Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Dec 2020
ReviewInvasive Mechanical Ventilation in Chronic Obstructive Pulmonary Disease Exacerbations.
Chronic obstructive pulmonary disease (COPD) continues to be an important cause of morbidity, mortality, and health care costs worldwide. Although there exist some heterogeneity between patients, the course of COPD is characterized by recurrent acute exacerbations, which are among the most common causes of medical admission to hospital. ⋯ Therefore, interest is growing in assessing the effectiveness of interventions used to treat exacerbations. The present review summarizes the current evidence regarding the use of ventilatory management to treat COPD and the implementation of novel cost-effective strategies, such as high-flow oxygenation or extracorporeal carbon dioxide removal to improve clinical outcomes and functional recovery in this disease and to reduce the associated costs.
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Semin Respir Crit Care Med · Dec 2020
ReviewComorbidities and Readmissions in Survivors of Acute Hypercapnic Respiratory Failure.
Chronic obstructive pulmonary disease (COPD) is defined by chronic airflow obstruction, but is presently considered as a complex, heterogeneous, and multicomponent disease in which comorbidities and extrapulmonary manifestations make important contributions to disease expression. COPD-related hospital readmission. In particular frequent intensive care unit (ICU) readmissions for exacerbations represent a major challenge and place a high burden on patient outcomes and health-related quality of life, as well as on the healthcare system. ⋯ Second, we present predictors of hospital and ICU readmission and discuss various strategies to reduce such events. There is a strong rationale to detect and treat major comorbidities early after index ICU admission for acute hypercapnic respiratory failure. It still remains unclear, however, if a comprehensive and holistic approach to comorbidities in frail patients surviving hypercapnic respiratory failure can efficiently reduce the readmission rate.
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Semin Respir Crit Care Med · Dec 2020
ReviewInvasive Pulmonary Aspergillosis in Chronic Obstructive Pulmonary Disease Exacerbations.
Nowadays, reports in the literature support that patients with severe chronic obstructive pulmonary disease (COPD) are at higher risk to develop invasive pulmonary aspergillosis (IPA). However, the interpretation of Aspergillus-positive cultures from the airways in critically ill COPD is still a challenge. Indeed, as the patient could be merely colonized, tissue samples are required to ascertain IPA diagnosis but they are rarely obtained before death. ⋯ To facilitate the analysis of these data, several algorithms have been developed, and the best effectiveness has been demonstrated by the Clinical algorithm. This is of importance as IPA prognosis in these patients remains presently very poor and using such an algorithm could promote prompter diagnosis, early initiation of treatment, and subsequently improved outcome. While the most classical presentation of IPA in critically ill COPD patients features a combination of obstructive respiratory failure, antibiotic-resistant pneumonia, recent or chronic corticosteroid therapy, and positive Aspergillus cultures from the lower respiratory tract, the present article will also address less typical presentations and discuss the most appropriate treatments which could alter prognosis.
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Severe emphysema with hyperinflation presents a therapeutic challenge. Inhaled medication has limited efficacy in individuals with mechanical constraints to the respiratory pump and impaired gas exchange. Lung volume reduction surgery (LVRS) reestablishes some semblance of normal physiology, resecting grossly expanded severely diseased tissue to restore the function of compromised relatively healthy lung, and has been shown to significantly improve exercise capacity, quality of life, and survival, especially in individuals with upper-lobe predominant emphysema and low-baseline exercise capacity, albeit with higher early morbidity and mortality. ⋯ Endobronchial coils are proving a viable treatment option in severe hyperinflation in the presence of collateral ventilation in selected cases of homogeneous disease. Modalities including vapor and sealant are delivered using a segmental strategy preserving healthier tissue within the same target lobe-efficacy and safety-data are, however, limited. This article will review the data supporting these novel technologies.
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Semin Respir Crit Care Med · Dec 2020
ReviewNonantibiotic Pharmacological Treatment of Severe Chronic Obstructive Pulmonary Disease Exacerbations.
Severe, acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are a rapid deterioration of the respiratory symptoms of patients with COPD, requiring hospital admission and escalation of pharmacological and nonpharmacological care including the more severe cases of respiratory failure and admission to an intensive care unit (ICU). These events severely impact patients' quality of life and prognosis. This review will describe the nonantibiotic, pharmacological treatment options available for critically ill patients with AECOPD. ⋯ Finally, recently developed drugs, such as the specific phosphodiesterase-4 inhibitors, may play a role in the prevention of relapsing AECOPD following a critical event than the treatment of the exacerbation itself. Although they significantly improve the survival of critically ill patients with AECOPD, none of available drugs, alone or combined, is able to significantly modify the prognosis of patients with COPD. This remains an open challenge for the current and future generations of researchers and clinicians.