DPI, capsule-based
(Sunovion) dosage form
Lonhala Magnair Nebulization

(Sunovion) solution
Revefenacin Yupelri (Mylan) Nebulization

solution
Tiotropium Spiriva HandiHaler DPI, capsule-based

(Boehringer dosage form
Ingelheim)
Spiriva Respimat SMI

(Boehringer
Ingelheim)
Umeclidinium Incruse Ellipta DPI

(GlaxoSmithKline)
Combination, Albuterol/ Generics (various) Nebulization

SABA/SAMA ipratropium solution
Combivent SMI
Respimat
(Boehringer
Ingelheim)
Combination, Formoterol/ Duaklir Pressair DPI

LABA/LAMA aclidinium (Circassia)
Formoterol/ Bevespi MDI

glycopyrrolate Aerosphere
(AstraZeneca)
Indacaterol/ Utibron Neohaler DPI, capsule-based

glycopyrrolate (Sunovion) dosage form
Vilanterol/ Anoro Ellipta DPI

umeclidinium (GlaxoSmithKline)

1

class name
Olodaterol/ Stiolto Respimat SMI
tiotropium (Boehringer
Ingelheim)
Combination, Formoterol/ Symbicort MDI

LABA/inhaled budesonide (AstraZeneca)
corticosteroid
Formoterol/ Dulera (Merck) MDI
mometasone
Salmeterol/ Advair HFA MDI

fluticasone (GlaxoSmithKline)
Advair Diskus DPI

(GlaxoSmithKline)
AirDuo RespiClik DPI

(Teva)
Wixela Inhub DPI

(Mylan)
Vilanterol/ Breo Ellipta DPI

fluticasone (GlaxoSmithKline)
Triple Vilanterol/ Trelegy Ellipta DPI

combination, umeclidinium/ (GlaxoSmithKline)
LABA/LAMA/ fluticasone
inhaled
corticosteroid
MDI use requires hand–breath coordination, and conditions that can de-
crease dexterity (e.g., rheumatoid arthritis, Parkinson’s disease) or cognitive
performance may limit a patient’s ability to accurately use the inhaler. Due
to the propellant contained in MDIs, failure to coordinate breath with dose
activation can result in medication being deposited in the mouth and/or
throat or loss of drug into the air. Holding chamber/spacer devices, when
combined with MDIs, may improve patient technique in terms of hand–
breath coordination but still require some manual dexterity to manipulate
and are bulky to handle.

12
TABLE 2.2. Advantages and Disadvantages of Inhalation Devices
Inhalation Advantages Disadvantages

device
MDI • Convenient/portable • Hand–breath
• Multidose devices coordination required
• Short administration time • Multiple steps
• Counter indicates doses • Requires priming
remaining • Throat deposition,
leading to adverse drug
events
DPI • Convenient/portable • Requires moderate

• Single-dose and multidose to high inspiratory
devices flow rate
• Short administration • May require priming
time • Throat deposition,
• Counter indicates doses leading to adverse drug
remaining events
• Breath-actuated
SMI • Convenient/portable • Hand–breath

• Multidose devices coordination required
• Short administration • Requires assembly
time • Multiple steps
• Counter indicates doses • Requires priming
remaining
Jet nebulizer • Hand–breath coordination • Temperature change

not required of medication during
• Minimal dexterity needed use (cool)
• Limited portability
• Power source or battery
pack needed
• Requires assembly
• Lengthy administration
time (10–15 minutes)
• Requires frequent
cleaning
• Not all medications
available in this
dosage form
• Generates noise
• Single dose

13
Inhalation Advantages Disadvantages

device
Ultrasonic • Portable • Temperature change
nebulizer • Quiet of medication during
• Hand–breath coordination use (heat)
not required • Power source or battery
• Minimal dexterity needed pack needed
• Requires assembly
• Administration time
(5 minutes)
• Requires frequent
cleaning
available in this
dosage form
• Single dose
Vibrating • Portable • Expensive

mesh • Quiet • Power source or battery
nebulizer • Hand–breath coordination pack needed
not required • Requires assembly
• Minimal dexterity needed • Administration time
• No temperature change of (5 minutes)
medication during use • Requires frequent
cleaning
available in this
dosage form
• Single dose
Asking the patient to demonstrate their technique with the inhaler may
allow the provider to identify any potential errors in use that could pre-
vent the medication from being effective. Common errors encountered in
MDI use that could easily be identified through patient observation include
failing to remove the device’s mouthpiece cover before use; not sealing the
mouth around the mouthpiece when actuating the dose; lack of coordina-
tion between activating the dose and inhaling; and inhaling via the nose
rather than the mouth.

14
FIGURE 2.1. Metered-dose inhaler
Photo by Katherine Newman, PharmD.
DPIs
DPIs include a medication reservoir, an air inlet area, and a mouthpiece
(Figures 2.2 and 2.3). The medication is in a dry powder dosage form that
is drawn from the device using the patient’s own breath. This may sim-
plify the hand–breath coordination required by MDIs; however, the lack
of propellant in these devices requires the patient to generate a sufficient
inspiratory flow rate to inhale the entire dose of the medication. Patients

15
FIGURE 2.2. Dry powder inhaler: Ellipta
with advanced COPD may experience disease-related airflow limitation,

leading to difficulties in taking a breath with sufficient force and volume
to inhale the full dose of the medication. One complicating factor is that
DPIs are manufactured with some degree of variability in design, including
the turbulence and resistance of the product and device. Due to this, the
patient’s ability to use one type of DPI does not predict success with a DPI
containing a different medication or administration device. A patient’s peak

16
FIGURE 2.3. Dry powder inhaler: Neohaler
inspiratory flow rate (PIFR) can be obtained using a handheld inspiratory

flow meter with an adjustable dial to simulate internal resistances of dry
powder devices. For optimal DPI use, the patient should be able to attain
at least 60 L/min; a PIFR less than 30 L/min is not likely to be sufficient.
All patients receiving a DPI should be educated to avoid breathing into
the device or getting it wet. Each device contains unique instructions about
breathing in (e.g., quickly and deeply; a long, steady, deep breath; inhaling
deeply and forcefully; taking two breaths from the same dosage). Simple
instructions could be given as “breathe in hard and fast.” For DPIs, it is
critical to consider the mechanism by which the dose is prepared for use;
while the patient’s breath is the driving force to disperse and deliver the
medication, each device uses a different approach to allow this to happen.
For some devices, the dose may be prepared by opening the mouthpiece
cover with or without the need to activate an additional lever (e.g., Diskus,
Ellipta). For others (e.g., HandiHaler, Neohaler), the patient needs to
open a capsule from a blister pack, place the capsule into the device, and
pierce the capsule before inhaling. These device differences should also be

17
considered when selecting the device (i.e., whether the patient has the dex-
terity required to manipulate the capsule or the cognitive ability to follow
dosing instructions) and when evaluating the patient’s inhaler technique.
Each step of the device’s usage process creates the potential for user error.
Finally, patients using DPIs should be educated that once the dose has
been prepared for inhalation they should not tip, shake, or otherwise dis-
turb the contents inside the inhaler. If they do, they risk losing some of the
medication prior to use.
SMIs
SMIs do not use a propellant; rather, a liquid formulation delivers med-
ication as a fine mist aerosol for inhalation. The unique nozzle delivers
medication at a slower velocity (1.5 seconds) compared to MDIs (100–400
milliseconds). SMIs were designed to make medication delivery easier than
with MDIs, although some hand–breath coordination is still required. In
addition, the devices require assembly before use, which may require some
degree of manual dexterity and/or cognition (Figure 2.4).
FIGURE 2.4. Soft mist inhaler

18
Nebulizers
Nebulizers turn liquid medication into an aerosol for inhalation. They offer
an alternative to MDIs and DPIs for providing inhaled therapy to patients
with COPD. Evidence suggests that the efficacy of nebulizer treatments
in patients with COPD is similar to that with MDIs and DPIs. Several
options are available for the type of nebulizer (e.g., jet, ultrasonic, and
vibrating mesh). Nebulized medications eliminate the need for hand–
breath coordination, but some dexterity may be needed to open the vial
of liquid medication. Other considerations with nebulizer therapy include
the possibility of longer treatment times compared to inhalation by MDIs,
DPIs, or SMIs; portability of the nebulizer device selected; and the fre-
quent cleaning required to maintain the device. Newer nebulizers have a
shorter administration time (5–10 minutes vs. 15 minutes or more), use
batteries rather than wall outlets, and are smaller in size to enhance port-
ability. As COPD progresses and particularly at the end of life, patients
may experience decreased PIFR, so use of handheld inhalers may become
difficult. In this population, nebulized medication may offer improvement
in symptom control and quality of life. Not every medication is available in
nebulizer dosage forms, so each patient’s regimen needs to be customized
(see Table 2.1).
COMBINATION THERAPY REGIMENS
Once a patient’s optimal device type has been identified and both the pa-
tient and the provider are comfortable with the patient’s device technique,
every effort should be made to continue the patient on the same device
type when making changes to the inhaled regimen. For instance, if the
patient has demonstrated proper technique with a tiotropium SMI (i.e.,
Spiriva Respimat) and the prescriber wishes to add a LABA for symptom
control, switching to a combination olodaterol/ tiotropium SMI (i.e.,
Stiolto Respimat) would allow the patient to use two medications with
a single device to which they’ve already become accustomed. When it is
necessary to switch device types or add an additional device, it is critical
to provide patient education on device use and any key differences they
should be aware of (e.g., using a slow, deep breath for the MDI vs. a quick,
forceful breath for the DPI). Every effort should be made to verify the

