1. Management of Dyspnea in Severe Chronic Obstructive Pulmonary Disease
Jean-Paul Janssens, MD, Benoı̂t de Muralt, MD, Véronique Titelion 
Journal of Pain and Symptom Management 
Volume 19, Issue 5, Pages (May 2000)
DOI: /S (00)

2. Fig. 1 The Borg scale for quantifying dyspnea
Journal of Pain and Symptom Management  , DOI: ( /S (00) )

3. Fig. 2
Static pressure–volume curve of the respiratory system (rs). Pressures on the x-axis (cm H2O), volume on the y-axis. RV = residual volume; TLC = total lung capacity; FRC = functional residual capacity; PEEPi = intrinsic positive end-expiratory pressure. Palv = alveolar pressure; Patm = atmospheric pressure. 1: Normal respiration: the subject reaches the FRC at the end of a normal expiration; transpulmonary pressure = 0 (Palv = Patm). 2: Subject with dynamic hyperinflation: at the end of expiration, there is a residual positive transpulmonary pressure (PEEPi); Palv > Patm. Note that the subject breathes on a more horizontal (less economical) portion of the pressure/volume curve: i.e., for a given change in volume, a higher change in pressure must be generated
Journal of Pain and Symptom Management  , DOI: ( /S (00) )

4. Fig. 3
Changes in the geometry of the diaphragm associated with hyperinflation. On the left, normal curvature of the diaphragm and normal configuration of the zone of apposition, the muscular part of the diaphragm. On the right, hyperinflation is associated with flattening of the diaphragm (increase in the radius of curvature), shortening of muscle fibers, and disappearance of the zone of apposition
Journal of Pain and Symptom Management  , DOI: ( /S (00) )

5. Fig. 4
Breathing effort during spontaneous breathing in an acute exacerbation of COPD. Above: inspiratory and expiratory flow, in liters/s−1. Below: intrapleural pressure swings, in cm H2O. First vertical line: inspiratory effort begins; second vertical line: inspiratory flow begins. The pressure generated by the inspiratory muscles between the two vertical lines (without inspiratory flow) is equivalent to the intrinsic PEEP. This illustrates the additional burden placed on the inspiratory muscles by PEEPi: the inspiratory muscles must generate an intrapleural pressure equivalent to PEEPi before inspiratory flow can begin. Adapted from Rossi and Polese.74
Journal of Pain and Symptom Management  , DOI: ( /S (00) )

6. Fig. 5
A commercially available CPAP. Usually prescribed for home treatment of sleep apnea syndrome, CPAP can be used, with a nasal mask, to relieve dyspnea in patients with COPD, severe obstruction, and hyperinflation, in order to counter the deleterious effect of PEEPi on work of breathing
Journal of Pain and Symptom Management  , DOI: ( /S (00) )

7. Fig. 6
Intermittent positive pressure breathing. IPPB devices can be used for nebulization of bronchodilators in patients with severe respiratory insufficiency in whom conventional nebulized treatment is a source of fatigue and discomfort. Inspiratory pressure support decreases work of breathing while improving peripheral deposition of bronchodilators. An IPPB device is shown with mouthpiece, nebulizing chamber, and control panel (trigger, inspiratory pressure, FIO2)
Journal of Pain and Symptom Management  , DOI: ( /S (00) )