Management of Chronic Obstructive Pulmonary Disease
http://www.100md.com
《新英格兰医药杂志》
To the Editor: In their comprehensive review article on the management of chronic obstructive pulmonary disease (COPD) (June 24 issue),1 Sutherland and Cherniack discuss noninvasive ventilation as a means of improving hypercapnia and increasing the quality of life in patients with COPD. In contrast, in a recent randomized trial of the use of noninvasive ventilation in patients in whom respiratory failure developed after extubation, mortality was almost twice as high among patients treated with noninvasive ventilation as among patients receiving standard medical therapy.2 In addition, there was no difference in the rate of reintubation between the groups. This study suggests that the use of noninvasive ventilation is not without risks. Even though the study was focused on patients with postextubation respiratory failure, it seems likely that the observations may apply also to other groups of patients receiving noninvasive ventilation.3 Therefore, a high level of vigilance and surveillance seems to be necessary when noninvasive ventilation is used in the management of COPD in order to identify those patients who require early invasive management of the airway.
Holger K. Eltzschig, M.D.
Tobias Eckle, M.D.
University Clinic for Anesthesiology and Intensive Care Medicine
72076 Tübingen, Germany
Thomas W. Felbinger, M.D.
Harvard Medical School
Boston, MA 02115
tfelbinger@partners.org
References
Sutherland ER, Cherniack RM. Management of chronic obstructive pulmonary disease. N Engl J Med 2004;350:2689-2697.
Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004;350:2452-2460.
Truwit JD, Bernard GR. Noninvasive ventilation -- don't push too hard. N Engl J Med 2004;350:2512-2515.
To the Editor: Sutherland and Cherniack state that "oral corticosteroids should not be used in the routine management of stable COPD disease." The previous generation of pulmonologists, however, used alternate-day oral corticosteroid therapy for both COPD and asthma, because this regimen was shown to be efficacious, safe, and convenient.1 The cost of the daily administration of an inhaled steroid exceeds $50 per month, whereas the cost of alternate-day oral therapy is, by comparison, negligible.2 For this reason, many physicians continue to prescribe alternate-day oral therapy for underinsured patients. A controlled clinical trial to compare the efficacy of alternate-day oral corticosteroids and daily inhaled corticosteroids would be helpful. Such a trial is not likely to be sponsored, however, because its outcome would probably discourage the use of the more expensive regimen.
Marc H. Lavietes, M.D.
New Jersey Medical School
Newark, NJ 07103
lavietmh@umdnj.edu
References
Harter JG, Reddy WJ, Thorn GW. Studies on an intermittent corticosteroid dosage regimen. N Engl J Med 1963;269:591-596.
Nebulized budesonide for asthma in children. Med Lett Drugs Ther 2001;43:6-7.
To the Editor: Sutherland and Cherniack provide an excellent overview of the management of COPD. To the options included in their article, we add the recent attempts to manage this disease with the use of endobronchial treatment. The concept of nonresectional reduction of lung volume has emerged recently; new devices and strategies are being developed to achieve endoscopic lung-volume reduction without open surgery.1,2,3 When one-way endobronchial valves are placed bronchoscopically into the most severely emphysematous segments of the lung, air is prevented from entering the isolated segments but distal bronchial secretions are permitted to escape.4 The net result is an induced atelectasis of the most severely emphysematous segments and the redirection of air flow (or ventilation) to the least emphysematous lung segments to reproduce the clinical benefits of lung-volume–reduction surgery without exposing the patient to the risks associated with a major operation.4 The placement of the endobronchial valves is a safe procedure that results in considerable short-term improvement in the median forced expiratory volume in one second2 and gas transfer3 and in the functional status, quality of life, and relief of dyspnea in selected patients.4
Sanjay Kumar, M.Ch., F.R.C.S.
Leeds General Infirmary
Leeds LS1 3EX, United Kingdom
sanjaykr33@hotmail.com
Bharati Sinha, M.D.
