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Intraoperative Management of Hypercapnia With an Extracorporeal Carbon Dioxide Removal Device During Giant Bullectomy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016; 11:142-5. [PMID: 27088168 DOI: 10.1097/imi.0000000000000250] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Extracorporeal CO2-removal devices have been introduced in clinical practice to provide protective and ultraprotective ventilation strategies in different settings to avoid retention of carbon dioxide. The need to facilitate lung-protective ventilation is required not only for the treatment of acute respiratory distress syndrome but also in thoracic surgery during complex operations, especially in respiratory compromised patients. This report describes a case of giant bullectomy for vanishing lung syndrome in which intraoperative hypercapnia secondary to protective ventilation was managed with a CO2-removal device (Decap-Hemodec s.r.l., Salerno, Italy). To the best of our knowledge, this is the first report in the literature of the intraoperative use of the Decap system for giant bullectomy.
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Dell'Amore A, D'Andrea R, Caroli G, Mazzoli CA, Rocca A, Stella F, Bini A, Melotti R. Intraoperative Management of Hypercapnia with an Extracorporeal Carbon Dioxide Removal Device during Giant Bullectomy. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2016. [DOI: 10.1177/155698451601100212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | | | | | - Alberto Rocca
- Pneumology Department, S. Orsola Malpighi University Hospital, Bologna, Italy
| | | | | | - Rita Melotti
- Anesthesiology and Intensive Care Unit, Bologna, Italy
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Abstract
Lung volume reduction surgery (LVRS) is a costly procedure that can improve quality and quantity of life. Given the prevalence of emphysema, the costs involved with its management, and resource constraints on all health care delivery systems, evaluating the cost-effectiveness of LVRS is important. In this article, we describe the purposes and principles of cost-effectiveness analysis and how those principles were applied in evaluating LVRS. We present the results of the cost-effectiveness analysis that was conducted alongside the National Emphysema Treatment Trial and other economic studies of LVRS and discuss how these should be interpreted in the context of current reimbursement guidelines.
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Gorman RB, McKenzie DK, Butler JE, Tolman JF, Gandevia SC. Diaphragm length and neural drive after lung volume reduction surgery. Am J Respir Crit Care Med 2005; 172:1259-66. [PMID: 16109977 DOI: 10.1164/rccm.200412-1695oc] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Patients with chronic obstructive pulmonary disease have shorter inspiratory muscles and higher motor unit firing rates during quiet breathing than do age-matched healthy subjects. Lung volume reduction surgery (LVRS) in patients with chronic obstructive pulmonary disease improves lung function, exercise capacity, and quality of life. OBJECTIVES We studied the effect of LVRS on length and motor unit firing rates of diaphragm and scalene muscles. METHODS Diaphragm length was estimated by ultrasound and magnetometers, and firing rates were recorded with needle electrodes in patients (five females and seven males) with severe chronic obstructive pulmonary disease, before and after surgery. MEASUREMENTS AND MAIN RESULTS Pre-LVRS total lung capacity was 135 +/- 10% predicted (mean +/- SD), and FEV1 was 30 +/- 12% predicted. After surgery, median firing frequency of diaphragmatic motor units fell from 17.3 +/- 4.2 to 14.5 +/- 3.4 Hz (p < 0.001), and scalene motor unit firing rates were reduced from 15.3 +/- 6.9 to 13.4 +/- 3.8 Hz (p < 0.001). Tidal volume and diaphragm length change during quiet breathing did not change, but at end expiration, the zone of apposition length of diaphragm against the rib cage (L(Zapp)) increased (30 +/- 28%, p = 0.004). Improvements in quality-of-life measures and exercise performance after surgery were related to increased forced vital capacity and L(Zapp). CONCLUSIONS Increased diaphragm length resulted in lower motor unit firing rates and reduced breathing effort, and this is likely to contribute to improved quality of life and exercise performance after LVRS.
