Q: What are the safest treatment options for
anxiety in adults with chronic respiratory
A: Anxiety is a common and troubling symptom in
many patients with chronic obstructive pulmonary
disease (COPD), even when their degree of respiratory
impairment is only mild to moderate. Anxiety may also
accompany other chronic, progressive pulmonary disorders,
such as interstitial fibrosis and cystic fibrosis, and a
wide variety of other, less common diseases that are characterized
by progressive dyspnea on exertion.
The scope of the problem. My colleagues and I noted
a high level of anxiety, depression, and somatic preoccupation
among the patients in our comprehensive care program
for severe COPD.1 The anticipation of an event, such
as a sudden attack of uncontrolled dyspnea in business or
social situations, caused the most intense anxiety. Panic attacks
were also common, and they could be exacerbated
during smoking cessation attempts, probably as a result of
We found that patients' anxiety, depression, and somatic
preoccupation improved significantly during the
course of our pulmonary rehabilitation program, most
likely because of the extensive counseling that was a feature
of the program.2 We used few anxiolytic drugs.
Other researchers have also found that both anxiety
and panic disorder are prevalent among patients with
symptomatic COPD.3,4 How to manage these perplexing
symptoms has been a challenge, because some of the
medications used in COPD--such as β-agonists, anticholinergics,
theophylline and, above all, systemic corticosteroids--
may aggravate anxiety.5Suggested therapies. Small doses of anxiolytics,
such as alprazolam and diazepam, and some older antidepressants,
such as amitriptyline and nortriptyline, are generally
safe and effective in relieving anxiety and depression.
Some clinicians prescribe small doses of oral narcotics
to blunt the symptoms of intolerable dyspnea and
associated anxiety.6 Selective serotonin reuptake inhibitors
may be useful in mitigating depression that accompanies
Clinicians may be concerned about respiratory depression
with anxiolytics or narcotics, but dangerous carbon
dioxide retention almost never occurs when these
drugs are used carefully, along with patient counseling.
Counseling involves helping patients understand the
nature of anxiety and panic and tips on how to avoid triggers
that might set off these feelings. Alternative therapies--
such as biofeedback, relaxation training, and
yoga--may be helpful.
In my opinion, there is no "magic bullet" for anxiety,
dyspnea, or panic. However, the following agents can
be used in small doses about every 6 hours to provide
safe, effective relief: diazepam, 2 to 5 mg; alprazolam, 0.25
to 0.5 mg; codeine, 30 mg; and hydrocodone, 5 mg.
These drugs are not intended to be taken for the long
term, except in extreme cases when the need to relieve
symptoms is greater than concerns about habituation.
Discretionary doses of anxiolytics, antidepressants, or analgesics
to blunt dyspnea may improve quality of life for
many patients with advanced respiratory insufficiency.