Treatment of chronic respiratory failure: lung volume reduction surgery versus rehabilitation.
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Several treatment options are available for end-stage chronic obstructive pulmonary disease (COPD). Respiratory rehabilitation and lung volume reduction surgery are reviewed here. Respiratory rehabilitation can now be considered a prime treatment for COPD. Indeed, it has been clearly shown to improve exercise capacity and health status in these patients. Improvements in the former fell just below the minimal clinically important difference, whereas those in the latter exceeded it. In addition, after a respiratory rehabilitation programme, a reduction in the number of hospital admissions and duration of each admission was demonstrated. It remains, however, difficult to predict accurately which patients will improve after rehabilitation and which will not. Factors that may contribute to this prediction are: baseline peak exercise ventilation/maximal voluntary ventilation, maximal inspiratory pressure, peripheral muscle force, and 6-min walking distance. Several studies have clearly shown that training effects are as pronounced in patients with severe as in those with moderate airflow obstruction. This is the most significant insight in this area of the 1990s. Lung volume reduction surgery may also be of benefit in patients with end-stage COPD. It is clear that lung function, exercise capacity and health status improve after this procedure, although the results of only six randomised studies are currently available. It remains difficult to accurately predict which patients will benefit from the procedure. From a model analysis, the most important action mechanism appears to be resizing of the lungs. Only in patients with an increased residual volume/total lung capacity ratio are beneficial effects expected. The model analysis, however, did not fit the experimental data very well in a recent publication. Emphysema heterogeneity is also likely to be related to the response. The question remains as to whether or not lung volume reduction surgery accelerates the decline in forced expiratory volume in one second in the long run. The technique is undergoing considerable progress as numerous new surgical and endoscopic procedures are currently being developed. The results of these procedures have not yet been systematically evaluated. (+info)
Smoking cessation.
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Cigarette smoking is the primary cause of chronic obstructive pulmonary disease, and smoking cessation is the most effective means of stopping the progression of chronic obstructive pulmonary disease. Worldwide, approximately a billion people smoke cigarettes and 80% reside in low-income and middle-income countries. Though in the United States there has been a substantial decline in cigarette smoking since 1964, when the Surgeon General's report first reviewed smoking, smoking remains widespread in the United States today (about 23% of the population in 2001). Nicotine is addictive, but there are now effective drugs and behavioral interventions to assist people to overcome the addiction. Available evidence shows that smoking cessation can be helped with counseling, nicotine replacement, and bupropion. Less-studied interventions, including hypnosis, acupuncture, aversive therapy, exercise, lobeline, anxiolytics, mecamylamine, opioid agonists, and silver acetate, have assisted some people in smoking cessation, but none of those interventions has strong research evidence of efficacy. To promote smoking cessation, physicians should discuss with their smoking patients "relevance, risk, rewards, roadblocks, and repetition," and with patients who are willing to attempt to quit, physicians should use the 5-step system of "ask, advise, assess, assist, and arrange." An ideal smoking cessation program is individualized, accounting for the reasons the person smokes, the environment in which smoking occurs, available resources to quit, and individual preferences about how to quit. The clinician should bear in mind that quitting smoking can be very difficult, so it is important to be patient and persistent in developing, implementing, and adjusting each patient's smoking-cessation program. One of the most effective behavioral interventions is advice from a health care professional; it seems not to matter whether the advice is from a doctor, respiratory therapist, nurse, or other clinician, so smoking cessation should be encouraged by multiple clinicians. However, since respiratory therapists interact with smokers frequently, we believe it is particularly important for respiratory therapists to show leadership in implementing smoking cessation. (+info)
Pulmonary rehabilitation for chronic obstructive pulmonary disease: a scientific and political agenda.
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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 Global Initiative for Chronic Obstructive Lung Disease, which is also evidence-based, included the recommendation for referral to PR. Despite those recommendations, the availability of comprehensive PR programs (defined as being compliant with national practice standards) is limited. In the United States the lack of a national policy for PR reimbursement has led to differences in compensation among insurance providers, based on differences in the Local Medical Review Policies established by the "fiscal intermediaries." Since 1998 the American Association for Respiratory Care, the American College of Chest Physicians, the American Thoracic Society, and the National Association for Medical Direction of Respiratory Care have jointly lobbied for clear, consistent guidelines from the United States Health Care Financing Administration (HCFA, which was recently renamed the Centers for Medicare and Medicaid Services [CMS]). In 2002 new Medicare/Medicaid billing codes ("G codes") became available for billing PR procedures, but unfortunately the instructions for the use of those codes differ among the Local Medical Review Policies. There has been little success in the effort to establish a national coverage policy for PR. 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. (+info)
Noninvasive ventilation for chronic obstructive pulmonary disease.
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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. Predictors of success with NPPV for COPD exacerbations have been identified and include patient cooperativeness, ability to protect the airway, acuteness of illness not too severe, and a good initial response (within first 1-2 h of NPPV). In applying NPPV, the clinician must pay attention to patient comfort, mask fit and air leak, patient-ventilator synchrony, sternocleidomastoid muscle activity, vital signs, hours of NPPV use, problems with patient adaptation to NPPV (eg, nasal congestion, dryness, gastric insufflation, conjunctival irritation, inability to sleep), symptoms (eg, dyspnea, fatigue, morning headache, hypersomnolence), and gas exchange while awake and asleep. 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. (+info)
Translating new understanding into better care for the patient with chronic obstructive pulmonary disease.
