In: Lung Carcinoma17 Sep 2014
Assigning patients to a particular pTNM subset and stage will allow the most appropriate individual therapeutic decision. The new international staging system developed in 1986 relies heavily on the nodal descriptors Nl, N2, and N3. Lymph node involvement is usually defined as involvement by metastases. However, involvement can also be caused by direct extension complicating the current staging system. In reviewing 57 hospital survivors with pTINlMO disease, it became clear that the type of lymph node involvement related to survival in a statistically highly significant way.
This group of patients taken from a consecutive series of 2,009 patients operated on for bronchial carcinoma between 1977 and 1994 represents a homogeneous group. Overall survival at 5 years was 45.7%, which is compatible with other studies. Survival was not related to histologic features, sex, and type of resection. However, multivariate analysis showed a slighdy significant difference in survival for age: prognosis is worse in patients older than 60 years (p=0.042). Read the rest of this entry »
Our chronic NPPV therapy compliance rate of 65% occurred in a comprehensive outpatient program that was geared toward maximizing patient comfort and the efficacy of NPPV application with frequent face mask changes or ventilator settings to optimize patient comfort and gas exchange. In the patients who were compliant with NPPV, they underestimated their use of noninvasive ventilation at least 45% of the time as compared with objective meter logs. This highlights the problems of prior studies that have commented on the efficacy of NPPV. Some patients who were previously reported not to have benefited from NPPV may have failed not because of lack of clinical efficacy, but rather because of noncompliance with prescribed NPPV therapy. ventolin inhaler
Future studies must address the issue of efficacy vs compliance and ensure that objective parameters of NPPV use are measured. Read the rest of this entry »
Although the above reasons support the notion that COPD patients do not tolerate NPPV as well as patients with restrictive disorders, some COPD patients chronically use NPPV for long periods of time and appear to derive physiologic and functional benefit. What makes this patient group distinct from other patient groups with COPD is currently unknown, but several hypotheses could be put forth.
First, some COPD patients have been shown to have an overlapping syndrome (ie, combination of COPD and obstructive sleep apnea syndrome) that may benefit from the use of nocturnal ventilation. This patient group may, therefore, favorably influence the beneficial effects of NPPV in chronic respiratory failure and COPD. Most studies that tend to demonstrate an improvement in symptoms and gas exchange with NPPV in severe COPD have included patients with moderate to severe hypercap-nia on implementation. Indeed, our patients had higher levels of PaCo2 than did any other patients in whom NPPV has been applied on a chronic basis. Read the rest of this entry »
Why different investigators have found varying results in using NPPV in COPD patients, in contrast to patients with restrictive disorders, is not known, but several theories exist. First, patients with restrictive ventilatory disorders and hypercapnia suffer primarily from hypoventilation resulting from either respiratory muscle weakness or chronic resetting of the CO2 threshold. Application of noninvasive ventilation in this patient group improves nocturnal ventilation and acts to reset the CNS CO2 threshold. Some have suggested that the use of noninvasive ventilation provides intermittent chronic respiratory muscle resting and/or improves lung and chest wall compliance, thereby resulting in an improvement in respiratory mechanics that improves respiratory function, gas exchange, and functional status. Read the rest of this entry »
Our data show that in moderately ill patients with chronic respiratory failure, NPPV was associated with acute and chronic improvements in gas exchange and functional status. In contrast, chronic NPPV was not associated with an improvement in spirometry or respiratory muscle strength. Despite enrollment in a comprehensive program (with both inpatient and outpatient components), only 65% of patients continued to use NPPV on a chronic basis, Only half of the patients with severe COPD and hypercapnic respiratory failure continued to chronically use NPPV therapy, whereas 16 of 20 patients (80%) with restrictive disorders remained compliant with NPPV. Minor complications and changes in gas exchange necessitated frequent adjustments in face mask or ventilator settings to maintain effectiveness and compliance with outpatient therapy. add comment
Based on the data, we suggest that comprehensive follow-up is needed to correct equipment problems and maximize patient compliance with NPPV therapy. Read the rest of this entry »
To determine whether NPPV had an independent effect on the improvement observed in gas exchange, arterial blood gas values at discharge and follow-up were compared in patients who complied with NPPV vs patients who were noncompliant with NPPV. As shown in Figure 4, Pao2/Fio2 tended to decrease (294 ± 12 to 259 ± 16; p = 0.10) and PaC02 tended to rise (54 ± 2 to 60 ± 4 mm Hg; p = 0.19) in the noncompliant group, but remained stable in patients who complied with NPPV. Read the rest of this entry »
In all patients who started NPPV, 34 used BiPAP (15 with COPD, 19 with restrictive disorders) and 6 required a portable volume ventilator (5 with COPD, 1 with restrictive disorder) in order to achieve ventilation goals. The average level of inspiratory positive airway pressure was 17 ± 4 cm H2O, and expiratory positive airway pressure was 3 ± 2 cm H2O with a mean pressure boost of 14 ± 3 cm H2O. The average delivered expired Vt was 725 ± 140 mL with a rate of 22 ± 4 breaths/min in patients receiving NPPV via the portable volume ventilator. Read the rest of this entry »
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