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Affiliation(s)
- Robert B Gorman
- Prince of Wales Medical Research Institute, Barker Street, Sydney, Randwick NSW 2031, Australia
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Thomas M, Griffiths C. Asthma and panic: scope for intervention? Am J Respir Crit Care Med 2005; 171:1197-8. [PMID: 15914565 DOI: 10.1164/rccm.2503005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Ramsey SD, Sullivan SD. Evidence, economics, and emphysema: Medicare's long journey with lung volume reduction surgery. Health Aff (Millwood) 2005; 24:55-66. [PMID: 15647216 DOI: 10.1377/hlthaff.24.1.55] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Use of lung volume reduction surgery (LVRS) increased in the mid-1990s as a palliative therapy for severe emphysema. Rapid growth in procedure volume despite little evidence supporting its safety and effectiveness prompted the Centers for Medicare and Medicaid Services (CMS) to suspend payments and cosponsor a nationwide randomized controlled trial to evaluate the procedure. In this paper we describe the trial and its influence on the CMS's recent coverage decision for LVRS. We describe the implications of this study for evidence-based evaluation of surgical procedures and Medicare's potential role in evaluating experimental treatments that affect its beneficiaries.
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Affiliation(s)
- Scott D Ramsey
- Fred Hutchinson Cancer Research Center, Seattle, Washington, USA.
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7
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Hartigan PM, Pedoto A. Anesthetic Considerations for Lung Volume Reduction Surgery and Lung Transplantation. Thorac Surg Clin 2005; 15:143-57. [PMID: 15707352 DOI: 10.1016/j.thorsurg.2004.08.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Anesthetic considerations for lung transplantation and LVRS have been reviewed, with an emphasis on critical intraoperative junctures and decision points. Cognizance of these issues promotes coordinated and optimal care and provides the potential to improve outcome in this particularly high-risk population.
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Affiliation(s)
- Philip M Hartigan
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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8
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Patel SA, Luketich JD, Landreneau RP, Sciurba FC. Clinical trials in lung volume reduction surgery. Semin Thorac Cardiovasc Surg 2004; 15:464-71. [PMID: 14710389 DOI: 10.1053/j.semtcvs.2003.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- S A Patel
- Division of Pulmonary, Allergy and Critical Care Medicine, University of Pittsburgh, PA 15213, USA
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9
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Jörgensen K, Houltz E, Westfelt U, Nilsson F, Scherstén H, Ricksten SE. Effects of lung volume reduction surgery on left ventricular diastolic filling and dimensions in patients with severe emphysema. Chest 2003; 124:1863-70. [PMID: 14605061 DOI: 10.1378/chest.124.5.1863] [Citation(s) in RCA: 83] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Data on the influence of lung volume reduction surgery (LVRS) on cardiac function and hemodynamics are scarce and controversial. Previous studies have focused mainly on right ventricular function and pulmonary hemodynamics. Here, we evaluated the effects of LVRS on left ventricular (LV) end-diastolic filling pattern, dimensions, stiffness, and performance, as well as pulmonary and systemic hemodynamics. DESIGN A prospective, open, controlled study. PATIENTS Patients with severe emphysema undergoing LVRS (10 patients). Patients scheduled for pulmonary lobectomy due to carcinoma (ie, the lobectomy group) served as control subjects (10 patients). MEASUREMENTS LV dimensions and mitral flow velocities were measured by transesophageal, two-dimensional, Doppler echocardiography, and central hemodynamics were measured by a pulmonary artery thermodilution catheter. Measurements were performed during anesthesia in the supine position, before and after surgery, without and with passive leg elevation. RESULTS Baseline cardiac index (CI) [- 21%], stroke volume index (SVI) [- 31%], stroke work index (SWI) [- 26%], and LV end-diastolic area index (EDAI) [- 15%] were significantly (p < 0.001) lower, whereas LV end-diastolic stiffness (LVEDS) did not differ in the LVRS group compared to the lobectomy group. The time from peak early diastolic filling to zero flow (E-dec time) [58%] and the deceleration slope of early diastolic filling (E-dec slope) [45%] were significantly higher (p < 0.01), whereas peak early diastolic filling velocity (E-max) [- 31%; p < 0.01] and the proportion of E-max vs peak late diastolic filling velocity (A-max) [ie, the E/A ratio] (- 27%; p < 0.001) were significantly lower compared to the lobectomy group. LVRS significantly increased CI (40%; p < 0.001), SVI (34%; p < 0.001), SWI (58%; p < 0.001), LV EDAI (18%; p < 0.001), E-max (44%; p < 0.01), A-max (15%; p < 0.05) and E/A ratio (28%; p < 0.01), decreased E-dec time (- 31%; p < 0.05) and E-dec slope (- 98%; p < 0.01), and had no effect on LVEDS. In the lobectomy group, surgery affected none of these variables. CONCLUSIONS LV function is impaired in patients with severe emphysema due to small end-diastolic dimensions. LVRS increases LV end-diastolic dimensions and filling, and improves LV function.