19
patient’s understanding of the devices, optimally through use of demon-

stration and/or teach-back.
INHALER DEVICE TRAINING
The complexity of COPD regimens and devices and the likelihood of med-
ication changes over the course of the chronic disease make comprehensive
patient education of the utmost importance. Demonstrating inhaler tech-
nique, working with the patient until they can properly use the device,
and using the teach-back method are crucial to prepare patients for safe
and effective medication use. In addition, patients should regularly have
their technique reviewed and receive additional education on any technique
errors. Patients who are advanced in age and those who have cognitive im-
pairment, complicated regimens, or multiple device types may require ad-
ditional time and training in order to be successful. If available, devices
such as the InCheck DIAL or the Vitalograph AIM (Aerosol Inhalation
Monitor) may be used to assess the patient’s inspiratory flow and appropri-
ateness for a variety of devices. The InCheck includes the ability to simulate
the resistance of a selected DPI to determine if the patient has an adequate
inspiratory flow. The Vitalograph can be used with an attachment MDI
or DPI simulator mouthpiece to analyze the patient’s inhaler technique at
various stages of the inhalation process, including breath-hold time at the
end of the inhalation.
KEY POINT S TO REMEMBER
• Selection of therapy for COPD should consider not only

the patient’s disease characteristics but also their physical
capabilities, cognitive function, and other comorbidities.
• Adherence and inhaler technique should be assessed prior to
adding and/or changing pharmacotherapy.
• A variety of inhalation devices, including MDIs, DPIs, SMIs,
and nebulizers, are available to individualize therapy, but these
devices may require hand–breath coordination and/or dexterity
so that the medication is administered correctly.

20
Further Reading
Ari A. Jet, ultrasonic, and mesh nebulizers: an evaluation of nebulizers for better
clinical outcomes. Eurasian J Pulmonol. 2014;16:1–7.
Dal Negro RW. Dry powder inhalers and the right things to remember: a concept
review. Multidiscip Respir Med. 2015;10(1):13.
Dhand R, Cavanaugh T, Skolnik N. Considerations for optimal inhaler device selection
in chronic obstructive pulmonary disease. Cleveland Clin J Med. 2018;85(2 supp
1):S19–S27. doi:10.3949/ccjm.85.s1.04
GOLD Science Committee. Global Strategy for the Diagnosis, Management, and
Prevention of Chronic Obstructive Lung Disease. https://goldcopd.org/wp-cont
ent/uploads/2019/11/GOLD-2020-REPORT-ver1.1wms.pdf
Loh CH, Ohar JA. Personalization of device therapy: prime time for peak
inspiratory flow rate. Chronic Obstr Pulm Dis. 2017;4(3):172–176. doi:10.15326/
jcopdf.4.3.2017.0155
Mahler DA. Peak inspiratory flow rate as a criterion for dry powder inhaler use in
chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2017;14(7):1103–1107.
doi:https://doi.org/10.1513/AnnalsATS.201702-156PS
Rogliani P, Calzetta L, Coppola A, et al. Optimizing drug delivery in COPD: the role of
inhaler devices. Respir Med. 2017;124:6–14.
Tashkin DP. A review of nebulized drug delivery in COPD. Int J Chron Obstruct
Pulmon Dis. 2016;11:2585–2596.

3 Treating Chronic
Breathlessness in Severe
Chronic Obstructive
Pulmonary Disease
Lynn F. Reinke, Mary M. Roberts,

and Tracy A. Smith
Mr. B is a 72-year-old man with severe chronic

obstructive pulmonary disease (COPD) on 2 liters
per minute (LPM) of supplemental oxygen therapy
continuously. Past medical history: congestive heart
failure, anorexia, and anxiety. He presented to the
emergency department twice last year for COPD
exacerbations and was admitted to the hospital once,
requiring bilevel ventilation. Today, at the clinic, he is alert
and frail and has a body mass index (BMI) of 17 kg/m2. At
rest he can speak in full sentences; however, ambulating
25 feet induces breathlessness. On a scale from 1 to
10 (1 =no dyspnea, 10 =severe dyspnea) he rates his
dyspnea at rest as 5, and on exertion as 8. Physical exam
findings: barrel-chested, decreased breath sounds with
mild crackles at bilateral bases. His wife of 50 years is his
primary caregiver and assists with daily care, including
bathing, dressing, medications, and meal preparation.
What do I do now?
21
2
CLINICAL PROBLEM: OVERVIEW OF COPD AND DYSPNEA
Worldwide, COPD currently ranks seventh as the cause of years of life lost,
sixth as the cause of years living with disability for women, and ninth as the
cause of years living with disability for men. Dyspnea, also known as breath-
lessness, affects 56–98% of patients with advanced COPD, and it impacts
every aspect of their lives. Often patients live with breathlessness for years.
The American Thoracic Society (ATS) defines dyspnea as a subjective
experience of breathing discomfort that comprises qualitatively distinct
sensations that vary in intensity. The experience derives from interactions
among multiple physiological, psychological, social, and environmental
factors and may induce secondary physiological and behavioral responses.
Like all symptoms, breathlessness is a complex phenomenon that may
be impacted by a number of interrelated issues, such as anxiety, depression,
culture, previous experiences, and comorbidity. Breathlessness-related an-
ticipatory fear and anxiety has recently been shown to exacerbate the expe-
rience. Breathlessness may occur during exertion or at rest, and it increases
during exacerbations. Patients may be unable to walk small distances and
can even get breathless with toileting.
PHYSIOLOGY OF BREATHLESSNESS
COPD is characterized by obstructive spirometry following the adminis-

tration of a bronchodilator. While spirometry, in part, delineates severity
in COPD, some people with relatively preserved spirometry will describe
significant breathlessness, while some with physiologically advanced disease
do not describe the symptom.
Breathlessness may be thought of as an imbalance between the demand
to breathe and the ability to respond to this demand, sometimes called
neuromechanical/neuroventilatory dissociation. Essentially, the respiratory
center in the brainstem determines what respiration is required to meet
the current physiological needs. This requirement is communicated to the
respiratory system and to higher centers in the brain. When the respiratory
system is unable to match the requirements, breathlessness ensues.
In COPD, the predominant problem leading to breathlessness is reduced
inspiratory capacity. This occurs as bronchial obstruction and/or pulmonary

23
emphysema, leading to “gas trapping” inside the lung. This reduces the space
available for inspiration. Importantly, this “trapped gas” does not contribute
to the exchange of oxygen and carbon dioxide. Exertion induces dynamic
hyperinflation, leading to worse gas trapping and further compromising in-
spiratory capacity, as well as contributing to the development of hypoxemia
and hypercarbia. When inspiratory capacity is less than the required tidal
volume, breathlessness ensues. To experience this, try the following experi-
ment: Find a set of stairs; breathe in; breathe in a little more; breathe out just
that last little bit; try walking up the stairs just breathing in and out that last
little bit without letting go of the first breath you took in. Other factors, such
as poor gas exchange, skeletal/respiratory muscle weakness, and muscular
fatigability, also contribute.
PSYCHOSOCIAL NEEDS
Living with advanced COPD often has psychological consequences and

engenders high social support needs. For example, symptoms of depression
are reported by 17–77% of patients and anxiety is reported by 32–57%.
Breathlessness and anxiety are closely related. Anxiety is an emotional re-
sponse to breathlessness and in turn increases the perception of breathless-
ness (Figure 3.1). Patients may fear death and suffocation. Distress and
panic during the night are frequently experienced, resulting in sleep dis-
turbance. Both anxiety and depression result in considerable burden and
impaired quality of life but are also associated with a worse survival prog-
nosis. Nevertheless, recognition of anxiety and depression is often limited,
so screening for these symptoms is important. It is enormously reassuring
for patients to learn that they are very unlikely to die during an acute epi-
sode of breathlessness, and that most people who die of COPD do so com-
fortably, without significant breathlessness.
The high daily symptom burden, physical limitations, and care de-
pendency may result in social isolation, as well as a change in social role.
Some patients feel ashamed of their symptoms (such as coughing) and
the treatments they require (such as supplemental oxygen or an inhaler),
while others may feel stigma related to current or previous behaviors that
may be illness-related (such as smoking). As the disease progresses, patients
Chronic Breathlessness in Severe COPD 23

24
Something triggers your anxiety. For example, you

might get breathless or have a worrying thought.
You feel breathless
You experience physical You have worrying

changes, like chest thoughts, for example “I’m
muscles tightening or going to die” or “I don’t want
breathing faster. people to see me like this.”
You feel anxious, panicky

and overwhelmed.
FIGURE 3.1. The dyspnea/anxiety cycle
become more restricted in their activities, including hobbies and socializing.