Royal London Hospital
London E1 1BG, United Kingdom
References
Fann JI, Berry GJ, Burdon TA. Bronchoscopic approach to lung volume reduction using a valve device. J Bronchol (in press).
Toma TP, Hopkinson NS, Hillier J, et al. Bronchoscopic volume reduction with valve implants in patients with severe emphysema. Lancet 2003;361:931-933.
Snell G, Holsworth L, Borrill ZL, et al. The potential for bronchoscopic lung volume reduction using bronchial prosthesis: a pilot study. Chest 2003;124:1073-1080.
Yim AP, Hwong TM, Lee TW, et al. Early results of endoscopic lung volume reduction for emphysema. J Thorac Cardiovasc Surg 2004;127:1564-1573.
To the Editor: The excellent review article on the management of COPD includes a recommendation that I have often seen, but never with a satisfactory explanation. Sutherland and Cherniack state that in patients with established disease, "spirometry should be performed at least annually . . . to assess clinical status or the response to therapy." They then state that "smoking cessation is the only intervention known to be . . . effective in modifying the disease." Therefore, since the results of spirometry cannot be used as a basis for instituting therapy that would have an effect on the disease process, and since, for the most part, therapy in COPD is directed toward improving the patients' symptoms, it would seem that annual spirometry in the many patients with COPD would be performed at a substantial cumulative cost to our health care system while providing little if any benefit to individual patients.
Mark Joy, M.D.
New York University Downtown Hospital
New York, NY 10038
mark_joy@nymc.edu
The authors reply: Dr. Eltzschig and colleagues comment on the risks of noninvasive positive-pressure ventilation in COPD. We agree that, if not carefully titrated in patients with airflow limitation, positive-pressure ventilation can worsen hyperinflation, increase the work of breathing, and even result in barotrauma and hypotension in the most severe cases. However, we recommend caution in extrapolating from the findings of Esteban and colleagues1 to the treatment of patients with stable COPD. In their study of critically ill subjects, only a small minority (approximately 10 percent) had COPD, which suggests that in most patients the risk of reintubation or death could have been influenced by physiological processes other than airflow limitation. Furthermore, airflow limitation, hyperinflation, hypercarbia, hypoxia, and respiratory-muscle insufficiency are likely to be more severe in patients recently liberated from mechanical ventilation. Observations made in this setting may have limited relevance to patients with stable disease.
Dr. Lavietes tempers our recommendations with a real-life concern — drug costs. Although we agree that costs must be considered, so must efficacy. There is little evidence to suggest that alternate-day systemic corticosteroid therapy is beneficial in stable COPD. We suggest that one strategy to reduce the costs associated with the use of inhaled corticosteroids is, as recommended in our article, to restrict the use of these drugs to those patients most likely to benefit from them.
The techniques for nonresectional lung-volume reduction described by Drs. Kumar and Sinha are of interest. Until controlled studies with long-term follow-up are performed, the safety and efficacy of this method of lung-volume reduction remain unclear.
Dr. Joy requests justification for our recommendation regarding annual spirometry, suggesting that such a strategy is unlikely to influence management decisions. Long-term studies to evaluate the benefit of regular spirometry in the management of COPD have not yet been conducted. Until such studies can be carried out, we discourage nihilistic conclusions about the usefulness of spirometry and reiterate our recommendations. First, spirometry is the key to the diagnosis of early COPD. Recognition of the disease when lung function is still relatively preserved allows the initiation of smoking cessation and other preventive measures before disabling symptoms develop, thereby reducing the risk of further disease progression2 and death.3 Second, the measurement of the forced expiratory volume in one second after the administration of a bronchodilator should be performed repeatedly over the course of the disease in order to define the rate of decline in lung function, thereby helping to focus both treatment decisions and discussions regarding prognosis.
