Respiratory Care Clinics Of North America[JOURNAL]
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200 papers
Surgical viewpoints for the definitive treatment of lung cancer.
Bilfinger TV
Respir Care Clin N Am · 2003 Jun · PMID 12911287 · Publisher ↗
Surgery remains a central pillar in the treatment of lung cancer. To optimize surgical interventions, careful preoperative assessment is necessary. Pulmonary status and cardiac status are the main risks to be considered....
Surgery remains a central pillar in the treatment of lung cancer. To optimize surgical interventions, careful preoperative assessment is necessary. Pulmonary status and cardiac status are the main risks to be considered. After operability has been established, resectability is assessed by staging the lung cancer. Surgery offers a variety of tools to accomplish complete staging before resection. Successful resection is defined as the complete removal of the cancer. To accomplish this goal, a multidisciplinary approach is evolving rapidly. For patients with nonoperable cancer, surgical techniques have been developed to manage airway obstructions and to drain effusions.
Positron emission tomography scanning in lung cancer.
Lowe VJ
Respir Care Clin N Am · 2003 Mar · PMID 12820714 · Publisher ↗
Continuing advances in imaging technology have resulted in an improved ability to evaluate thoracic malignancies with PET. Published reports demonstrate that PET provides accurate, noninvasive detection of malignancy tha...
Continuing advances in imaging technology have resulted in an improved ability to evaluate thoracic malignancies with PET. Published reports demonstrate that PET provides accurate, noninvasive detection of malignancy that is useful in the characterization of nonspecific radiographic lung lesions, staging of known lung cancer, and identification of recurrent disease. Preliminary studies suggest that PET may also be able to accurately assess therapeutic response. The incorporation of PET into routine clinical practice has advanced rapidly and undoubtedly PET will continue to be an increasingly important part of the clinical assessment of patients with lung malignancy.
Staging tools for nonsmall cell lung cancer.
Zawin M
Respir Care Clin N Am · 2003 Mar · PMID 12820713 · Publisher ↗
Accurate staging remains the cornerstone of initial managment of nonsmall cell lung cancer. CT offers the potential advantage of identifying early stage tumors when broadly applied as a screening tool, although studies t...
Accurate staging remains the cornerstone of initial managment of nonsmall cell lung cancer. CT offers the potential advantage of identifying early stage tumors when broadly applied as a screening tool, although studies that are evaluating the sensitivity, specificity, and impact on survival are ongoing. PET is a functional imaging tool with ever-broadening applications. New techniques, such as CT-PET fusion imaging, endoscopic ultrasound, virtual bronchoscopy, and three-dimensional volumetric reconstruction may further refine noninvasive diagnostic and staging options.
Tissue diagnosis of suspected lung cancer: selecting between bronchoscopy, transthoracic needle aspiration, and resectional biopsy.
Yung RC
Respir Care Clin N Am · 2003 Mar · PMID 12820712 · Publisher ↗
In pursuing a tissue diagnosis of a suspected lung cancer, there is a range of procedures to choose from. The principal goals are ideally to diagnose and pathologically stage the patient's lung cancer at the same time, p...