Although these social consequences of the disease are of major importance
to patients, they are often ignored by clinicians. Patients’ spiritual needs
are also often overlooked. Approximately 90% of patients with advanced
COPD reported that their clinician didn’t ask about their spiritual or re-
ligious beliefs. Patients may experience loss of hope and dreams. Finding
ways to bring meaning into their lives and/or making referrals to chaplaincy
or patients’ religious leaders may help ease distress.
NONPHARMACOLOGICAL INTERVENTIONS
FOR BREATHLESSNESS
As the pathophysiology of chronic breathlessness is complex and multi-

dimensional, its treatment is similarly complex and multidimensional.
When treating chronic breathlessness, a comprehensive assessment of the
patient must be undertaken, and all reversible issues must be addressed and
comorbidities maximally treated. If breathlessness remains, there are many
nonpharmacological interventions that can be tried to address it (Box 3.1).

25
BOX 3.1. Nonpharmacological Interventions for Breathlessness

Pulmonary rehabilitation/physical activity: encourage pedometers
Positioning: lean forward
Breathing techniques: pursed-lip breathing, recovery breathing
(“breathe around the rectangle”)
Handheld fan: direct air movement 8–12 inches from lower portion
of face
Energy conservation techniques: shower chair, adaptive aids
Wheeled walking aids: rollator, shopping cart
Cognitive-behavioral therapy and relaxation
Pulmonary Rehabilitation and Physical Activity

Breathlessness may lead to avoidance of activity, resulting in deconditioning
and increased symptom experience. Pulmonary rehabilitation (PR) reduces
breathlessness and ameliorates deconditioning; however, some patients de-
cline to participate, citing breathlessness. Encouraging a simple increase in
physical activity may be the first step. Getting patients to try a pedometer
may encourage increased physical activity, potentially leading to increased
confidence to accept enrollment in PR.
Positioning and Breathing Techniques

Showing patients different positions and breathing techniques gives them
tools to manage their breathlessness and gain some control. Mr. B and his
wife should be taught these techniques so that she can encourage and guide
him to try these when he is experiencing breathlessness at rest and during
exertion. Such techniques include the lean-forward position, pursed-lip
breathing, controlled breathing, and recovery breathing.
By adopting a lean-forward position, which passively fixes the shoulder
girdle, patients effectively increase the efficiency of the diaphragm
by improving the length– tension state, diminishing breathlessness.
Encouraging Mr. B to also drop his shoulders will allow the accessory mus-
cles to work more efficiently.
Other simple breathing techniques, such as pursed- lip breathing
(“smell the roses, flicker the candle”) and controlled breathing (normal
tidal breathing, moving the stomach out during inhalation with relaxed
shoulders and upper chest), can decrease breathlessness and give patients

26
a sense of control. Controlled breathing promotes efficient breathing and

use of accessory muscles, but regular practice is required. Mr. B needs to be
encouraged to practice this technique when he is not breathless so that he
can master the skill.
Recovery breathing (concentrating on the “breath out,” gradually
increasing in duration to prevent/reverse dynamic hyperinflation) can be
taught by recommending that the patient “breathe around the rectangle,”
using the short side of the rectangle to guide the “in breath” and the longer
sides to guide the “out breath.” Visualizing a rectangle also helps distract the
patient from the uncomfortable sensation of breathlessness. Encouraging
Mr. B to look for a rectangular shape to focus on when he is breathless can
assist with mastering recovery breathing.
Handheld Fans
Using a handheld fan directed at the lower half of the face can reduce the
sensation of breathlessness. Handheld fans are a simple, cheap intervention
that give patients a sense of control over their breathlessness. Giving Mrs.
B the task of getting the fan during an attack can also give her the sense
that she can assist with treatment. Patients and caregivers may think a fan
is a “gimmick,” so a brief explanation of the evidence and mode of action
may encourage usage. Handheld fans vary in quality (airflow, noise, ease of
use), so demonstrating and/or providing a high-quality fan is important.
A tabletop fan near the patient may be useful when the patient becomes too
weak to hold the small fan.
Energy Conservation
Energy conservation techniques enable people to participate in both essen-
tial activities (such as self-care activities) and leisure pursuits that promote
social interaction, meaning, and enjoyment. Such techniques include sit-
ting to perform activities often associated with standing (such as showering
and cooking) and using aids.
Wheeled walking aids reduce breathlessness and increase walking dis-
tance by utilizing the lean-forward position for ambulating. Many walking
aids incorporate a seat to enable rest if needed. Patients may resist using
walking aids for a variety of reasons, but, once again, explaining the mode
of action may help. Many patients find that a shopping cart provides similar

27
support to a wheeled walker; encouraging patients to try a shopping cart on

their next outing also may be helpful.
Other nonpharmacological interventions have been shown to reduce
breathlessness but are less easily adopted into clinical practice (chest wall
vibration, neuromuscular electrical stimulation) or have a lower evidence
base (cognitive-behavioral therapy, relaxation, acupuncture).
PHARMACOLOGICAL MANAGEMENT OF BREATHLESSNESS
A variety of pharmacological approaches have been used. As in all areas

of clinical care, all nonpharmacological interventions should be exhausted
before pharmacological methods are added. Of particular relevance to
COPD, patients should complete PR, preferably within the last 12 months,
as the benefits of rehabilitation may wane after a year. Additionally, patients
with severe COPD should receive maximally tolerated inhaled therapy,
instructions on how to use an inhaler, and regular review to ensure cor-
rect inhaler technique. Long-term oral steroids have no role in reducing
breathlessness.
Systemic Opioid Therapy

Opioids, particularly low-dose morphine (<30 mg/day), have the most evi-
dence for efficacy for breathlessness. Constipation often occurs with opioid
therapy at any dose, and laxatives should be prescribed concomitantly. While
more serious side effects are rare, the literature is divided as to whether there
may be long-term mortality impacts. Due consideration should be given
to medication intolerances and other clinical considerations, particularly
renal function. Patients and families may have concerns about initiating
opioids; an open discussion regarding the goals of therapy and any concerns
they may have is recommended. Opioids would be appropriate for Mr. B
if nonpharmacological therapy is insufficiently effective. Start at a small
dose (for instance, 10 mg/day) and increase to a maximum of 30 mg/day,
depending on efficacy and side effects.
Benzodiazepines
This class of medication is sometimes used to relieve breathlessness; how-
ever, evidence suggests poor efficacy, significant side effects (falls, fractures,

28
COPD exacerbations, pneumonia, dementia, pancreatitis, cancer), and

increased mortality. Given the limited evidence of benefit and documented
risk of harms, careful, individualized consideration should be made before
prescribing these agents for breathlessness.
Other Therapies
A range of other therapies have been trialed with limited evidence of effi-
cacy and/or a limited literature base. Oral N-acetylcysteine, mirtazapine,
and theophylline have been trialed but require further investigation. There
are physiological reasons to consider nebulized opioids or nebulized furo-
semide; however, again, more research is needed. As yet, there is no re-
search to support the use of cannabinoids. While patients, and some health
professionals, often believe oxygen ameliorates breathlessness, there is little
evidence to support this claim unless hypoxia is present.
MANAGEMENT OF ACUTE EPISODES OF BREATHLESSNESS
“Dyspnea crisis” is defined as a “sustained and severe resting breathing dis-

comfort that occurs in patients with advanced, often life-limiting illness and
overwhelms the patient and caregivers’ ability to achieve symptom relief.”
Dyspnea crisis usually occurs in patients with underlying chronic breathless-
ness and may result in overutilization of healthcare resources. Management
requires an individualized approach, focused on prevention of episodes,
early identification and management of exacerbations, and judicious use of
hospitalizations. The ATS statement provides a mnemonic, COMFORT,
that caregivers can use to remember the steps for managing a dyspnea crisis:
Call for help.

Observe the degree of respiratory difficulty.
Medications such as inhaled bronchodilators or morphine may help.
Fan to create air movement.
Oxygen can be administered or increased.
Reassure.
Take your time.
Simpler interventions include the 3 F’s (Fan, lean Forward, and Focus on
the out breath) and the 3 P’s (Pause, Position [lean forward], and Purse lips).

29
BREATHLESSNESS SERVICES
An integrated way of assisting patients with chronic breathlessness has re-

cently emerged: holistic breathlessness services that combine respiratory
and palliative care. While such services are not universal, a recent systematic
review examined a number of randomized controlled trials investigating the
use of multidisciplinary teams to address breathlessness. Overall, these serv-
ices were found to have a positive impact on breathlessness and were highly
valued by patients and their loved ones.
Now back to Mr. B. He and his wife have learned various approaches
to help outsmart his breathlessness. Now when he experiences a breathless-
ness episode, instead of becoming panicked he uses his handheld fan, leans
slightly forward, and begins pursed-lip breathing and/or “breathing around
the rectangle.” If this doesn’t help after 5 minutes, he tries his short-acting
bronchodilator. Mr. B uses recovery breathing (breathing around the rec-
tangle) during exertion, and he ambulates with a rollator. He conserves
energy by using a terrycloth bathrobe to dry off after showering instead of
toweling himself dry, and he sits on a shower stool to shave, groom, and
shower. He enjoys sitting in his yard or at a window watching birds at the
feeder and interacts with his grandchildren online. He goes to PR twice
a week.
KEY POINT S TO REMEMBER
• Altered respiratory mechanics pathognomonic to COPD drive

breathlessness.
• Nonpharmacological interventions, particularly when delivered
by a multidisciplinary team, frequently improve breathlessness
so well that no further measures are required.
• If medications are required, oral long-acting opioids, particularly
morphine, have the best evidence for efficacy and safety.
Further Reading
Abdallah SJ, Jensen D, Lewthwaite H. Updates in opioid and nonopioid treatment for
chronic breathlessness. Curr Opin Support Palliat Care. 2019;13(3):167–173.
Booth S, Burkin J, Moffat C, Spathis A, eds. Managing Breathlessness in Clinical
Practice. Springer; 2014.

