Key Treatment

Smoking cessation is the best intervention to slow the long-term rate of decline in FEV1 (Anthonisen et al., 1994) (SOR: A). Among patients with COPD, inhaled corticosteroid use for at least 24 weeks is associated with a significantly increased risk of serious pneumonia but not death, especially among those using the highest dose of ICS and those with the lowest baseline FEV1 (Drum-mond, 2008; Singh, 2009) (SOR: A).

Patients with COPD receiving LABAs showed significant benefits in airflow limitation measures, health-related quality of life, and use of rescue medication, but the anticholinergic drug tiotropium decreased the incidence of severe COPD exacerbations even more than LABAs (Rodrigo, 2008) (SOR: A).

Tiotropium reduces the rate of decline of FEV1 in patients with GOLD stage II COPD (Decramer, 2009). Unfortunately, inhaled anticholinergics may also be associated with a significantly increased risk of cardiovascular death, myocardial infarction, or stroke in COPD patients (Singh et al., 2008) (SOR: A). All patients should be counseled on smoking cessation; combining effective behavioral therapies (behavioral group therapy, social support) with pharmacologic therapy (nicotine replacement therapy, antidepressants) (Hughes et al., 2004; Lancaster and Stead, 2004; Stead and Lancaster, 2005) (SOR: A). Pulmonary rehabilitation, including patient education and cardiopulmonary exercise training, significantly improves clinical outcomes and health-related quality of life (Lacasse et al., 2001) (SOR: A).

Home oxygen therapy helps patients with resting Pao2 less than 60 mm Hg but not patients with normal oxygen levels or with hypoxemia only on exertion (Crockett et al., 2000) (SOR: A).

inadequate ventilation (resulting in hypercarbia and respiratory acidosis). Although patients might initially present with severe shortness of breath, the hypoxia and increased Paco2 can ultimately lead to suppression of respiratory centers in the brain, as well as lethargy, stupor, or coma.

An especially serious form of respiratory failure that can occur is acute respiratory distress syndrome (ARDS), which can occur in patients with severe trauma, especially those who have received massive blood transfusions, overwhelming pneumonia, septic shock, and the acute chest syndrome associated with sickle cell disease.

Indications for intubation and mechanical ventilation include hypoxia and hypoventilation unresponsive to phar-macologic intervention and supplemental oxygen delivery by mask or cannula. Patients unable to protect their own airway because of central nervous system (CNS) depression or inadequate gag reflex might also need intubation. The detailed management of mechanical ventilation is beyond the scope of this chapter, but ventilation can be thought of in terms of ventilator settings that increase or decrease ventilation (ventilator mode, respiratory rate, and tidal volume) and ventilator settings that improve oxygenation: forced inspiratory oxygen concentration (Fio2) and continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP].

Weaning patients from the ventilator, especially those with chronic lung disease, can be challenging. Reintubation carries risks of trauma and of ventilator-associated pneumonia. Protocols based on objective criteria (vs. individual clinical judgment) significantly reduce time, costs, and complications related to weaning patients from mechanical ventilation.

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