In pursuing a tissue diagnosis of a suspected lung cancer, there is a range of procedures to choose from. The principal goals are ideally to diagnose and pathologically stage the patient's lung cancer at the same time, preferably by using the safest, least invasive, and least costly tests. If there is clinical or radiographic evidence of extrapulmonary spread of disease, including supraclavicular N3 nodal involvement or a malignant pleural effusion, then radiology-guided or open biopsy will confirm tumor cell type and stage the patient as unresectable. For patients with symptoms, such as increasing cough or hemoptysis, that are suggestive of airways involvement. with or without radiographic finding of central lesions, sputum cytology is the least invasive study with a high specificity. A positive finding of cancer is especially helpful if the patient is not a surgical candidate because of anatomic location of the lesion or severe physiologic limitations. The limited sensitivity of sputum cytology and poor NPV may improve with improved sputum induction and collection and processing techniques. Bronchoscopy with direct examination of the visible airways is most often the preferred invasive diagnostic procedure. Although the procedure should be geared toward sampling the highest staged lesion to provide an accurate tissue staging at the time of diagnosis, additional procedures can be performed in sequence to sample different nodal stations, is well as the primary lung mass. The incidental finding of an unexpected central airways lesions or a synchronous second endobronchial lung primary will also affect plans for treatment. Autofluorescence bronchoscopy can improve the sensitivity for detecting early intraepithelial neoplasia. Bronchoscopy for central and peripheral lung masses that are suspected to be lung cancer should be performed with ROSE whenever available. For visible endobronchial lesions, given the similar yield of EBBX and EBNA, EBNA may provide an immediate diagnosis, thus obviating additional, possibly morbid, procedures such as BB or EBBX. For submucosal lesions, EBNA is superior. For central cancers that are peribronchial, TBNA performed as for regional nodal sampling should have a yield that is comparable to TBNA for staging. TBBX and TBNA of peripheral nodules that are smaller than 3 cm have a lower diagnostic yield. Coming generations of thin bronchoscopes and improved radiographic guidance systems may improve our ability to biopsy these lesions with greater accuracy and safety. Under all circumstances, immediate cytology feedback with ROSE will confirm the adequacy of the retrieved specimen for a definitive tissue diagnosis, thus avoiding the need for extra biopsies, or worse yet, the need for a second invasive procedure because of insufficient diagnostic material. ROSE is educational to the clinician and fellow-in-training in getting immediate feedback on the procedural techniques and in learning pulmonary pathology, as well. The diagnostic sensitivity of TTNA is high, especially for the larger peripheral-based lung lesion, and TTNA is a relatively rapid procedure. TTNA's sensitivity falls for smaller or more central lesions, where the false negative rate can approach 25% to 30%; the risk of pneumothoraces and bleeding increases with central biopsies. Furthermore, TTNA usually does not provide information about nodal staging, unless the TTNA is initially directed toward central lymph nodes. The central airways are not examined in the same appointment to address issues of resection margins when there may be central spread of disease. TTNA should, therefore, be held in reserve for cases in which the sputum cytology and subsequent bronchoscopy are negative, and the patient is not a surgical candidate or refuses surgery, even if the cancer is potentially resectable. TTNA may then provide the tissue diagnosis to permit initiation of cytotoxic chemotherapy and radiotherapy. TTNA may also be helpful in cases where the likelihood of cancer is only intermediate, such that a specific benign diagnosis or an adequate sample without cancer will greatly reduce the likelihood ratio of missing a cancer, and justify to the patient and physician an approach of careful observation. To maximize the yield of these diagnostic procedures, there must be continued improvement in the hands-on teaching of clinical fellows and pulmonary practitioners in the use of the various techniques of TBNA and TBBX, as well as the applications of new endoscopic technology, such as EBUS. Definitive curative surgery remains the goal for patients with lung cancer, with accurate pathological staging performed intraoperatively. Complete lobectomy or pneumonectomy remains the standard resectional approach. Therefore, for patients with sufficient cardiopulmonary reserve who can be clinically staged as IA or IB, either by good quality CT with contrast or increasingly with 18-FDG PET, the initial tissue diagnosis may be at the time of surgery, when a frozen section preceding a complete lobectomy with lymph node sampling will combine diagnosis and therapy.
Screening for lung cancer: an old idea revisited.
Sachs S
Respir Care Clin N Am · 2003 Mar · PMID 12820711 · Publisher ↗
Standardly diagnosed and treated NSCLC remains a disease of high prevalence and high mortality. Although lessons from the past do not confirm advantage from screening high-risk people, the questions about the design of t...