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Affiliation(s)
- Kirsten Jörgensen
- Department of Cardiothoracic Anesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
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Abstract
Lung volume reduction surgery is a surgical treatment for severe emphysema that is increasing in popularity. The aim is to reverse the hyperexpansion of the lungs that leads to expiratory airflow limitation, compromises the diaphragm and chest wall mechanics, and tamponades the right ventricle. Optimal patient selection has not yet been established, but it has become clear that those patients with the most severe disease have an unacceptably high surgical mortality. The anaesthetic management of patients undergoing lung volume reduction surgery requires a good understanding of both the pathophysiology of the disease and the surgical procedure. It is important for the anaesthetist and the surgeon to work closely, supported by a large multidisciplinary team. Excellent analgesia is essential to a successful outcome; whether this is best provided by thoracic epidural is as yet unclear.
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Affiliation(s)
- J Hillier
- Department of Anaesthesia and Critical Care Medicine, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
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11
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Abstract
Lung volume reduction surgery (LVRS) is a costly new procedure that could influence quality of life and survival for persons who have severe emphysema. This article reviews the history of LVRS from an economic and policy perspective and provides estimates of the cost effectiveness of LVRS derived from the National Emphysema Treatment Trial, a recently completed multicenter evaluation of LVRS, compared with medical care. Estimates of the potential impact of LVRS on the national health care budget are provided. The high cost and uncertainty regarding the long-term cost effectiveness of LVRS warrant further evaluation after public and private health insurers make coverage decisions for this procedure, particularly if it is adopted as part of the standard of care.
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Affiliation(s)
- Scott D Ramsey
- Cancer Prevention Program, Division of Public Health Sciences, Fred Hutchinson Cancer Research Center, 1100 Fairview Avenue North (MP-900), Seattle, WA 98109, USA.
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Schmeichel BJ, Vohs KD, Baumeister RF. Intellectual performance and ego depletion: role of the self in logical reasoning and other information processing. J Pers Soc Psychol 2003; 85:33-46. [PMID: 12872883 DOI: 10.1037/0022-3514.85.1.33] [Citation(s) in RCA: 468] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Some complex thinking requires active guidance by the self, but simpler mental activities do not. Depletion of the self's regulatory resources should therefore impair the former and not the latter. Resource depletion was manipulated by having some participants initially regulate attention (Studies 1 and 3) or emotion (Study 2). As compared with no-regulation participants who did not perform such exercises, depleted participants performed worse at logic and reasoning (Study 1), cognitive extrapolation (Study 2), and a test of thoughtful reading comprehension (Study 3). The same manipulations failed to cause decrements on a test of general knowledge (Study 2) or on memorization and recall of nonsense syllables (Study 3). Successful performance at complex thinking may therefore rely on limited regulatory resources.
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Affiliation(s)
- Brandon J Schmeichel
- Department of Psychology, Case Western Reserve University, Cleveland, Ohio 44106-7123, USA.
