Anxiety in Patients With Respiratory Disorders:How to Help

March 2, 2004

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.

Q: What are the safest treatment options foranxiety in adults with chronic respiratoryinsufficiency?A: Anxiety is a common and troubling symptom inmany patients with chronic obstructive pulmonarydisease (COPD), even when their degree of respiratoryimpairment is only mild to moderate. Anxiety may alsoaccompany other chronic, progressive pulmonary disorders,such as interstitial fibrosis and cystic fibrosis, and awide variety of other, less common diseases that are characterizedby progressive dyspnea on exertion.The scope of the problem. My colleagues and I noteda high level of anxiety, depression, and somatic preoccupationamong the patients in our comprehensive care programfor severe COPD.1 The anticipation of an event, suchas a sudden attack of uncontrolled dyspnea in business orsocial situations, caused the most intense anxiety. Panic attackswere also common, and they could be exacerbatedduring smoking cessation attempts, probably as a result ofnicotine withdrawal.We found that patients' anxiety, depression, and somaticpreoccupation improved significantly during thecourse of our pulmonary rehabilitation program, mostlikely because of the extensive counseling that was a featureof the program.2 We used few anxiolytic drugs.Other researchers have also found that both anxietyand panic disorder are prevalent among patients withsymptomatic COPD.3,4 How to manage these perplexingsymptoms has been a challenge, because some of themedications 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 generallysafe and effective in relieving anxiety and depression.Some clinicians prescribe small doses of oral narcoticsto blunt the symptoms of intolerable dyspnea andassociated anxiety.6 Selective serotonin reuptake inhibitorsmay be useful in mitigating depression that accompaniesanxiety.Clinicians may be concerned about respiratory depressionwith anxiolytics or narcotics, but dangerous carbondioxide retention almost never occurs when thesedrugs are used carefully, along with patient counseling.Counseling involves helping patients understand thenature of anxiety and panic and tips on how to avoid triggersthat might set off these feelings. Alternative therapies--such as biofeedback, relaxation training, andyoga--may be helpful.In my opinion, there is no "magic bullet" for anxiety,dyspnea, or panic. However, the following agents canbe used in small doses about every 6 hours to providesafe, effective relief: diazepam, 2 to 5 mg; alprazolam, 0.25to 0.5 mg; codeine, 30 mg; and hydrocodone, 5 mg.These drugs are not intended to be taken for the longterm, except in extreme cases when the need to relievesymptoms is greater than concerns about habituation.Discretionary doses of anxiolytics, antidepressants, or analgesicsto blunt dyspnea may improve quality of life formany patients with advanced respiratory insufficiency.