Standardly diagnosed and treated NSCLC remains a disease of high prevalence and high mortality. Although lessons from the past do not confirm advantage from screening high-risk people, the questions about the design of these studies and the development of newer technologies merit critical re-evaluation of a more refined, targeted, and integrated screening process. Evaluation of further screening efforts should involve selection of appropriate diagnostic tools and definition of the appropriate population, so that the patients who are most likely to benefit from early intervention (those with adequate cardiopulmonary reserve for resection), as well as those with highest risk, are selected. The technologic evolutions in the screening process, in conjunction with refinement in the definition of the appropriate target population through characterization of the molecular biologic markers of lung cancer risk, offer great promise for development of a minimally invasive approach to the identification of early stage disease.
An overview of lung cancer.
Sachs S, Fiore JJ
Respir Care Clin N Am · 2003 Mar · PMID 12820710 · Publisher ↗
Small cell lung cancer remains a devastating disease. A reduction in its impact will most likely come in the immediate future from smoking cessation programs. Because it is a rapidly growing disease, it seems unlikely th...
Small cell lung cancer remains a devastating disease. A reduction in its impact will most likely come in the immediate future from smoking cessation programs. Because it is a rapidly growing disease, it seems unlikely that screening programs will have a significant impact on its curability. New chemotherapeutic agents with greater activity in this disease are desperately needed. Biologic agents such as the anti-idiotypic antibody BEC2 when combined with BCG may offer some hope to those with minimal residual disease after standard chemotherapy and radiation. Finally, an improved understanding of the biology of small cell cancer may ultimately provide the necessary clues to more effective treatment.
Complications of long-term mechanical ventilation.
Chatila WM, Criner GJ
Respir Care Clin N Am · 2002 Dec · PMID 12602419 · Publisher ↗
Complications of LTMV should be considered in the context of underlying diseases and comorbidities, the trigger for ventilator dependency, and site of care. These factors have an impact on outcome and on the type and sev...
Complications of LTMV should be considered in the context of underlying diseases and comorbidities, the trigger for ventilator dependency, and site of care. These factors have an impact on outcome and on the type and severity of complications. In view of the complexity of chronically ill VAIs, complications of mechanical ventilation become the major impediment in achieving the ultimate goal of LTMV, extending life, and improving psychophysiologic function and quality of life. Efforts should not be spared to prevent and aggressively treat these complications while continuing plans to wean and rehabilitate the patient.
Sleep and long-term ventilation.
Krachman SL, Criner GJ
Respir Care Clin N Am · 2002 Dec · PMID 12602418 · Publisher ↗
The development of sleep-disordered breathing is common in patients with chronic respiratory insufficiency due to neuromuscular and restrictive disorders, as well as in those with COPD. Nocturnal hypoventilation and obst...
The development of sleep-disordered breathing is common in patients with chronic respiratory insufficiency due to neuromuscular and restrictive disorders, as well as in those with COPD. Nocturnal hypoventilation and obstructive and central apneas result in daytime symptoms of hypersomnolence and fatigue, and contribute to abnormalities in awake gas exchange. Long-term mechanical ventilation, delivered invasively by tracheostomy or more recently by NPPV, has been shown to eliminate sleep-disordered breathing and correct abnormalities in nocturnal gas exchange, resulting in an improvement in sleep quality. Improved daytime symptoms and gas exchange, with the suggestion of a decrease in morbidity and mortality, support the use of long-term mechanical ventilation during sleep in selected patients with these disorders.
Whole-body rehabilitation in long-term ventilation.
Martin UJ
Respir Care Clin N Am · 2002 Dec · PMID 12602417 · Publisher ↗
Advances in critical care and mechanical ventilation have improved long-term survival of critically ill patients, some of whom develop the need for prolonged mechanical ventilator assistance. The rehabilitation of these...
Advances in critical care and mechanical ventilation have improved long-term survival of critically ill patients, some of whom develop the need for prolonged mechanical ventilator assistance. The rehabilitation of these individuals is aimed at restoring function, facilitating independence from mechanical ventilation, and in some cases returning them to the community. To accomplish these goals, rehabilitation programs require a multidisciplinary approach that includes physicians, respiratory therapists, nurses, physical and occupational therapists, nutrionists, speech therapists, and social services workers in a concerted effort. Chronic mechanical ventilation patients are often complicated by multiple comorbidities and by complex physiologic and psychological interactions. A careful selection and an individualized assessment are therefore paramount in identifying and achieving long-term goals. Special attention has to be paid to aggressive respiratory and nonrespiratory muscle rehabilitation, early ambulation, nutritional repletion, and psychological support. Careful evaluation and treatment by members of a multidisciplinary team may foster the patients' independence and ability to tolerate spontaneous ventilation, ultimately resulting in an improvement in their quality of life.