30
Brighton LJ, Miller S, Farquhar M, et al. Holistic services for people with advanced
disease and chronic breathlessness: a systematic review and meta-analysis.
Thorax. 2019;74(3):270.
Janssen DJ, Spruit MA, Leue C, et al. Symptoms of anxiety and depression in COPD
patients entering pulmonary rehabilitation. Chron Respir Dis. 2010;7(3):147–157.
Johnson M, Barbetta C, Currow D, et al. Management of chronic breathlessness.
In: Bausewein C, Currow D, Johnson M, eds. Palliative Care in Respiratory
Disease. ERS monograph 73. European Respiratory Society; 2016: 19.
Luckett T, Phillips J, Johnson MJ, et al. Contributions of a hand-held fan to self-
management of chronic breathlessness. Eur Respir J. 2017;50(2):1700262.
Mularski RA, Reinke LF, Carrieri-Kohlman V, et al. An official American Thoracic
Society workshop report: assessment and palliative management of dyspnea
crisis. Ann Am Thorac Soc. 2013;10(5):S98–S106.
O’Donnell DE, Webb KA, Harle I, Neder JA. Pharmacological management of
breathlessness in COPD: recent advances and hopes for the future. Expert Rev
Respir Med. 2016;10(7):823–834.
Parshall MB, Schwartzstein RM, Adams L, et al. An official American Thoracic Society
statement: update on the mechanisms, assessment, and management of
dyspnea. Am J Respir Crit Care Med. 2012;185(4):435–452.
Qaseem A, Wilt TJ, Weinberger SE, et al. Diagnosis and management of stable
chronic obstructive pulmonary disease: a clinical practice guideline update from
the American College of Physicians, American College of Chest Physicians,
American Thoracic Society, and European Respiratory Society. Ann Intern Med.
2011;155(3):179–191.

4 Dyspnea, Chronic
Obstructive Pulmonary
Disease, and Pulmonary
Rehabilitation
DorAnne Donesky and Julie Howard
Dr. Timothy Smith, a wheelchair-bound 74-year-old

man has severe chronic obstructive pulmonary
disease (COPD) with air trapping.
He has been selected by his previous university to
receive a lifetime achievement award for his cutting-
edge contributions to his field, and he would like to walk
from his chair to the stage and back when he receives
this award. Currently, he is able to walk a maximum of
30 feet with a walker around his home; otherwise, he
requires a wheelchair whenever he leaves the home
because of severe dyspnea with minimal exertion.
Assessment reveals a cachectic elderly gentleman
using 3 liters per minute of continuous oxygen with
e-tanks attached to the wheelchair and an oxygen
saturation of 92% at rest. Six-minute walk was terminated
after 40 feet due to dyspnea. Uses accessory muscles
with quiet breathing. Lungs: Increased anteroposterior
diameter, clear but diminished lung sounds. No
peripheral edema. He has no other comorbidities.
What do I do now?
31
32
T his patient is on maximum therapy for his severe COPD according to

the Global Initiative for Chronic Obstructive Lung Disease (GOLD)
guidelines.1,2 His dyspnea, worsened by hyperinflation, is limiting his ac-
tivities.3 It is unclear whether his limitations on the 6-minute walk are re-
lated to lung impairment alone, or whether enhanced conditioning and
symptom management strategies might provide functional improvement.
His physiological testing results might indicate that he is unlikely to meet
this goal, but outliers occur frequently enough that it is worthwhile to offer
him a graduated pulmonary conditioning treatment plan that begins with
minimal exertion and see if he can tolerate slight increases in exercise over
time; he is anxious and also highly motivated. He needs to improve his con-
fidence, decrease his anxiety, and ensure he has the strength and endurance
to walk the distance required to receive his award.
The Breathing, Thinking, Functioning (BTF) Model developed by
the Cambridge Breathlessness Intervention Service4 provides guidance for
addressing the dyspnea of a patient in this condition (Figure 4.1). All three
Inefficient breathing
Increased work of Attention to the sensation
breathing Memories of past experiences
Misconceptions and thoughts
about dying
Breathing Thinking
Increased respiratory rate
Inappropriate accessory muscle use Breathlessness
Dynamic hyperinflation
Anxiety, feelings of panic
Frustration, anger, low mood
Functioning
Cardiovascular and Reduced activity
muscular deconditioning Social isolation
Reliance on help
FIGURE 4.1. The Breathing, Thinking, Functioning Model
Reproduced with permission of the Cambridge Breathlessness Intervention Service4 (email

communication from Anna Spathis, November 11, 2019)

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the deep stream, which on the left meandered through a verdant
vale towards the town of Hîra; a canal led up in the same direction to
the lake of Najaf, on the margin of which stood the palace of
Khawarnac. His right was guarded by an impassable swamp, and his
rear rested on the Khandac and the desert.’[259] Omar, satisfied with
his general’s report, enjoined upon him vigilance and patience. But
first, he said, Yezdegird must be summoned to embrace the Faith at
the peril of his kingdom. With this commission, a party of twenty
warriors, chosen for their commanding mien, crossed the plain and
presented themselves at the gates of Medâin.[260] As they were led
to the royal presence, the rabble crowded around, and jeered at the
rough habit of the Arabs, clad in striped Yemen stuff, and armed with
the rude weapons of the desert, all contrasting strangely with the
courtly splendour of the regal city. ‘Look!’ they cried mocking, ‘look at
the woman’s distaff,’ meaning the Bedouin bow slung over the
shoulder, little thinking of the havoc it was soon to make in their
crowded ranks. As the Chiefs entered the precincts of the palace,
the prancing and champing of the beautiful steeds, and the wild
bearing of the stalwart riders, struck awe into the heart of the king
and his effeminate nobles. Yezdegird demanded, through an
interpreter, wherefore, thus unprovoked, they had dared to invade
his kingdom. One after another the Arabian spokesmen told him of
the Prophet who had wrought a mighty change in their land, and they
explained to him the nature of Islam, its blessings and its obligations.
‘Embrace the Faith,’ they said, ‘and thou shalt be even as one of us;
or, if thou wilt, pay tribute, and come under our protection; which
things if thou shalt refuse, the days of thy kingdom are numbered.’
The king replied contemptuously: ‘Ye are naught, ye are naught!
hungry adventurers from a naked land; come, I will give you a
morsel, and ye shall depart full and content.’ The Arabs replied in
strong but modest words. ‘Thou speakest truth. We are poor and
hungry; but the Lord will enrich and satisfy us. Thou hast chosen the
sword; and between us shall the sword decide.’ The king’s wrath
was kindled. ‘If it were not,’ he cried, ‘that ye are ambassadors, ye
should have been put to death, all of you. Bring hither a clod of
earth, and let the mightiest among them bear it as a burden from out
the city gates.’ The Arabs embraced the happy augury. Asim
forthwith seized the load, and binding it over his shoulders, mounted
his charger and rode away. Rustem coming up at that moment, the
king told him of the affront he had put upon the simple Arabs.
‘Simple!’ cried Rustem, ‘it is thou that art simple;’ and he sent in
haste to get the burden back again: but Asim was already far away
with his treasure. Hastening to Câdesîya, he cast the clod before his
chief, and exclaimed, ‘Rejoice, O Sád! for, lo, the Lord hath given
thee of the soil of Persia!’[261]
Rustem could now no longer delay the
campaign. Elephants, cavalry, and soldiers Rustem, with immense host,
had been gathered from every quarter to marches from Medâin,
swell the host. He set out at the head of an army 120,000 strong.
[262] But he still delayed, marching slowly and unwillingly. The
auguries, drawn from astrology and divination, all boded some great
disaster. But he cherished the hope that the Arabs, pinched in their
supplies, might, as in days of old, break up and disappear; or, at any
rate, that, wearied with the suspense, they might be drawn from their
strong position across the river. After many weeks’ delay upon the
road, he passed over the Euphrates below Babylon, and encamped
under the ruined pile of Birs Nimrûd.
Advancing on Hîra, he chided the people and encamps opposite the
for siding with the Arabs; they replied with Arabs.
a.d. 635.
a.h. XIV. October,
justice, that, deserted by their King, they

