Resp Care
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In the last 2 decades, anticholinergic agents have been generally regarded as the first-choice bronchodilator therapy in the routine management of stable chronic obstructive pulmonary disease (COPD) and, to a lesser extent, asthma. Anticholinergics are particularly important bronchodilators in COPD, because the vagal tone appears to be the only reversible component of airflow limitation in COPD. The inhaled anticholinergics approved for clinical use are synthetic quaternary ammonium congeners of atropine, and include ipratropium bromide, oxitropium bromide, and tiotropium bromide. This article reviews the most current evidence for inhaled anticholinergics in obstructive airway disease and summarizes outcomes reported in randomized controlled trials.
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Numerous case reports, uncontrolled studies, and small randomized placebo-controlled trials have investigated the role of aerosolized opioids in the treatment of both dyspnea and pain. Recently, aerosolized furosemide was studied for the treatment of dyspnea. A direct effect on either pulmonary stretch receptors or irritant receptors has been proposed to explain the apparent effectiveness of these drugs. ⋯ Small, generally uncontrolled, studies suggest that aerosolized furosemide may relieve dyspnea both in patients with terminal cancer and those with chronic obstructive pulmonary disease. Routine clinical use of aerosolized opioids to treat dyspnea in terminal illness will require large randomized placebo-controlled trials. However, until these studies are done, the risk/benefit ratio favors use of aerosolized opioids and furosemide in selected patients, based on the principle of compassionate care.
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Pulmonary vasodilators are an important treatment for pulmonary arterial hypertension. They reduce pulmonary artery pressure; improve hemodynamic function; alter ventilation/perfusion matching in the lungs; and improve functional quality of life, exercise tolerance, and survival in patients with severe pulmonary arterial hypertension. This paper reviews the currently available pulmonary vasodilators and those under development, many of which can be administered via inhalation. I will also give an overview of the clinical pharmacology of, the indications for, and the evidence supporting pulmonary vasodilators, their delivery via inhalation, and potential toxic and adverse effects.
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In health, the airways are lined by a layer of protective mucus gel that sits atop a watery periciliary fluid. Mucus is an adhesive, viscoelastic gel, the biophysical properties of which are largely determined by entanglements of long polymeric gel-forming mucins, MUC5AC and MUC5B. This layer entraps and clears bacteria and inhibits bacterial growth and biofilm formation. ⋯ DNA-active medications such as dornase alfa (Pulmozyme) and potentially actin-depolymerizing drugs such as thymosin beta(4) may be of value in helping to break down airway pus. Mucokinetic agents can increase the effectiveness of cough, either by increasing expiratory cough airflow or by unsticking highly adhesive secretions from the airway walls. Aerosol surfactant is one of the most promising of this class of medications.
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Numerous mechanical ventilators are designed and marketed for use in patient transport. The complexity of these ventilators differs considerably, but very few data exist to compare their operational capabilities. ⋯ Only 2 of the ventilators met all the trial targets in all the bench and animal tests. With many of the ventilators, certain of the set ventilation parameters were inaccurate (differed by > 10% from the values from a cardiopulmonary monitor). The physical characteristics and high gas consumption of some of these ventilators may render them less desirable for patient transport.