Resp Care
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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.
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Despite an enormous amount of research and many official statements, the definition, diagnosis, and staging of chronic obstructive pulmonary disease (COPD) remain inconsistent, and we have yet to agree on who should be tested with spirometry or on where and how to do it. We know that inflammation, not just airflow limitation, is important in determining the course of COPD, especially with respect to exacerbations. We can detect and treat alpha-1 antitrypsin deficiency, an under-recognized condition, but whether alpha-1 antitrypsin augmentation therapy affects the disease's clinical course remains unclear. ⋯ New pharmaceutical agents are being developed for treating COPD, and at least one of them (tiotropium) should soon be available in the United States. Noninvasive ventilation is effective in treating acute decompensations of COPD and should be the standard of care in that setting; evidence supporting its use in stable patients with end-stage disease is scant. Appropriate palliative care can greatly benefit patients and their families in the terminal phase of COPD and needs to be more widely applied.
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Exacerbations of chronic obstructive pulmonary disease (COPD) cause morbidity, hospital admissions, and mortality, and strongly influence health-related quality of life. Some patients are prone to frequent exacerbations, which are associated with considerable physiologic deterioration and increased airway inflammation. About half of COPD exacerbations are caused or triggered primarily by bacterial and viral infections (colds, especially from rhinovirus), but air pollution can contribute to the beginning of an exacerbation. ⋯ A 2-week course of oral corticosteroids is as beneficial as an 8-week course, with fewer adverse effects, and might extend the time until the next exacerbation. Antibiotics have some efficacy in treating exacerbations. Exacerbation frequency increases with progressive airflow obstruction; so patients with chronic respiratory failure are particularly susceptible to exacerbation.