Care of the patient requiring invasive mechanical ventilation.
Criner GJ
Respir Care Clin N Am · 2002 Dec · PMID 12602416 · Publisher ↗
Patients who require prolonged invasive mechanical ventilation pose a unique set of circumstances to the pulmonary and critical care practitioner. This requires a delineation of the primary cause for respiratory failure,...
Patients who require prolonged invasive mechanical ventilation pose a unique set of circumstances to the pulmonary and critical care practitioner. This requires a delineation of the primary cause for respiratory failure, and, in most cases, a comprehensive multidisciplinary approach to the treatment of not only the primary disturbance causing respiratory failure, but the consequences that immobility, illness, and prolonged ventilation have on swallowing and ambulatory function, psychosocial interaction, and the ability to wean from mechanical ventilation. The development of multidisciplinary rehabilitative units for patients requiring prolonged mechanical ventilation have showed not only a reduction in hospital costs and lengths of stay, but also an improvement in patient survival, functional status, reduction in ventilator days or need for mechanical ventilation at discharge, and, overall, the achievement of a satisfactory quality of life.
Outcome of long-term noninvasive positive-pressure ventilation.
Wedzicha JA
Respir Care Clin N Am · 2002 Dec · PMID 12602415 · Publisher ↗
The introduction of NPPV has been one of the most important advances in the management of patients at home with chronic respiratory failure. The benefit obtained from the therapy depends, however, on the underlying cause...
The introduction of NPPV has been one of the most important advances in the management of patients at home with chronic respiratory failure. The benefit obtained from the therapy depends, however, on the underlying cause of the respiratory failure. Patients with chest wall disease and postpolimyelitis show the best improvements in survival and quality of life. But even in patients with Duchenne muscular dystrophy, useful benefits for survival and quality of life are obtained. The longer-term effects of NPPV in hypercapnic COPD are not so clear, and further large, well-designed controlled studies are required to evaluate the effects of NPPV not only on survival, but also on quality of life and disease exacerbation. If the initial experience with NPPV in COPD is confirmed in larger trials, then this important therapy will be available to an even larger group of patients worldwide.
Long-term negative pressure ventilation.
Corrado A, Gorini M
Respir Care Clin N Am · 2002 Dec · PMID 12602414 · Publisher ↗
Noninvasive mechanical ventilatory techniques include the use of negative and positive pressure ventilators. Negative pressure ventilators support ventilation by exposing the surface of the chest wall to subatmospheric p...
Noninvasive mechanical ventilatory techniques include the use of negative and positive pressure ventilators. Negative pressure ventilators support ventilation by exposing the surface of the chest wall to subatmospheric pressure during inspiration, whereas expiration occurs when the pressure around the chest wall increases and becomes equal to or greater than atmospheric pressure. In this article, a description of negative pressure ventilators and the physiologic effects of negative pressure ventilation (NPV) is given, and the application of this technique in the long-term treatment of chronic respiratory failure is summarized. Many studies, although uncontrolled, have shown that long-term treatment with NPV can improve respiratory muscle function, arterial blood gases, and survival in patients with neuromuscular and chest wall disorders. NPV devices, however, are more cumbersome and difficult to use than home positive pressure ventilators (PPVs) and tend to predispose to obstructive apnoeas during sleep. In the last several decades, NPV has been supplanted by mask PPV. In experienced hands, NPV remains a second viable option in patients with neuromuscular and chest wall disorders who, for technical or other reasons, cannot be offered mask PPV. There is no evidence, however, that long-term treatment with NPV can improve respiratory muscle function, exercise endurance, quality of life, and survival in patients with severe chronic obstructive pulmonary disease.