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Ramsey SD, Berry K, Etzioni R, Kaplan RM, Sullivan SD, Wood DE. Cost effectiveness of lung-volume-reduction surgery for patients with severe emphysema. N Engl J Med 2003; 348:2092-102. [PMID: 12759480 DOI: 10.1056/nejmsa030448] [Citation(s) in RCA: 168] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The National Emphysema Treatment Trial, a randomized clinical trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema, included a prospective economic analysis. METHODS After pulmonary rehabilitation, 1218 patients at 17 medical centers were randomly assigned to lung-volume-reduction surgery or continued medical treatment. Costs for the use of medical care, medications, transportation, and time spent receiving treatment were derived from Medicare claims and data from the trial. Cost effectiveness was calculated over the duration of the trial and was estimated for 10 years of follow-up with the use of modeling based on observed trends in survival, cost, and quality of life. RESULTS Interim analyses identified a group of patients with excess mortality and little chance of improved functional status after surgery. When these patients were excluded, the cost-effectiveness ratio for lung-volume-reduction surgery as compared with medical therapy was 190,000 dollars per quality-adjusted life-year gained at 3 years and 53,000 dollars per quality-adjusted life-year gained at 10 years. Subgroup analyses identified patients with predominantly upper-lobe emphysema and low exercise capacity after pulmonary rehabilitation who had lower mortality and better functional status than patients who received medical therapy. The cost-effectiveness ratio in this subgroup was 98,000 dollars per quality-adjusted life-year gained at 3 years and 21,000 dollars at 10 years. Bootstrap analysis revealed substantial uncertainty for the subgroup and 10-year estimates. CONCLUSIONS Given its cost and benefits over three years of follow-up, lung-volume-reduction surgery is costly relative to medical therapy. Although the predictions are subject to substantial uncertainty, the procedure may be cost effective if benefits can be maintained over time.
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Affiliation(s)
- Scott D Ramsey
- Fred Hutchinson Cancer Research Center, Public Health Sciences Division, Seattle, WA 98109, USA.
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14
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Abstract
Over the past decades, extensive literature has been published regarding surgical therapies for advanced COPD. Lung-volume reduction surgery would be an option for a significantly larger number of patients than classic bullectomy or lung transplantation. Unfortunately, the initial enthusiasm has been tempered by major questions regarding the optimal surgical approach, safety, firm selection criteria, and confirmation of long-term benefits. In fact, the long-term follow-up reported in patients undergoing classical bullectomy should serve to caution against unbridled enthusiasm for the indiscriminate application of LVRS. Those with the worst long-term outcome despite favourable short-term improvements after bullectomy have consistently been those with the lowest pulmonary function and significant emphysema in the remaining lung who appear remarkably similar to those being evaluated for LVRS. With this in mind, the National Heart, Lung and Blood Institute partnered with the Health Care Finance Administration to establish a multicenter, prospective, randomized study of intensive medical management, including pulmonary rehabilitation versus the same plus bilateral (by MS or VATS), known as the National Emphysema Treatment Trial. The primary objectives are to determine whether LVRS improves survival and exercise capacity. The secondary objectives will examine effects on pulmonary function and HRQL, compare surgical techniques, examine selection criteria for optimal response, identify criteria to determine those who are at prohibitive surgical risk, and examine long-term cost effectiveness. It is hoped that data collected from this novel, multicenter collaboration will place the role of LVRS in a clearer perspective for the physician caring for patients with advanced emphysema.
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Affiliation(s)
- K R Flaherty
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Health System, Ann Arbor, Michigan, USA
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Porter SH, Ruffin RE, Pfitzner J, Peacock M, Southcott AM, Homan S. Videoscopic lung volume reduction surgery in an Australian public teaching hospital. AUSTRALIAN AND NEW ZEALAND JOURNAL OF MEDICINE 2000; 30:202-8. [PMID: 10833111 DOI: 10.1111/j.1445-5994.2000.tb00808.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Lung volume reduction surgery (LVRS) has been a frequent literature topic in emphysema management recently. Opinions differ in regard to usefulness, efficacy, and selection criteria. AIMS To present the results of our first 55 bilateral videoscopically resected group, with follow-up of up to three years, and to present some of the local methodology problems faced. METHODS Thirty-nine men and 16 women, age range 40-77, had either upper lobe (42), mixed (two), or lower lobe (11) resections without buttressing (except for unilateral buttressing in several of the latter patients as part of an intrapatient comparison trial) according to their pattern of emphysema determined by CT and perfusion scanning. RESULTS Thirty day mortality was 5.5%. Follow-up pulmonary function is available for 44 patients, and demonstrates a mean 51% improvement in FEV1, and significant improvement in FVC, PaO2, dyspnoea indices and walking distance, with a reduction in mean RV, TLC, PaCO2. FEV1 improvement is maintained above baseline at three years. Lower lobe surgery outcomes are at least as good as their upper lobe counterparts. CONCLUSIONS Outcomes confirm improvements reported elsewhere, and suggest that videoscopic resection may provide worthwhile benefit to lower lobe patterns of emphysema. Other managment issues are discussed.
