Clinics in chest medicine
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Clinics in chest medicine · Dec 1994
Review Case ReportsAssessment of ventilatory function in patients with neuromuscular disease.
In early phases of neuromuscular disease, patients are either free of respiratory symptoms or have exertional dyspnea not explained by obvious obstructive or restrictive lung disease. Physical examination may be negative because generalized muscle weakness does not correlate with the degree of respiratory muscle involvement. When the diaphragm is involved, one may detect the absence of outward excursion during inspiration or even paradoxic inward inspiratory movement of the abdomen on one side. ⋯ It is important to be aware that overt ventilatory failure can occur abruptly and that measurement of arterial blood gas composition is not a reliable indicator of this danger. Therefore, it is critically important to heed clinical phenomena, such as increasing dyspnea and tachypnea, and symptoms of sleep disturbance, such as morning headache and daytime somnolence. Physicians should make serial measurements of VC and respiratory muscle strength in patients considered to be at risk for further deterioration.(ABSTRACT TRUNCATED AT 400 WORDS)
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This article examines the pathophysiology, diagnosis, treatment, and outcome of acute cardiogenic pulmonary edema, as well as re-expansion, high-altitude, postobstructive, and neurogenic pulmonary edemas. Acute cardiogenic pulmonary edema most commonly presents as a consequence of congestive heart failure. The other important causes are acute myocardial dysfunction, documented myocardial infarction, postoperative cardiac dysfunction, and pulmonary hypertension. All these entities have in common increased pulmonary vascular pressures that lead to pulmonary edema.
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Severe acute lung injury, also known as the adult respiratory distress syndrome (ARDS), is a dynamic and explosive clinical syndrome which exacts a mortality of approximately 50%. The criteria for the diagnosis of severe acute lung injury include five principal elements: hypoxemia despite high concentrations of supplemental oxygen, diffuse pulmonary infiltrates on chest radiographs, decreased lung compliance, appropriate antecedent history, and the absence of congestive heart failure. Identifying an appropriate antecedent history requires consideration of a diverse group of etiologies which may injure alveolar structures via either the air-lung or blood-lung interface. ⋯ Recent observations have suggested that conventional methods of positive-pressure ventilation may indirectly injure alveolar tissue, thereby perpetuating lung injury. Furthermore, the optimal use of fluid and hemodynamic support remains controversial. Thus, controlled clinical trials are necessary to develop oxygenation, ventilatory, and hemodynamic support strategies which optimize recovery and minimize further injury and to define the role of newer pharmacologic agents in the prevention and treatment of acute lung injury.
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Clinics in chest medicine · Jun 1994
ReviewRole of exercise stress testing in preoperative evaluation of patients for lung resection.
Patients with diagnosed or suspected lung cancer first require appropriate staging and proven anatomic resectability. Excellent pre-operative spirometric data (FEV1 > 2.0 L, > 60% predicted) should recommend the patient for surgery immediately without further testing. Those whose preoperative FEV1 is less than 60% predicted or whose DLCO is less than 60% predicted should be sent for quantitative lung scanning to estimate postoperative spirometry and diffusing capacity. ⋯ Those who do not meet these criteria, however, should not be summarily refused surgery if they are willing to accept the possibility of an earlier death or prolonged disability over the certainty of a cancer-related death in the foreseeable months ahead. Because the lung scan prediction of postoperative regional physiology and the exercise test of global oxygen transport examine different aspects of physiologic operability, we would not disagree with anyone who would advocate doing both tests in those at high risk by virtue of spirometric criteria. The logic of this combined approach is illustrated by Figure 1.
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Clinics in chest medicine · Jun 1994
ReviewExercise limitation and clinical exercise testing in chronic obstructive pulmonary disease.
Clinical exercise testing is an important tool in assessment of exercise limitation in COPD patients, in assessment of physiologic and psychological factors that contribute to exercise limitation, and in the differential diagnosis of cardiorespiratory disease. Further studies that examine the clinical utility of exercise testing are needed because there are currently insufficient data regarding the utility of many exercise variables.