E. Rand Sutherland, M.D., M.P.H.
Reuben M. Cherniack, M.D.
National Jewish Medical and Research Center
Denver, CO 80206
References
Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004;350:2452-2460.
Anthonisen NR, Connett JE, Murray RP. Smoking and lung function of Lung Health Study participants after 11 years. Am J Respir Crit Care Med 2002;166:675-679.
Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ 2004;328:1519-1519.
Holger K. Eltzschig, M.D.
Tobias Eckle, M.D.
University Clinic for Anesthesiology and Intensive Care Medicine
72076 Tübingen, Germany
Thomas W. Felbinger, M.D.
Harvard Medical School
Boston, MA 02115
tfelbinger@partners.org
References
Sutherland ER, Cherniack RM. Management of chronic obstructive pulmonary disease. N Engl J Med 2004;350:2689-2697.
Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004;350:2452-2460.
Truwit JD, Bernard GR. Noninvasive ventilation -- don't push too hard. N Engl J Med 2004;350:2512-2515.
To the Editor: Sutherland and Cherniack state that "oral corticosteroids should not be used in the routine management of stable COPD disease." The previous generation of pulmonologists, however, used alternate-day oral corticosteroid therapy for both COPD and asthma, because this regimen was shown to be efficacious, safe, and convenient.1 The cost of the daily administration of an inhaled steroid exceeds $50 per month, whereas the cost of alternate-day oral therapy is, by comparison, negligible.2 For this reason, many physicians continue to prescribe alternate-day oral therapy for underinsured patients. A controlled clinical trial to compare the efficacy of alternate-day oral corticosteroids and daily inhaled corticosteroids would be helpful. Such a trial is not likely to be sponsored, however, because its outcome would probably discourage the use of the more expensive regimen.
Marc H. Lavietes, M.D.
New Jersey Medical School
Newark, NJ 07103
lavietmh@umdnj.edu
References
Harter JG, Reddy WJ, Thorn GW. Studies on an intermittent corticosteroid dosage regimen. N Engl J Med 1963;269:591-596.
Nebulized budesonide for asthma in children. Med Lett Drugs Ther 2001;43:6-7.
To the Editor: Sutherland and Cherniack provide an excellent overview of the management of COPD. To the options included in their article, we add the recent attempts to manage this disease with the use of endobronchial treatment. The concept of nonresectional reduction of lung volume has emerged recently; new devices and strategies are being developed to achieve endoscopic lung-volume reduction without open surgery.1,2,3 When one-way endobronchial valves are placed bronchoscopically into the most severely emphysematous segments of the lung, air is prevented from entering the isolated segments but distal bronchial secretions are permitted to escape.4 The net result is an induced atelectasis of the most severely emphysematous segments and the redirection of air flow (or ventilation) to the least emphysematous lung segments to reproduce the clinical benefits of lung-volume–reduction surgery without exposing the patient to the risks associated with a major operation.4 The placement of the endobronchial valves is a safe procedure that results in considerable short-term improvement in the median forced expiratory volume in one second2 and gas transfer3 and in the functional status, quality of life, and relief of dyspnea in selected patients.4
Sanjay Kumar, M.Ch., F.R.C.S.
Leeds General Infirmary
Leeds LS1 3EX, United Kingdom
sanjaykr33@hotmail.com
Bharati Sinha, M.D.
Royal London Hospital
London E1 1BG, United Kingdom
References
Fann JI, Berry GJ, Burdon TA. Bronchoscopic approach to lung volume reduction using a valve device. J Bronchol (in press).
Toma TP, Hopkinson NS, Hillier J, et al. Bronchoscopic volume reduction with valve implants in patients with severe emphysema. Lancet 2003;361:931-933.
Snell G, Holsworth L, Borrill ZL, et al. The potential for bronchoscopic lung volume reduction using bronchial prosthesis: a pilot study. Chest 2003;124:1073-1080.