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Affiliation(s)
- S H Porter
- Division of Medicine, The Queen Elizabeth Hospital, Campus, North West Adelaide Health Service, SA
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Buettner AU, McRae R, Myles PS, Snell GI, Bujor MA, Silvers A, Weeks AM. Anaesthesia and postoperative pain management for bilateral lung volume reduction surgery. Anaesth Intensive Care 1999; 27:503-8. [PMID: 10520392 DOI: 10.1177/0310057x9902700512] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Bilateral lung volume reduction surgery was introduced into Australia in 1995 for treatment of selected patients with emphysema. We present our experience of the anaesthetic management of our first 55 cases and describe factors associated with outcome. There were four postoperative deaths (7%). Mean (SD) total operation time was 231 (72) minutes. Median intensive care unit (ICU) stay was 26 hours. There was a significant improvement in postoperative lung function (FEV1, VC, 6-minute walk test, all P < 0.001). Eight patients (15%) required reintubation for respiratory failure; three of these patients subsequently died. With multivariate analysis, total operation time was the only significant predictor of length of ICU stay R2 = 0.25, P = 0.001), which itself was the only significant predictor of hospital stay duration (R2 = 0.36, P < 0.001).
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Affiliation(s)
- A U Buettner
- Department of Anaesthesia and Pain Management, Alfred Hospital, Melbourne, Victoria
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Abstract
Over the past several decades, a number of surgical techniques have been developed for the treatment of chronic obstructive pulmonary disease. Many of these procedures have been abandoned because of lack of efficacy and/or high morbidity and mortality. At the present time, lung transplantation, reduction pneumoplasty for giant bullous emphysema, and lung volume reduction surgery are being performed in a number of centers. Data concerning the effectiveness of these procedures is accumulating and will ultimately need careful analysis to determine long-term outcomes in this group of patients.
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Affiliation(s)
- D K Payne
- Department of Medicine, Section of Pulmonary and Critical Care, Louisiana State University Medical Center at Shreveport, 71130-3932, USA.
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Keith Payne D, Markewitz BA, Owens MW. Surgical Treatment of Chronic Obstructive Pulmonary Disease. Am J Med Sci 1999. [DOI: 10.1016/s0002-9629(15)40588-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Antunes MJ. Cirurgia de redução de volume no enfisema pulmonar**Conferêcia proferida nas I Jornadas de Pneumologia do Centro Hospitalar do Funchal. Março. 1999. REVISTA PORTUGUESA DE PNEUMOLOGIA 1999. [DOI: 10.1016/s0873-2159(15)30993-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Carr-Lopez S, Salem H, Catania PN. Medication use in home care patients with COPD. HOME CARE PROVIDER 1998; 3:144-8. [PMID: 9782845 DOI: 10.1016/s1084-628x(98)90321-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is the fourth-leading cause of death in the United States. Although many other diseases have seen a gradual decline in their associated mortality, COPD rates have increased nearly 33% from 1979 to 1991. The disease is defined as a slowly progressive obstruction of airflow that is predominantly irreversible. COPD usually begins in the fifth decade of life as an increased cough. Dyspnea on exertion is frequently observed in the sixth or seventh decade.
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Affiliation(s)
- S Carr-Lopez
- Department of Pharmacy Practice, School of Pharmacy, University of the Pacific, Stockton, Calif. 95211, USA
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