had no resource left them but to bow before the invaders. At last,
having whiled away four months from the time of starting, Rustem,
passing Najaf, came within sight of the Moslem force, and pitched
his camp on the opposite bank of the river.
During this long period of inaction, the
impatience of the Arabs was, not without Moslem army restrained by
difficulty, checked by the strong hand of Sád.
Sád, to whom as Ameer, and lieutenant of the supreme Ameer, the
Moslems were bound to yield implicit obedience. Excepting raids and
reconnoitring expeditions nothing was attempted. Some of these,
however, were sufficiently daring and exciting. On one occasion,
Toleiha, the quondam prophet, entered by night the enemy’s camp
alone, and cutting the ropes of a tent, carried off three horses. Hotly
pursued, he slew his pursuers one after another, excepting the last;
who, seized by Toleiha single-handed, and carried off a prisoner,
embraced Islam, and fought ever after faithfully by his captor’s side.
[263] As the enemy drew near, the Moslem host lay couched like the
tiger in its lair, ready for the fatal spring.
The contending armies being now face
to face, Rustem had no longer excuse for Rustem obtains truce for
putting off the decisive day. On the three days.
morning after his arrival he rode along the river bank to reconnoitre;
and, standing on an eminence by the bridge, sent for Zohra, who
with the foremost column was guarding the passage. A colloquy
ensued; and Sád consented that an embassy proceeding to the
Persian camp, should there set forth his demands. Three envoys,
one after another, repaired to Rustem. All held the same language:
Islam, Tribute, or the Sword. The Persian, now contemptuous in his
abuse, now cowering under the fierce threats of the envoys, and
scared (as we are to believe) by his dreams and auguries, at last
demanded time to consider. Three days’ grace, they replied, was the
limit of delay which their Prophet allowed for choice; and that was
given.[264]
When the term was over, Rustem (as
was common in that day) sent to inquire Rustem throws a dam over
whether he or they should cross the river the river,
for battle. Strongly pitched, his rear resting on the trench of Sapor,
flanked by Codeis and by a morass, and with the river in front, Sád
had no thought of moving; and he bade the Persian cross as best he
might. Rustem advanced, but passage was denied. All night the
Arabs watched the bridge. But Rustem had another scheme; he
meant to cross the river by a dam. During the night his myrmidons
cast fascines and earth into the channel, and the morning light
discovered a causeway over which it was possible to pass.
As soon as it was day, Rustem, clad in
helmet and double suit of mail, leaped and crosses.
gaily, as it would seem, upon his horse. ‘By
the morrow we shall have beaten them small,’ he cried.[265] But
apart with his familiars he confessed that celestial omens were
against him. And, indeed, previous mishaps, and the brave bearing
of the Arab chiefs, were sufficient—astrology apart—to inspire grave
forebodings. Crossing the dam unopposed, he marshalled his great
host on the western bank, with the centre facing the fortress of
Codeis. There were thirty war elephants in the field; eighteen were
posted with the centre, and the remainder under Jalenûs and
Firuzân with the wings.[266] A canopy covering a golden throne was
pitched for Rustem by the river side; and, seated there, he watched
the issue of the day. Messengers posted within earshot of one
another the whole way from the battle-field to Medâin, shouted
continually the latest news, and kept Yezdegird informed of all that
passed.
As the Persians began to cross, the
advanced guard of the Arabs fell back on Sád disabled by illness,
Codeis, beneath which the main body was marshals the army from the
ramparts of Codeis.
drawn up. On the rampart of the fortress,
Sád, disabled by blains and boils, lay stretched upon a litter; from
whence casting down his orders inscribed on scraps of paper, he
guided thus the movements of the army. The troops, unused to see
their leader, at such a moment, in a place of safety, murmured; and
verses lampooning him were soon in the mouth of everyone. That
he, the archer of renown, and the ‘first to shed blood in Islam,’
should be thus aspersed was insupportable, and Sád accordingly
had the ringleaders seized and imprisoned in the fortress. He then
descended, and discovered to the troops the grievous malady which
rendered it impossible for him even to sit upright, much less to mount
his horse. They accepted his excuse; for no man could doubt his
bravery; but still a certain feeling of discontent survived.[267]
Resuming his recumbent posture, he harangued the army from the
battlements, and then he sent his chief captains, with the orators and
poets that accompanied his force, along the ranks to rouse their
martial spirit.
At the head of every column, as a
preparation for the battle, was recited the Sura Jehâd recited before
the army.
Sura Jehâd, with the stirring story of the
thousand angels that fought on the Prophet’s side at Bedr, and such
hortatory texts as these:—‘Stir up the Faithful unto battle. If there be
twenty steadfast among you, they shall put to flight two hundred of
the Unbelievers, and a hundred shall put to flight a thousand. Victory
cometh from the Lord alone; He is mighty and wise. I will cast terror
into the hearts of the Infidels. Strike off their heads, and their fingers’
ends. Beware that ye turn not your back in battle. Verily he that
turneth his back shall draw down upon him the wrath of God. His
abode shall be Hell-fire; an evil journey thither.’[268] The mention of
the great day of ‘Decision’ at Bedr, with the Divine command to
fight, never failed to fire the souls of the Moslem host. And here we
are told that upon the recital ‘the heart of the people was refreshed,
and their eyes lightened, and they felt the Tranquillity that followeth
thereupon.’
The word was then passed round. Till
the midday prayer, no one should stir. The Battle of Câdesîya.
Ameer would give the first signal by
proclaiming the Takbîr, Great is the Lord! Ramadhân a.h. XIV.
and the whole host would then take up the November, a.d. 635.
shout from him. At the second and third

Takbîr, they were to gird their weapons on, I. Day, called Armâth.[269]
and make ready their horses for action. At
the fourth, the ranks were to rush in one body forward with the battle-
cry, Our help is from the Lord! The order was deranged by the
enemy, who, hearing the shouts, advanced upon the third Takbîr;
whereupon several warriors from the Moslem front stepped forward,
and challenging the enemy to single combat, did prodigies of valour.
We are reminded of the similar feats at Bedr; only the spoil, stripped
from the fallen champions here, was rich beyond comparison. Thus,
Amr ibn Mádekerib carried off triumphantly the bracelets and
jewelled girdle of a princely victim. Ghâlib, of the Beni Asad,
advanced, shouting gaily—
The maid, with hanging tresses,
Milk-white breast and fingers tapering,
Knows that when the battle waxeth hot,
I am he that lays the warriors low.
Singing thus, he closed with Hormuz, ‘a prince of the Gate,’ and,
spoiling him of his armour, bore him, along with his diadem, a captive
to Sád. Asim, leader of the Beni Temîm, singing a like war-song,
pursued his adversary right into the enemy’s ranks; there he seized
a mule-driver, and carried him off with his laden beast to the Moslem
lines; it was the king’s baker with a load of his choicest viands. More
remarkable still is the story of Abu Mihjan the Thâckifite. He was a
ringleader in the detraction of Sád, and his offence was aggravated
by drunkenness. Bound as a prisoner in the fort, under charge of
Selma, he was seized by an irrepressible ardour to join the battle. At
his earnest entreaty, and under pledge of an early return, she set
him free, and mounted him on her husband’s white mare. An
unknown figure, he dashed in circuits, now into and now around the
enemy’s host, performing marvels of bravery. Some thought it might
be the chief of the Syrian contingent, expected that day. Others
opined that it was Al Khizr, precursor of the angelic band. But Sád
said, ‘If it were not that Abu Mihjan is safe in durance under Selma’s
care, I would take an oath that it were he, and the mare my own.’
According to promise, the hero, satisfied with his exploits, returned to
Selma, who reimposed his fetters as before, securing, shortly after,
his release.[270] But now the elephants bore down upon the Bedouin
lines. The brunt of the onset fell upon the Beni Bajîla. The horrid
sight of huge beasts swaying to and fro,—‘the howdas, manned with
warriors and banners, like unto moving castles,’—affrighted the Arab
horses, and they broke away in terror. At Sád’s command the Beni
Asad diverted the attack upon themselves; but in the heroic act they
left four hundred dead upon the field. Then the elephants attacked
the wings, spreading consternation all around; and the enemy,
profiting by the confusion, pressed forward. The position was now
critical; and Sád, as a last resource, bade Asim to rid them from the
danger at whatever cost. At once that gallant chief chose from the
Beni Temîm a band of archers and of agile skirmishers, who,
drawing near, picked off the riders one by one, and boldly cut the
girths. The howdas fell, and the great beasts, with none to guide
them, fled. Thus relieved, the Arabs regained their ground. But the
shades of darkness were falling, and both armies retired for the
night.
The Moslem force was downcast. The
uncertain issue added point to the Sád upbraided by his wife.
invectives of Sád’s accusers, and, what
was still harder for him to bear, the reproaches of Selma. As during
the day, seated by her lord, they watched the lines swaying in deadly
conflict to and fro, she exclaimed bitterly, ‘O for an hour of Mothanna!
Alas, alas, there is no Mothanna to-day!’ Stung by the taunt, Sád
struck her on the face, and pointing to Asim and his band, said,
‘What of Mothanna? Is he to be compared with these?’ ‘Jealousy
and cowardice!’ cried the high-spirited dame, faithful to her first
husband’s memory. ‘Not so, by any means,’ said Sád somewhat
softened; ‘I swear that no man will this day excuse me if thou dost
not, who seest in what plight I lie.’ The people sided with the lady;
but (tradition adds) Sád was no coward, and he lived the contumely
down.
The morning was occupied with the
wounded and the dead; and the day was II. Day, called Aghwâth.
advanced before fighting was resumed.
Just then the first column of the Syrian contingent came in view. It
was led by Cacâa, a host in himself, who hurried forward with a
thousand men, leaving Hâshim to bring up the main body of five
thousand more, the following day. By a skilful disposition Cacâa
magnified his force, in the eyes both of friend and foe. He arranged
his men in bands of a hundred, each following at a little distance
behind the other. Advancing, he saluted Sád and his comrades, and
bade them joy of the coming help. Then calling upon the rest to
follow, he at once rode forth to defy the enemy. Dzul Hâjib, the hero
of the Bridge, accepted the challenge. Cacâa recognised his foe;
and crying out, ‘Now will I avenge Abu Obeid and those that
perished at the Bridge,’ rushed on his man and cut him lifeless to the
ground. As each of Cacâa’s squadrons came up, it charged with all
the appearance of a fresh and independent column across the plain
in sight of both armies, shouting the Takbîr, which was answered by
the same ringing cheer, Allah Akbar, from the Moslem line. The
spirits of the Arabs rose, and they forgot the disasters of yesterday.
Equally the heart of the Persians sank. These saw their heroes slain,
one after another, at the hands of Cacâa and his fellows.[271] They
had no elephants this day, for their gear was not yet repaired.
Pressed on all sides, their horse gave way, and Rustem was only
saved by a desperate rally. The Persian infantry, however, stood their
ground, and the day closed with the issue still trembling in the
balance. The fighting was severe and the carnage great. Two
thousand Moslems lay dead or wounded on the field, and ten
thousand Persians. All night through the Arabs kept shouting the
names and lineage of their several tribes. There was shouting, too,
in the Persian camp. And so, encouraging themselves, each side
awaited the final struggle.[272]
On the third morning, the army was
again engaged in the mournful task of III. Day, called Ghimâs.
removing their fallen comrades from the
field. The space of a mile between the two lines was strewn with
them. The wounded were made over to the
women to nurse, if perchance they might Burial of the dead.
survive—or rather, in the language of Islam
—‘until the Lord should decide whether to grant, or to withhold from
them, the crown of martyrdom.’ The dead were borne to a valley in
the rear towards Odzeib, where the women and children hastily dug
graves for them in the sandy soil. The wounded, too, were carried to
the rear. For the suffering sick it was a weary passage under the
burning sun. A solitary palm-tree stood on the way, and under its
welcome shade they were laid for a moment as they passed by. Its
memory is consecrated in such plaintive verse as this:
Hail to the grateful palm that waves between Câdesîya and Odzeib.
By thy side are the wild sprigs of camomile and hyssop.
May dew and shower water thy leaves beyond all others.
Let there never want a palm-tree in thy scorching plain!
A day and a night of unceasing conflict