Yim AP, Hwong TM, Lee TW, et al. Early results of endoscopic lung volume reduction for emphysema. J Thorac Cardiovasc Surg 2004;127:1564-1573.
To the Editor: The excellent review article on the management of COPD includes a recommendation that I have often seen, but never with a satisfactory explanation. Sutherland and Cherniack state that in patients with established disease, "spirometry should be performed at least annually . . . to assess clinical status or the response to therapy." They then state that "smoking cessation is the only intervention known to be . . . effective in modifying the disease." Therefore, since the results of spirometry cannot be used as a basis for instituting therapy that would have an effect on the disease process, and since, for the most part, therapy in COPD is directed toward improving the patients' symptoms, it would seem that annual spirometry in the many patients with COPD would be performed at a substantial cumulative cost to our health care system while providing little if any benefit to individual patients.
Mark Joy, M.D.
New York University Downtown Hospital
New York, NY 10038
mark_joy@nymc.edu
The authors reply: Dr. Eltzschig and colleagues comment on the risks of noninvasive positive-pressure ventilation in COPD. We agree that, if not carefully titrated in patients with airflow limitation, positive-pressure ventilation can worsen hyperinflation, increase the work of breathing, and even result in barotrauma and hypotension in the most severe cases. However, we recommend caution in extrapolating from the findings of Esteban and colleagues1 to the treatment of patients with stable COPD. In their study of critically ill subjects, only a small minority (approximately 10 percent) had COPD, which suggests that in most patients the risk of reintubation or death could have been influenced by physiological processes other than airflow limitation. Furthermore, airflow limitation, hyperinflation, hypercarbia, hypoxia, and respiratory-muscle insufficiency are likely to be more severe in patients recently liberated from mechanical ventilation. Observations made in this setting may have limited relevance to patients with stable disease.
Dr. Lavietes tempers our recommendations with a real-life concern — drug costs. Although we agree that costs must be considered, so must efficacy. There is little evidence to suggest that alternate-day systemic corticosteroid therapy is beneficial in stable COPD. We suggest that one strategy to reduce the costs associated with the use of inhaled corticosteroids is, as recommended in our article, to restrict the use of these drugs to those patients most likely to benefit from them.
The techniques for nonresectional lung-volume reduction described by Drs. Kumar and Sinha are of interest. Until controlled studies with long-term follow-up are performed, the safety and efficacy of this method of lung-volume reduction remain unclear.
Dr. Joy requests justification for our recommendation regarding annual spirometry, suggesting that such a strategy is unlikely to influence management decisions. Long-term studies to evaluate the benefit of regular spirometry in the management of COPD have not yet been conducted. Until such studies can be carried out, we discourage nihilistic conclusions about the usefulness of spirometry and reiterate our recommendations. First, spirometry is the key to the diagnosis of early COPD. Recognition of the disease when lung function is still relatively preserved allows the initiation of smoking cessation and other preventive measures before disabling symptoms develop, thereby reducing the risk of further disease progression2 and death.3 Second, the measurement of the forced expiratory volume in one second after the administration of a bronchodilator should be performed repeatedly over the course of the disease in order to define the rate of decline in lung function, thereby helping to focus both treatment decisions and discussions regarding prognosis.
E. Rand Sutherland, M.D., M.P.H.
Reuben M. Cherniack, M.D.
National Jewish Medical and Research Center
Denver, CO 80206
References
Esteban A, Frutos-Vivar F, Ferguson ND, et al. Noninvasive positive-pressure ventilation for respiratory failure after extubation. N Engl J Med 2004;350:2452-2460.
Anthonisen NR, Connett JE, Murray RP. Smoking and lung function of Lung Health Study participants after 11 years. Am J Respir Crit Care Med 2002;166:675-679.
Doll R, Peto R, Boreham J, Sutherland I. Mortality in relation to smoking: 50 years' observations on male British doctors. BMJ 2004;328:1519-1519.