The patients with severe chronic obstructive pulmonary disease and chronic respiratory insufficiency.

Caring for patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) stages III and IV with chronic respiratory failure is difficult independent of whether the target is survival or quality of life (QOL). The role of inhaled drug therapy in this specific set of very severe COPD patients has not previously been assessed. The only drug able to prolong survival in these patients is long term oxygen therapy, whereas there is little evidence to indicate long-term domiciliary mechanical ventilation in the routine management of stable hypercapnic patients. Supplemental oxygen during exercise reduces exercise breathlessness and improves exercise capacity of the hypoxaemic patient. Pulmonary rehabilitation including nutritional supplementation is a significant component of therapy, even in these severe patients. Relief of dyspnoea with drugs such as morphine should not be denied to severely disabled patients who share poor QOL with cancer patients. Non-invasive ventilation has been used as a palliative treatment to reduce dyspnoea. Lung Volume Reduction Surgery may improve mortality, exercise capacity, and QOL in selected patients, but is associated with significant morbidity and an early mortality rate in the most severe patients. Lung transplantation is a final step in end-stage patients, but short- and long-term outcomes remain significantly inferior in relation to other "solid" organs recipients.