Resp Care
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The control of breathing in patients with chronic obstructive pulmonary disease (COPD) follows the same basic principles as in normal subjects, both awake and asleep, with an expected lower feedback response during sleep. This impacts nocturnal gas exchange and sleep quality most profoundly in patients with more severe COPD, as multiple factors come into play. Hypoventilation causes the most important gas-exchange alteration in COPD patients, leading to hypercapnia and hypoxemia, especially during rapid-eye-movement sleep, when marked respiratory muscle atonia occurs. ⋯ In the presence of more profound daytime hypercapnia, polysomnography should be considered (over nocturnal pulse oximetry) to rule out other co-existing sleep-related breathing disorders such as obstructive sleep apnea (overlap syndrome) and obesity hypoventilation syndrome. Present consensus guidelines provide insight into the proper use of oxygen, continuous positive airway pressure, and nocturnal noninvasive positive-pressure ventilation for those conditions, but several issues remain contentious. In order to provide optimal therapy to patients, the clinician must take into account certain reimbursement and implementation-process obstacles and the guidelines for treatment and coverage criteria.
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Noninvasive positive-pressure ventilation (NPPV) should be considered a standard of care to treat COPD exacerbations in selected patients, because NPPV markedly reduces the need for intubation and improves outcomes, including lowering complication and mortality rates and shortening hospital stay. Weaker evidence indicates that NPPV is beneficial for COPD patients suffering respiratory failure precipitated by superimposed pneumonia or postoperative complications, to allow earlier extubation, to avoid re-intubation in patients who fail extubation, or to assist do-not-intubate patients. NPPV patient-selection guidelines help to identify patients who need ventilatory assistance and exclude patients who are too ill to safely use NPPV. ⋯ For severe stable COPD, preliminary evidence suggests that NPPV might improve daytime and nocturnal gas exchange, increase sleep duration, improve quality of life, and possibly reduce the need for hospitalization, but further study is needed. There is consensus, but without strong supportive evidence, that COPD patients who have substantial daytime hypercapnia and superimposed nocturnal hypoventilation are the most likely to benefit from NPPV. Adherence to NPPV is problematic among patients with severe stable COPD.
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Surgical procedures for treating emphysema were first developed nearly 100 years ago. Despite a wide range of surgical procedures performed over the years, only three appear to have true clinical benefit: bullectomy, lung volume reduction surgery (LVRS), and lung transplantation. ⋯ Some individuals with emphysema may be candidates for either LVRS or lung transplantation. Patient-selection criteria for these procedures are being developed.
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As many as 10 million Americans have chronic obstructive pulmonary disease and as a consequence experience disabling symptoms, high cost of care, and substantial mortality. Several new approaches are being investigated for possible benefit in managing (or even reversing) chronic obstructive pulmonary disease. ⋯ Of those tiotropium appears to be the closest to receiving clinical approval in the United States. The risk/benefit ratio and the cost-effectiveness of the other compounds are less clear and await additional study.
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Pulmonary rehabilitation (PR) is the standard of care for patients suffering chronic obstructive pulmonary disease (COPD). This report describes and defines PR and reviews the evidence regarding the efficacy of PR. COPD management guidelines that include PR have been published by the European Respiratory Society, the American Thoracic Society, and the British Thoracic Society, and those guidelines were supported by evidence-based guidelines published jointly by the American College of Chest Physicians and the American Association of Cardiovascular and Pulmonary Rehabilitation. ⋯ The respiratory therapist holds a unique role in PR. In the respiratory therapist's training curriculum PR is specifically addressed, making the respiratory therapist an asset to the multidisciplinary PR team. With their many clinical opportunities for making contact with COPD patients and physicians, respiratory therapists can be effective advocates for PR.