Long-term ventilation in obstructive ventilatory disorders.
Simonds AK
Respir Care Clin N Am · 2002 Dec · PMID 12602413 · Publisher ↗
A large randomized, controlled study of NIV plus LTOT versus LTOT in patients with COPD is needed that evaluates morbidity, mortality, quality of life, and health economic impact. It is to be hoped that funding for this...
A large randomized, controlled study of NIV plus LTOT versus LTOT in patients with COPD is needed that evaluates morbidity, mortality, quality of life, and health economic impact. It is to be hoped that funding for this type of study will be forthcoming. In the meantime, it reasonably can be concluded from existing evidence that domiciliary NIV is unlikely to be effective in most patients with stable COPD, particularly if they are normocapnic. A subgroup of patients with severe hypercapnia, poor tolerance of LTOT, marked nocturnal hypoventilation, or recurrent infective exacerbations may benefit from domiciliary NIV. Systematic evaluation is required in patients with CF or bronchiectasis.
Long-term ventilation in restrictive ventilatory disorders.
Leger P
Respir Care Clin N Am · 2002 Dec · PMID 12602412 · Publisher ↗
Long-term ventilation (LTV) had its beginning with restrictive ventilatory disorders. Today, LTV is predominately represented by noninvasive ventilation (NIV). Invasive ventilation was used for a long time but is now usu...
Long-term ventilation (LTV) had its beginning with restrictive ventilatory disorders. Today, LTV is predominately represented by noninvasive ventilation (NIV). Invasive ventilation was used for a long time but is now usually restricted for selected patients in which NIV fails.
Costs and reimbursement of long-term ventilation.
Gracey DR
Respir Care Clin N Am · 2002 Sep · PMID 12481969 · Publisher ↗
Patients receiving long-term mechanical ventilation present a serious financial challenge to hospitals. Depending on the case mix in a particular hospital of Medicare, Medicaid, managed-care contract, and fully insured p...
Patients receiving long-term mechanical ventilation present a serious financial challenge to hospitals. Depending on the case mix in a particular hospital of Medicare, Medicaid, managed-care contract, and fully insured patients, the financial picture in most hospitals is bleak. Depending on the level of state Medicaid reimbursement, Medicaid losses on these patients vary. Because acute care hospitals cannot be reimbursed for chronic ventilator units, hospitals have resorted to leasing space to separate entities, which, when separately incorporated, accredited, and staffed, can secure waivered status from the PPS and can be paid at a per diem rate based on their costs. Hospital patients who are ventilator dependent can be transferred to these PPS-waived units. There are states where no chronic ventilator facilities exist and where nursing homes do not accept ventilator-dependent patients. This situation is serious for the hospital if the patient does not have caregivers at home who are capable of caring for a ventilator-dependent patient. The problem of the large numbers of patients who are ventilated mechanically with endotracheal tubes but who do not fall into MDC 4 needs to be addressed by Medicare. Medicare needs to evaluate the cost and use of NIV in ICU practice and develop a system to reimburse for this modality at a reasonable level under Part A.
Quality of life and long-term ventilation.
Carone M, Donner CF
Respir Care Clin N Am · 2002 Sep · PMID 12481968 · Publisher ↗
The interest in measuring HS or QoL in patients with respiratory diseases has increased progressively over the last decade, but only recently has it been applied to patients with more severe disease (ie, patients with CR...
The interest in measuring HS or QoL in patients with respiratory diseases has increased progressively over the last decade, but only recently has it been applied to patients with more severe disease (ie, patients with CRF who are receiving LTOT or NIPPV). The impact of CRF on the daily life and well being of patients can be measured in a number of different ways. There is evidence, however, that it is not possible to predict patients' health from surrogate measures (eg, spirometry or exercise performance) and that the size of the health gain following treatments or interventions cannot be predicted from changes in physiologic measurements. Adequate assessments of HS can be measured directly only through the use of valid and reliable QoL questionnaires. A range of different instruments is available in the literature. The SGRQ and MRF28 have been shown to be applicable and reliable in patients on long-term ventilation.
