Mrs D is a 74-year-old woman followed up for the past 4 years for management of dyspnea secondary to emphysema. Her pulmonologist, Dr M, relates that she has had a substantial active (25 pack-years) and passive (husband smoked 2 packs per day) tobacco exposure. She is thin, with pursed-lip breathing and sternocleidomastoid contractions. The results of pulmonary function tests demonstrate severe airflow obstruction, air trapping, and marked reduction in diffusing capacity.
Portable oxygen allows her to continue activities outside the home, including shopping, visiting family, and attending professional football games—her passion. With supplementary oxygen (4 L/min), her symptoms have improved, with increased exercise tolerance and resolution of pedal edema. She uses a variable regimen of inhaled ipratropium bromide, albuterol, and fluticasone propionate, in addition to oral prednisone.
Mrs I is a 65-year-old woman diagnosed as having limited-stage small cell lung cancer 5 years before she was interviewed. She was treated with chemotherapy (cisplatin and etoposide) and radiation, with substantial decrease in the size of the tumor. She is now cared for by Dr K, a pulmonary oncologist. A year before she was interviewed, she experienced a central nervous system (CNS) recurrence of her cancer and was treated with radiation and corticosteroids. Although her neurologic symptoms improved, she became extremely fatigued and dyspneic on exertion. Simple activities of daily living are difficult, in part due to her shortness of breath, and she has opted to forgo further antineoplastic therapy in favor of home hospice care.
Mrs D and Mrs I, as well as their physicians and family members, were interviewed by Perspectives editors.
MRS D: I was very short of breath. I stayed in the hospital overnight, and they gave me a test to find out what the matter was. She found out that I had emphysema. My doctor told me that my oxygen was low. It was 88 or something. That's low. They said I'd have to go on [oxygen] 24 hours a day. It's kind of hard to get your breath back. If you're riding a horse or you're swimming you can get the breath in and out fast enough. But with shortness of breath, coming out takes longer. It's the only way I can explain it…Once I lose it, it's kind of hard to catch it. That's what scares me.
DR M (MRS D'S PULMONOLOGIST): Mrs D has been coming to the chest practice for something close to 6 years…When she began, she had very severe emphysema and surprisingly had not had much attention paid to it…She has slowly deteriorated in terms of her exercise capability and her symptoms…We've talked on a number of occasions about prognosis. She…tries very hard to be very positive, has a lot of denial, and is in general reluctant to have these kinds of conversations. I've tried to go in that direction on more than one ...
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