were still before the combatants. The spirit Fighting resumed. Arrival of
of the Persians, whose dead troops lay Syrian troops.
unburied on the field, flagged at the disasters of the preceding day.
But much was looked for from the elephants, which, now refitted,
appeared anew upon the field, each protected by a company of
horse and foot. The battle was about to open, when suddenly
Hâshim came up with the main body of the Syrian troops. Sweeping
across the plain, he charged right into the enemy, pierced their
ranks, and having reached the river bank, turned and rode
triumphantly back, amidst shouts of welcome. The fighting was again
severe, and the day balanced by alternate victory and repulse.
Yezdegird, alive to the crisis, sent his own body-guard into the field.
The elephants were the terror of the Arabs, and again threatened to
paralyse their efforts. In this emergency,
Sád had recourse to Cacâa, who was The elephants put to flight.
achieving marvels, and had already slain
thirty Persians in single combat; so that the annalists gratefully
acknowledge, ‘if it had not been for what the Lord put it into the heart
of Cacâa to do, we had surely in that great battle been
discomfited.’[273] Sád learned from some Persian refugees that the
eye and trunk were the only vulnerable parts of the elephant: ‘Aim at
these,’ he said, ‘and we shall be rid of this calamity.’ So Cacâa took
his brother Asim, and a band of followers as a forlorn hope, and
issued on the perilous undertaking. There were two great elephants,
the leaders of the herd. Dismounting, they boldly advanced towards
these, and into the eye of one, the ‘great White elephant,’ Cacâa
succeeded in thrusting his lance. Smarting at the pain, it shook
fearfully its head, threw the mahout, and swaying its trunk with great
force, hurled Cacâa to a distance. The other fared still worse, for
they pierced both its eyes, and slashed its trunk. Uttering a shrill
scream of agony, blinded and maddened, it darted forward on the
Arab ranks. Shouts and lances drove it back upon the Persians. And
so they kept it rushing wildly to and fro between the armies. At last,
followed by the other elephants, it charged right into the Persian line;
and so the whole herd of huge animals,—their trunks raised aloft,
trumpeting as they rushed by, and trampling all before them,—
plunged into the river and disappeared on the farther shore. For the
moment the din of war was hushed as both armies gazed transfixed
at the portentous spectacle. But soon the battle was resumed, and
they fought on till evening, when darkness again closed on the
combatants with the issue still in doubt.
The third night brought rest to neither
side. It was a struggle for life. At first there The Night of Clangour.
was a pause, as the light faded away; and
Sád, fearing lest the vast host should overlap his rear, sent Amr and
Toleiha with parties to watch the lower fords. There had as yet been
hardly time for even momentary repose when, early in the night, it
occurred to some of the Arab leaders to call out their tribes with the
view of harassing the enemy. The movement, made at the first
without Sád’s cognisance, drew on a general engagement in the
dark. The screams of the combatants and din of arms made The
Night of Clangour, as it is called, without parallel in the annals of
Islam. It could only be compared to ‘the clang of a blacksmith’s
forge.’ Sád betook himself to prayer, for no sure tidings reached him
all night through.[274] Morning broke on the two hosts, weary but still
engaged in equal combat. Then arose Cacâa and said that one more
vigorous charge would surely bring the decisive turn, ‘for victory ever
followeth him that persevereth to the end.’ For four-and-twenty hours
the troops had maintained the struggle without closing an eye. Yet
now the Moslems issued with freshness and alacrity to a new attack.
The Persian wings began to waver. Then a fierce onslaught on their
centre shook the host: it opened and uncovered the bank on which
was pitched the throne of Rustem. A
tempestuous wind arose; and the canopy, The Persians discomfited and
no longer guarded, was blown into the Rustem slain.
river. The wretched prince had barely time, before his enemies were
upon him, to fly and crouch beneath a mule laden with treasure. The
chance blow of a passer-by brought down the pack and crushed the
prince’s back. He crawled to the bank and cast himself into the river;
but not before he was recognised by a soldier, who drew him out and
slew him, and then, mounting his throne, loudly proclaimed his end.
[275]
No sooner was their leader slain, than

the rout and slaughter of the Persian host Destruction of the Persian
began. Firuzân and Hormuzân succeeded host.
in passing their columns over the dam, and making good their flight
before their pursuers could cross the bridge. Jalenûs, standing by
the mound, exhorted his men to follow; but the dam (perhaps to
secure retreat) had been already cut, and was soon swept away, and
with it a multitude into the stream.[276] To the right and to the left, up
the river bank and down, the Mussulmans chased the fugitives
relentlessly. Jalenûs, vainly endeavouring to rally his men, was slain,
and his body rifled of its jewelled spoil. The plain, far and wide, was
strewn with dead bodies. The fugitive multitude, hunted even into the
fens and marshes, were everywhere put mercilessly to the sword.
But the army was too exhausted to carry the pursuit to any great
distance beyond the river.
The Mussulman loss far exceeded that
of any previous Moslem engagement. In Moslem loss.
the final conflict 6,000 fell, besides 2,500 in
the two days before. No sooner was the battle ended, than the
women and children, carrying pitchers of water, and armed with
clubs, on a double mission of mercy and of vengeance, spread
themselves over the field. Every fallen Mussulman, still warm and
breathing, they gently raised and wetted his lips with water. But
towards the wounded Persians they knew
no mercy; for them they had another Wounded Persians
despatched by women and
errand; raising their clubs they gave to children.
them the coup de grâce. Thus had Islam
extinguished the sentiment of pity, and, against nature, implanted in
the breasts of the gentler sex, and even of little children, the spirit of
fierce and cold-blooded cruelty.[277]
Like the loss of life, so also the spoil for
the survivors was great beyond all parallel, The vast booty.
both in its amount and costliness. Each
soldier had six thousand dirhems, besides special gifts for the
veterans and for such as had shown extraordinary valour. The jewels
stripped from Rustem’s body were worth 70,000 pieces, although the
tiara, most costly portion of his dress, had been washed away. The
great banner of the empire was captured on the field. It was made of
panthers’ skins, but so richly garnished with gems as to be valued at
100,000 pieces.[278] The prize taken by Zohra from the person of
Jalenûs was so costly, that Sád, doubting whether it might not be
altogether too great for one person, applied to Omar for advice. The
Caliph chided him in reply. ‘Dost thou grudge the spoil to such a one
as Zohra,’ he wrote, ‘after all that he hath wrought, and in view of all
the fighting yet to come? Thou wilt break his heart thus. Give him the
whole, and over and above add a special gift of 500 pieces.’ Thus
did the needy Arabs revel in the treasures of the East, the costliness
of which almost exceeded their power to comprehend.
For the enemy, the defeat was
crushing, and decisive of the the nation’s Decisive character of the
fate. It was little more than thirty months victory.
since Khâlid had set foot upon Irâc, and already that empire, which
fifteen years before had humbled the Roman arms, had ravaged
Syria, and encamped triumphantly on the Bosphorus, was crumbling
under the blows of an enemy whose strength never exceeded thirty
or forty thousand Arabs rudely armed. The battle of Câdesîya
reveals the secret. On one side there was but a lukewarm, servile
following; on the other, an indomitable spirit that nerved every heart
and arm, and after long weary hours of fighting enabled the Moslems
to deliver the final and decisive charge. The result was, that the vast
host, on which the last efforts of the empire had been spent, was
totally discomfited; and, although broken columns escaped across
the river, the military power of the empire never again gathered itself
into formidable shape. The country far and wide was terror-struck.
An important though indirect effect was that the Bedouin tribes on
the Euphrates hesitated no longer. Many of them, though Christian,
had fought on the Moslem side. Some of these now came to Sád
and said: ‘The tribes which at the first embraced Islam were wiser
than we. Now that Rustem hath been slain, all will accept the new
belief.’ So there came over many tribes in a body and made
profession of the faith.
The battle had been so long impending,
and the preparations of the empire on so Tidings how received by
grand a scale, that the issue was watched Omar.
all over the country, ‘from Odzeib away south to Aden, and from
Obolla across to Jerusalem,’ as that which would decide the fate of
Islam.[279] The Caliph used to issue forth alone from the gates of
Medîna early in the morning, if perchance he might meet some
messenger from the field of battle. At last a courier arrived outside
the city, who to Omar’s question replied shortly, ‘The Lord hath
discomfited the Persian host.’ Unrecognised, Omar followed the
camel-rider on foot, and gleaned from him the outline of the great
battle. Entering Medîna, the people crowded round the Caliph, and,
saluting, wished him joy of the triumph. The courier, abashed, cried
out, ‘O Commander of the Faithful, why didst thou not tell me?’ ‘It is
well, my brother,’ was the Caliph’s simple answer. Such was the
unpretending mien of one who at that moment was greater than
either the Kaiser or the Chosroes.
CHAPTER XVII.
EVENTS FOLLOWING THE BATTLE OF CADESIYA—CAPTURE
OF MEDAIN.
A.H. XV., XVI. A.D. 636–7.
After his victory, Sád, by desire of the