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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. Smoking cessation is the most important of all interventions for COPD, with proven techniques and adjuncts, but implementation remains difficult and success rates are disappointingly low. Similarly, pulmonary rehabilitation has well-documented benefits but is grossly underutilized because it is difficult to pay for and is not made available to most patients. Symptoms, costs, and other outcomes can be improved through comprehensive disease management, including the use of practice guidelines, yet multiple barriers prevent the potential benefits of these interventions to patients from being realized. Many patients who do not meet threshold oxygenation criteria for oxygen therapy during the daytime desaturate during sleep, but evidence that nocturnal oxygen administration benefits these patients is lacking. However, other sleep-related breathing disorders are common in COPD patients. Lung volume reduction surgery has recently been shown to improve function and survival for certain COPD patients, but lung transplantation has generally been disappointing. 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. (+info)
Effects of respiratory therapist-directed protocol on prescription and outcomes of pulmonary rehabilitation in COPD inpatients.
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BACKGROUND: The use of respiratory therapist-directed (RD) protocols in non-ICU hospitalized patients decreases respiratory care charges as compared with physician-directed (PD) protocols. OBJECTIVES: To determine whether RD or PD protocol assessments in COPD patients may impact: (1) prescription of respiratory treatments, and (2) outcomes of pulmonary rehabilitation program (PRP). METHODS: In a retrospective observational case-control study, 73 cases (RD) were compared with controls (PD) matched for age, sex, FEV1 and diagnosis of either chronic airflow obstruction (CAO), pulmonary emphysema (PE) or chronic respiratory insufficiency (CRI). PRP programs were specifically tailored and assessed for inpatients with moderate to severe COPD. Type of PRP protocol (P), number of respiratory treatments (RT), number of exercise training prescription (EXP) and failure (EXF), time to start PRP (T) and length of hospital stay (LOS) were recorded. Perceived breathlessness (B) as assessed by MRC scale, 6-min walk meters (6MWD), and BORG-dyspnea at rest (D-rest) and end of effort (D-effort) were also assessed as outcome measures before (T0) and after (T1) the PRP. RESULTS: Frequency distribution of P, EXP and EXF was similar in the two groups. However, prescription of additional RT (1.9 +/- 0.8 and 2.5 +/- 1.1 days, p<0.01), T (1.2 +/- 0.4 and 1.8 +/- 1.2 days, p<0.001) and LOS (17.2 +/- 2.0 and 18.2 +/- 1.8 days, p<0.05) were lower in cases than in controls. Both cases and controls similarly improved (p<0.0001) B, 6MWD, D-rest and D-effort at T1. CONCLUSIONS: RT-directed assessment results in less respiratory treatments prescription than PD-directed protocol and it does not affect the outcomes of in-hospital pulmonary rehabilitation of COPD patients. (+info)
Advancing beyond the average: the importance of mentoring in professional achievement.
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The profession of respiratory care is founded on rigorous scientific research, which in turn depends on rigorous training in research methods. Only a small part of that training is from written and audiovisual materials; the most important aspects of becoming a respiratory researcher are learned from. Becoming a thoroughly-involved respiratory care professional, then a researcher, and then a mentor is challenging but rich with the rewards of contributing to the advancement of science and, thereby, to the care and comfort of our patients. Becoming a respiratory researcher begins with. Only those with a burning desire to excel, to discover truth, and to contribute to the advancement of the profession will persevere through the setbacks and bring a research project to final fruition. The second requirement for long-term success is learning to maintain between enthusiasm and realism. It is crucial to avoid taking on more than you can realistically do, and it is necessary to devote adequate time to your family and/or non-work-related pursuits and recreation. The third aspect of becoming a contributor to respiratory care research is rigorous and ongoing education in the of respiratory care, the methods of medical research, and the basic sciences and mathematics that underlie the profession, including some calculus, engineering physics, and statistics. You must understand research design, critical analysis of research, and numerous aspects of presentation, including clear writing and concise speaking. The fourth aspect is : you must have a strong commitment to obtaining accurate, reproducible, and meaningful data. You must sustain strong attention to detail; mentors are essential because they teach the needed discipline, the required measurement skills, and how to select the appropriate equipment with which to conduct the research. is the fifth aspect. In addition to planning and using your time wisely, you must learn what are realistic expectations about how long a project will take, when to ask for help, and when to stop because you have reached your physical or mental limit and you need to rest and devote some time to your nutrition and recreation. The sixth aspect is : having achieved the basic skills and gained a fair amount of experience, your efficiency improves and you begin to achieve more in a day; you begin to start mentoring others; you can confidently and quickly handle multiple projects; if you don't know the answers you know where to find them; you are seen as an authority and people ask you for consultations and presentations and to participate in committees. The final aspect is, meaning that your practice of respiratory care reaches a level at which you meet challenges for which you feel you have no response in memory and yet you succeed. (+info)
Respiratory care in the computer age.
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Computerization in health care is rapidly advancing and is improving patient safety (eg, computerized physician order entry decreases the frequency of medical errors) and practitioner effectiveness and efficiency. Computerization and other developing technologies raise concern about the privacy of health information. In 1996 Congress passed the Health Insurance Portability and Accountability Act (HIPAA), which included privacy provisions that went into effect in April 2003. HIPAA has important impacts on health care providers. With the tremendous growth of health care information systems comes the need to standardize the storage and sharing of health information, so there is an initiative underway to develop a National Health Information Infrastructure, which will set standards for health information exchange among consumers, providers, and the public health sector, as well as consolidate the "silos" of health information that are in place today. (+info)