Where to perform long-term ventilation.
Ambrosino N, Vianello A
Respir Care Clin N Am · 2002 Sep · PMID 12481967 · Publisher ↗
Given that most VAI prefer to be cared for at home and that their return home is the desire of families, health care professionals, and others concerned with LTMV, the effort to transform prolonged mechanical ventilation...
Given that most VAI prefer to be cared for at home and that their return home is the desire of families, health care professionals, and others concerned with LTMV, the effort to transform prolonged mechanical ventilation from a hospital-centered to a home-centered treatment needs to be continued and further developed. Nevertheless, the future of high-technology home care will undoubtedly be influenced by improvements in quality and containment of costs, as in its current status treatment of VAI at home too often leads to family disruption and presents a dramatically increasing cost burden. Careful selection of patients, closer attention to education and training, and collection of outcome data are all factors that presumably will facilitate the development of better-quality and cost-saving home care.
Physiologic responses to long-term ventilation.
Hendra K, Celli B
Respir Care Clin N Am · 2002 Sep · PMID 12481966 · Publisher ↗
Long-term MV, delivered by way of a tracheostomy or noninvasive mask, often is indicated in patients with restrictive or neuromuscular pulmonary diseases and occasionally in patients with severe obstructive hypercapnic r...
Long-term MV, delivered by way of a tracheostomy or noninvasive mask, often is indicated in patients with restrictive or neuromuscular pulmonary diseases and occasionally in patients with severe obstructive hypercapnic respiratory failure. Regardless of the mode of ventilation, respiratory physiology seems to be significantly impacted in these patients. Although the effects of ventilation can be unpredictable, they often seem to be favorable. Selected patients can develop increased sensitivity to hypercapnia, with subsequent improvements in blood gas tensions and decreased pulmonary artery pressures, which result in augmented cardiac function and greater tolerance to exercise. The patient-ventilator interaction, mode of ventilation, and degree of support should be considered when managing these patients. For some patients, particularly patients with fibrotic lung disease or COPD, chronic MV likely does not alter pathophysiology or improve prognosis.
Choice of ventilator types, modes, and settings for long-term ventilation.
Schönhofer B
Respir Care Clin N Am · 2002 Sep · PMID 12481965 · Publisher ↗
Ventilator-associated issues are important for optimum short- and long-term outcome in patients treated with long-term mechanical ventilation, and may even influence compliance. This article discusses the individual choi...
Ventilator-associated issues are important for optimum short- and long-term outcome in patients treated with long-term mechanical ventilation, and may even influence compliance. This article discusses the individual choice of type, modeand settings ventilators, based on the efficacy of the intervention and patient-related factors, such as the patient's comfort and safety. Although this strategy may cause some overlap, from a methodological point of view it seems reasonable to deal separately with types, modes and different ventilator settings.
Evaluation of candidates for long-term ventilation.
Muir JF, Cuvelier A
Respir Care Clin N Am · 2002 Sep · PMID 12481964 · Publisher ↗
This article considers the evaluation of patients prior to institution of long-term ventilation (LTV). LTV has evolved from a concept of necessity ventilation to a more satisfactory approach of preventive LTV, enabled by...
This article considers the evaluation of patients prior to institution of long-term ventilation (LTV). LTV has evolved from a concept of necessity ventilation to a more satisfactory approach of preventive LTV, enabled by the impressive development of noninvasive mechanical ventilation (NIV). Due to its convenience and efficacy, and its safety compared with invasive ventilation, NIV has rapidly gained popularity among patients with chronic respiratory failure (CRF) requiring intermittent ventilatory assistance. Evaluation of candidates for LTV involves clinical and laboratory evaluations and sleep monitoring. It includes consideration of the etiology of CRF, be it restrictive lung disease, chronic obstructive pulmonary disease, obesity or other cause, and considers the feasibility of LTV as well as its desirability.
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