Caliph, paused for a little on the field of Sád re-occupies Hîra, end of
Câdesîya, and allowed the weary troops to a.h. XIV. January, a.d. 636.
rest. Fragments of the great Persian host escaped, broken and
dispersed, in the direction of the ruins of Babylon, and rallied there,
on the right bank of the Euphrates. After two months’ repose, Sád,
now recovered from his sickness, advanced to attack them. One or
two short marches brought him to Hîra. It was the third time the
unfortunate city had been taken and retaken. The punishment for
this its last helpless defection from the Moslem cause, was the
doubling of its tribute. Soon supplanted by Kûfa, at a few miles’
distance, the once royal city speedily dwindled into a common
village. But the neighbouring palace of Khawarnac, the beautiful
residence of the Lakhmite princes, was left standing on the lake of
Najaf, and was sometimes visited, as a country seat, by the Caliphs
in after days.
As the Moslems advanced, the Persian
troops made a stand, first at Birs Nimrûd, The Persians driven across
[280] and then, recrossing the Euphrates, the plain to Madâin, and the
Sawâd reoccupied.
under the great mound of Babylon. Driven
from thence with loss, they fell back upon the Tigris. Sád then
pitched a standing camp at Babylon, and, himself remaining there,
sent forward his lieutenants, Hâshim and Zohra. These, in a series of
minor but decisive engagements, cleared
the plain of Dura, here about fifty miles a.h. XV. a.d. 636.
broad, from the Euphrates to the Tigris.
[281] The territorial chiefs from all sides came in, tendering their
allegiance, some as converts, some as tributaries; and the Arabs
again became undisputed masters of the whole Sawâd, with the
channels and canals intersecting it. Several months thus passed;
and at last, in the summer of a.d. 636, Sád found himself able, now
with the full consent of Omar, to make an advance upon Medâin.[282]
This royal city of Persia was built, as
we have seen, on both banks of the Tigris, The queen-mother is
at a sharp and double bend of the river, discomfited.
fifteen miles below the modern Baghdad. Seleucia, on the right bank,
was the original seat of the Alexandrian conquerors. On the opposite
shore had grown up Ctesiphon, the winter residence of the Persian
monarchs. The combined city had now for ages superseded Babylon
as the capital of Chaldæa. Though repeatedly taken by the Romans,
it was now great and prosperous, but helplessly torn by intrigue and
enervated by luxury. The main quarter, with its royal palaces, was on
the eastern side, where the noble arch, the Tâk i Kesra, still arrests
the traveller’s eye as he floats down the Tigris.[283] On the nearer
side was the suburb, Bahar Sair;[284] and towards it, as immediately
accessible to attack, Sád now directed his march. Burân, the queen-
mother, animated by the ancient spirit of the Sassanides, and
swearing with a great oath that so long as the dynasty survived, the
empire was invincible, herself took the field, with an army
commanded by a veteran general, ‘the lion of Chosroes.’ She was
utterly discomfited, and her champion slain by the hand of Hâshim.
When he came to announce the victory, his cousin Sád kissed
Hâshim’s forehead, in token of approval and delight; and Hâshim
kissed the feet of Sád.
Sâd then marched forward; and, in
reference to the vainglorious boast of the Sád besieges the western
suburb of Medâin. Summer,
vanquished princess, he publicly recited a.h. XV. a.d. 636.
this passage from the Corân:—
Did ye not swear aforetime that ye would never pass away? Yet ye
inhabited the dwellings of a people that dealt unjustly by their own
souls; and ye saw how We dealt with them; for We made them a
warning and example unto you.[285]
In this spirit, they came upon the bend of the river; and lo! the
famous Iwân, or palace, with its great hall of white marble, stood
close before them on the opposite shore. ‘Good heavens!’ exclaimed
Sád, dazzled at the sight; ‘Allah akbar! What is this but the White
Palace of Chosroes! Now hath the Lord fulfilled the promise which
He made unto His Prophet.’ And each company shouted, Allah
akbar! ‘Great is the Lord!’ as it came up and gazed, wondering, at
the great white building, almost within their grasp. But the city was
too strong to storm, and Sád sat down before it. Catapults and
testudos were brought up, but they made no impression on the
massive ramparts of sunburnt brick. The besieged issued forth in
frequent sallies; and the siege is mentioned as the last occasion on
which the warriors of Persia adventured themselves in single combat
with the Arabs. The investment was so strict that the inhabitants
were reduced to great straits. The army lay for several months
before the city.[286] But it was not inactive in other directions; for
bands were despatched throughout Lower Mesopotamia, wherever
the great landholders failed to tender their submission. These
ravaged the country between the two rivers, and brought in
multitudes of prisoners; but, by Omar’s command, they were
dismissed peaceably to their homes.[287] Thus, all Mesopotamia,
from Tekrît downwards, and from the Tigris westward to the Syrian
desert, was brought entirely and conclusively under the sway of
Islam.
The siege at last pressed so heavily on
the western quarter, that the king sent a Persians evacuate western
messenger, proposing terms. He would suburb. Dzul Hijj a.h. XV.
January, a.d. 637.
give up Mesopotamia and all beyond the
Tigris, if they would leave him undisturbed on the eastern side. The
offer was met by an indignant refusal.[288] Not long after, observing
the walls no longer manned, an advance was ordered. They entered
unopposed; the enemy had crossed in boats, and entirely evacuated
the western bank. Not a soul was to be seen. Sád, however, was
unable to follow up the success by storming the further capital; for
the ferry-boats were all withdrawn to a distance beyond his reach.
So the army, for some weeks, was forced to rest; and, occupying the
deserted mansions of the western suburb, enjoyed a foretaste of
Persian luxury.
When Medâin was first threatened,
Yezdegird despatched his family, with Capture of Medâin. Safar,
a.h. XVI. March, a.d. 637.
some of the regalia and treasure, to
Holwân, a fortified town in the hilly country to the north: and now,
leaving Mihrân in command, he contemplated flight himself in the
same direction. The heart of Persia had sunk hopelessly; for
otherwise, the deep and rapid Tigris formed an ample defence
against sudden assault. Indeed, the Arabs themselves were, for
some considerable time, of this opinion; they were occupied, we are
told, for two months, in the search for boats, which had all been
removed from the western bank. Unexpectedly, a Persian deserter
apprised Sád of a place where the river could be swum or forded.
But the stream, always swift, was then upon the rise, and they feared
lest the horses should be carried down by the turbid flood. Just then,
news came in that Yezdegird was arranging to flee to the mountains
on the third day with the rest of his treasure. Sád at once resolved
upon the enterprise. Gathering his force together, he thus addressed
them:—‘We are now at the mercy of the enemy, who, having the
river at command, is able to attack us unawares. The position is
intolerable. Now, the Lord hath shown unto one amongst us a vision
of the Faithful upon their horses, crossing the stream triumphantly.
Arise, and let us stem the flood!’ The desperate venture, supported
by Salmân the Persian, was carried by acclamation.[289] Six hundred
picked cavalry were forthwith drawn up in bands of sixty. The
foremost rank plunged in, and bravely battled with the rapid flood.
Down and across, they neared the other shore, as a Persian picket
dashed into the water, and vainly endeavoured to beat them back.
‘Raise your lances,’ shouted the leader Asim, ‘and bear right into
their eyes.’ So they drove them back, and safely reached dry land.
Sád no sooner saw them land safe on shore, than he called on the
rest to follow; and thus, with the cry—‘Allah! Triumph to thy people—
Destruction to thine enemies!’—troop after troop leaped into the
river. So thick and close-arrayed were they, horses and mares
together,[290] that the water was hidden from view; and, treading as it
had been the solid ground, without a single loss, all gained the
farther side.[291] The Persians, taken by surprise, fled panic-stricken.
The difficulty of the passage afforded them time but barely to escape
with their families, and with such light stuff as they could hastily carry
with them. The few inhabitants remaining, submitted themselves as
tributaries. The Moslems, already in undisturbed possession,
pursued the fugitives; but, meeting with no opposition, soon
hastened back to share the royal spoil. They wandered over the
gorgeous pavilions of a court into which for ages the East had
poured its treasures, and they revelled in beautiful gardens, decked
with flowers and laden with every kind of fruit. The conqueror
established himself in the palace of the Chosroes. But first he was
minded to render thanks in a Service of Praise. One of the princely
buildings was turned for the moment into a house of prayer; and
there, followed by as many as could be spared (for military
precautions were yet observed), he ascribed the victory to the Lord
of Hosts. The lesson was taken from the Sura Smoke, which speaks
of Pharaoh and his host being overwhelmed in the Red Sea, and
contains a passage thought to be peculiarly appropriate:—
How many Gardens and Fountains did they leave behind,
And Fields of Corn, and fair Dwelling-places,
And pleasant things which they enjoyed!
Even thus have We made another people to inherit the same.[292]
The booty was rich beyond conception. Besides millions of

