Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Apr 2005
Review Comparative StudyRole of bronchodilators in chronic obstructive pulmonary disease.
The prevalence of chronic obstructive pulmonary disease (COPD) continues to be on the rise. Bronchodilators are first line agents for the symptomatic management of this disease and have proven to be effective in both stable disease status and exacerbations. The stepwise escalation of therapy for COPD according to severity has been outlined in international guidelines. ⋯ In contrast, the usage of theophylline, which used to be part of the mainstay of treatment for COPD, has declined, mainly secondary to a narrow therapeutic margin and side effects, but it is inexpensive and still has its role. New agents like phosphodiesterase-4-inhibitors are interesting substances that may become important adjuncts in COPD management, but there is limited experience so far. None of the bronchodilators have been shown to change outcome in COPD, but this issue is under active investigation.
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Pulmonary rehabilitation has been well established and increasingly recommended in disease management plans for patients with chronic obstructive pulmonary disease. Key elements include a multidisciplinary approach to care, focus on the individual patient, and attention to emotional and social as well as physical aspects of health. Appropriate candidates are symptomatic patients with chronic lung disease who are aware of their disability and motivated to participate actively in their own health care. ⋯ Program components include a careful patient evaluation, education, instruction in respiratory and chest physiotherapy techniques, exercise training, and psychosocial support. Benefits demonstrated in a growing body of evidence include improvement in symptoms, exercise tolerance, and quality of life and reduction in utilization of health care resources. Pulmonary rehabilitation has also been included as an adjunct to surgical programs such as lung transplantation and lung volume reduction surgery.
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Semin Respir Crit Care Med · Apr 2005
Review Comparative StudyA review of alpha-1 antitrypsin deficiency.
Alpha-1 antitrypsin (AAT) is a protein that prevents enzymes such as elastin from degrading normal host tissue. Individuals who are deficient in AAT (those with levels < 11 micromol/L) are at risk for developing such clinical manifestations as emphysema, cirrhosis, panniculitis, and anticytoplasmic neutrophilic antibody (C-ANCA)-positive vasculitis (Wegener's granulomatosis). Estimates suggest that 75 to 85% of those with severe deficiency of AAT will develop emphysema. ⋯ Diagnosis of AAT deficiency is made by measuring serum levels of AAT and, if reduced, an effort should then be made to identify the genetic abnormality responsible for the reduction. A recent evidence-based review has offered testing recommendations for AAT deficiency and includes the recommendation that all patients with COPD be tested for AAT deficiency. Augmentation with an intravenous form of purified pooled human plasma has been shown to increase the serum levels of AAT among deficient patients and its use appears to impact the rate of forced expiratory volume in 1 second (FEV (1)) decline and overall survival; to date, no confirmatory, large, prospective, randomized trials are available.
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Semin Respir Crit Care Med · Apr 2005
Review Comparative StudyNew concepts in the radiological assessment of COPD.
Chronic obstructive pulmonary disease (COPD) is a complex genetic disorder in which environmental factors, such as tobacco smoke, interact with genetic susceptibility to cause disease. Airway obstruction in COPD is due to an exaggerated inflammatory response that ultimately destroys the lung parenchyma (emphysema) and increases airway resistance by remodeling the airway wall. ⋯ This review describes some of the new CT techniques for quantitative assessment of lung structure. These techniques are extremely important to study the pathogenesis of COPD as well as differentiate patients with predominantly emphysema disease from those with airway wall remodeling, and to assess the effects of therapeutic interventions.
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Semin Respir Crit Care Med · Apr 2005
Review Comparative StudyEpidemiology and global impact of chronic obstructive pulmonary disease.
Chronic obstructive pulmonary disease (COPD) is a preventable and treatable disease that causes a heavy health and increasing economic burden both in the United States and around the world. Most of the risk factors for COPD are well known and include smoking, occupational exposures, air pollution, airway hyperresponsiveness, asthma, and certain genetic variations, although many questions, such as why a minority of smokers develop significant airway obstruction, remain. ⋯ In most of the world, COPD prevalence and mortality are still increasing and will likely continue to rise in response to increases in smoking, particularly by women and adolescents. Resources aimed at smoking cessation and prevention, COPD education and early detection, and better treatment will be of the most benefit in our continuing efforts against this important cause of morbidity and mortality.