treasure, there was countless store of silver and golden vessels,
gorgeous vestments and garniture, and precious things of untold
rarity and cost.[293] A lucky capture of sumpter mules disclosed an
unexpected freight—the tiara, robes, and girdle of the king. The
Arabs gazed in wonder at the crown and jewelled swords and all the
splendour of the throne, and, among other marvels, at a camel of
silver, large as life, with its rider of gold; and at a golden horse,
having emeralds for teeth, its neck set with rubies, and the trappings
of gold. The precious metals lost their conventional value, and gold
was parted with for its weight in silver. Works of art in sandal-wood
and amber were in the hands of everyone, with hoards of musk and
the spicy products of the East. Camphor lay about in sacks, and was
kneaded with the cakes as salt, till the pungent taste revealed the
mistake.[294] The agents of the prize had a heavy task, for each
man’s share (and the army now numbered 60,000, all mounted) was
twelve thousand pieces,[295] besides special largesses to the more
distinguished warriors. The army could afford to be generous, and so
they despatched to Medîna, over and above the royal Fifth, such
rare and precious things as might stir the wonder of the simple
citizens at home. To the Caliph they sent as a fitting gift the regalia of
the empire, and the swords of the Chosroes and of Nómân, the
prince of Hîra.[296] But the spectacle of the day was the banqueting
carpet of the king, seventy cubits long and sixty broad. It was a
garden, the ground of wrought gold and the walks of silver; green
meadows were represented by emeralds, running rivulets by pearls;
trees, flowers, and fruits by diamonds, rubies, and other precious
stones. When the rest of the spoil had been distributed at the Great
Mosque, and special gifts allotted to the more distinguished
Companions, Omar took counsel what should be done with the royal
carpet. The most advised to keep it as a trophy of Islam. But Aly,
reflecting on the instability of earthly things, objected; and the Caliph,
accepting his advice, had it cut in pieces and distributed with the
other booty. The piece that fell to Aly’s lot (and it was by no means
the richest) fetched Twenty thousand dirhems.
As Medâin offered every convenience
for the seat of government, Sád Sád establishes his head-
established his head-quarters there. The quarters at Medâin.
palaces and mansions of the fugitive nobles were divided amongst
his followers. The royal residence he occupied himself. The grand
hall, its garnishing unchanged, was consecrated to Divine worship,
and here, as a cathedral service, the Friday ritual was first
celebrated in Irâc.

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Respiratory Symptoms 1st Edition

Margaret L. Campbell, PhD, RN, FPCN

Pediatric Palliative Care, Edited by Lindsay B. Ragsdale & Elissa G. Miller

Margaret L. Campbell, PhD, RN, FPCN

List of Contributors vii

2. Reducing Dyspnea by Optimizing Treatment of Chronic

3. Treating Chronic Breathlessness in Severe Chronic Obstructive

4. Dyspnea, Chronic Obstructive Pulmonary Disease, and

5. Treating Episodic Breathlessness 39

6. Reducing Episodic Dyspnea in Heart Failure 49

7. Dyspnea in Pediatric Congenital Heart Disease 61

8. Treating Chronic Dyspnea in Patients with Lung Cancer 69

9. Treating Dyspnea Through Reducing Malignant Pleural

10. Treating Dyspnea in Lung Cancer with Noninvasive

11. Palliative Care for Infants with Bronchopulmonary

12. Reducing Dyspnea by Treating Ascites 101

13. Panting for Breath in End-​Stage Dementia 109

14. Last Days with Chronic Obstructive Pulmonary Disease 119

15. Withdrawal of Invasive Mechanical Ventilation 125

16. Palliative Sedation for Intractable Dyspnea 135

17. Sialorrhea in Amyotrophic Lateral Sclerosis 145

18. Death Rattle 153

Jennifer Arnoldi, PharmD, BCPS Christine A. Crader, MD

Christine A. Fortney, PhD, RN Ann S. Laramee, MS, ANP-​BC,

Mary M. Roberts, MSN, RN Jodi A. Ulloa, DNP, APRN-​CNP,

Miranda Wilhelm, PharmD Jennifer Wright, MS, CPNP

such as chronic obstructive pulmonary disease (COPD), advanced heart

Stella is a nursing home resident in the advanced

Dyspnea is a person’s awareness of uncomfortable or distressing breathing

Unidimensional Assessment Tools

2 WHAT DO I DO NOW? Respiratory Symptoms

Worst distress 100

FIGURE 1.1. Visual analog scale for dyspnea

Multidimensional Assessment Tools

TABLE 1.1. The Dyspnea-12

1. My breath does not go in all the way.

2. My breathing requires more work.

3. I feel short of breath.

4. I have difficulty catching my breath.

5. I cannot get enough air.

8. My breathing makes me feel depressed.

9. My breathing makes me feel miserable.

10. My breathing is distressing.

11. My breathing makes me agitated.

12. My breathing is irritating.

Reprinted with permission from J. Yorke.

4 WHAT DO I DO NOW? Respiratory Symptoms

TABLE 1.2. Respiratory Distress Observation Scale

Variable 0 points 1 point 2 points Total

Respiratory rate per ≤18 breaths 19–30 breaths >30 breaths

Restlessness: None Occasional, Frequent

Accessory muscle None Slight rise Pronounced

Paradoxical breathing None Present

Grunting at end- None Present

Nasal flaring: None Present

Look of fear None Eyes wide

Several unidimensional and multidimensional scales and an observation

KEY POINTS TO REMEMBER

• Assessment is critical to optimizing treatment.

6 WHAT DO I DO NOW? Respiratory Symptoms

Miranda Wilhelm and Jennifer Arnoldi

JW, a 75-​year old female, presents to the primary

T he Global Initiative for Chronic Obstructive Lung Disease (GOLD)

13. Panting for Breath in End-Stage Dementia 109

Christine A. Fortney, PhD, RN Ann S. Laramee, MS, ANP-BC,

Mary M. Roberts, MSN, RN Jodi A. Ulloa, DNP, APRN-CNP,

JW, a 75-year old female, presents to the primary

Beta2-agonists, Arformoterol Brovana Nebulization

Indacaterol Arcapta Neohaler DPI, capsule-based

Optimizing COPD Treatment 9

Tiotropium Spiriva HandiHaler DPI, capsule-based

Combination, Albuterol/ Generics (various) Nebulization

Combination, Formoterol/ Duaklir Pressair DPI

Formoterol/ Bevespi MDI

Indacaterol/ Utibron Neohaler DPI, capsule-based

Vilanterol/ Anoro Ellipta DPI

Combination, Formoterol/ Symbicort MDI

Salmeterol/ Advair HFA MDI

Vilanterol/ Breo Ellipta DPI

Triple Vilanterol/ Trelegy Ellipta DPI

Optimizing COPD Treatment 11

DPI • Convenient/portable • Requires moderate

SMI • Convenient/portable • Hand–breath

Jet nebulizer • Hand–breath coordination • Temperature change

Optimizing COPD Treatment 13

FIGURE 2.1. Metered-dose inhaler

with advanced COPD may experience disease-related airflow limitation,

Optimizing COPD Treatment 15

Optimizing COPD Treatment 17

Optimizing COPD Treatment 19