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García García MDC, Hernández Borge J, García García GM, Márquez Pérez FL. Supervivencia en pacientes con EPOC en tratamiento con oxigenoterapia continua domiciliaria. OPEN RESPIRATORY ARCHIVES 2021. [PMID: 37496844 PMCID: PMC10369520 DOI: 10.1016/j.opresp.2021.100119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Introduction Continuous home oxygen therapy (CHOT), along with smoking cessation, is the first treatment that has been shown to increase the survival of patients with chronic obstructive pulmonary disease (COPD) and chronic hypoxemia. Objective To determine survival in a cohort of COPD patients receiving CHOT and to analyze the main causes and risk factors associated with their mortality. Methods Prospective study of a cohort of COPD patients receiving CHOT. Numerous variables, including survival and cause of death at the end of follow-up, were collected. Results A total of 409 COPD patients receiving CHOT were included (85.6% men; mean age: 71.27 ± 9.74 years). Mean time of CHOT follow-up was 5.86 ± 3.24 years and median survival was 6 years (95% CI: 5.47-6.53). Mortality at the end of follow-up was 75.8%, the leading cause of death being respiratory (36.9%). Longer survival was significantly associated with lower age, correct CHOT compliance, absence of exacerbations in the previous year, use of long-acting anticholinergics (LAMA), less severe COPD, presence of sleep apnea-hypopnea syndrome/obesity hypoventilation syndrome (SAHS/SHO), absence of malignant disease, heart disease, cerebrovascular disease, and kidney disease. Conclusions The survival of COPD patients receiving CHOT was very long. The main causes of mortality were respiratory (36.9%). Independent predictors of mortality were age, presence of exacerbations in the previous year, previous diagnosis of cancer, and presence of cerebrovascular and renal disease.
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Suissa S, Ernst P. Observational Studies of Inhaled Corticosteroid Effectiveness in COPD: Lessons Learned. Chest 2018; 154:257-265. [PMID: 29679596 DOI: 10.1016/j.chest.2018.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 04/03/2018] [Accepted: 04/06/2018] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Randomized controlled trials at times investigate findings suggested by observational studies. For example, the Towards a Revolution in COPD Health (TORCH) trial, which did not show a mortality reduction with inhaled corticosteroids (ICS) in COPD, was motivated by some observational studies that suggested considerable reductions in mortality with these drugs. Reasons for these discrepancies are unclear. METHODS The literature was searched to identify all observational studies, including cohort and case-control studies, investigating the effectiveness of ICS on major outcomes in patients with COPD; these outcomes included death and hospitalization for COPD. RESULTS A total of 21 studies were identified. Nine studies were affected by immortal time bias, five by immeasurable time bias, and seven by the "asthma factor" bias; some studies were affected by more than one bias. These studies found important reductions in the rates of major COPD outcomes with ICS use, with pooled rate ratios of 0.71 (95% CI, 0.67-0.76), 0.76 (95% CI, 0.70-0.83), and 0.79 (95% CI, 0.73-0.87), respectively, for the three sources of bias. In contrast, the five studies unaffected by these major biases did not find an association (pooled rate ratio, 1.02 [95% CI, 0.88-1.17]). CONCLUSIONS Observational studies are important to provide evidence from real-world data on medication effects. However, appropriate study design and analysis are essential to avoid biases and ensure randomized trials with greater chances of success. The observational studies suggesting potential beneficial effects of nonrespiratory drugs to treat COPD, such as statins and beta-blockers, will also need careful review before long and expensive randomized trials are conducted.
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Affiliation(s)
- Samy Suissa
- Center for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, and the Departments of Epidemiology and Biostatistics and of Medicine, McGill University, Montreal, QC, Canada.
| | - Pierre Ernst
- Center for Clinical Epidemiology, Lady Davis Institute-Jewish General Hospital, and the Departments of Epidemiology and Biostatistics and of Medicine, McGill University, Montreal, QC, Canada
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Di Martino M, Agabiti N, Cascini S, Kirchmayer U, Bauleo L, Fusco D, Belleudi V, Pinnarelli L, Voci C, Patorno E, Pistelli R, Davoli M. The Effect on Total Mortality of Adding Inhaled Corticosteroids to Long-Acting Bronchodilators for COPD: A Real Practice Analysis in Italy. COPD 2015; 13:293-302. [DOI: 10.3109/15412555.2015.1044861] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Mirko Di Martino
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Nera Agabiti
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Silvia Cascini
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Ursula Kirchmayer
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Lisa Bauleo
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Danilo Fusco
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Valeria Belleudi
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Luigi Pinnarelli
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
| | - Claudio Voci
- Management Control Unit, Modena University Hospital, Modena, Italy
| | - Elisabetta Patorno
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Riccardo Pistelli
- Department of Respiratory Physiology, Catholic University, Roma, Italy
| | - Marina Davoli
- Department of Epidemiology, Lazio Regional Health Service, Roma, Italy
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Menezes AMB, Macedo SEC, Noal RB, Fiterman J, Cukier A, Chatkin JM, Fernandes FLA. Pharmacological treatment of COPD. J Bras Pneumol 2012; 37:527-43. [PMID: 21881744 DOI: 10.1590/s1806-37132011000400016] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Accepted: 06/21/2011] [Indexed: 11/21/2022] Open
Abstract
Approximately seven million Brazilians over 40 years of age have COPD. In recent years, major advances have been made in the pharmacological treatment of this condition. We performed a systematic review including original articles on pharmacological treatments for COPD. We reviewed articles written in English, Spanish, or Portuguese; published between 2005 and 2009; and indexed in national and international databases. Articles with a sample size < 100 individuals were excluded. The outcome measures were symptoms, pulmonary function, quality of life, exacerbations, mortality, and adverse drug effects. Articles were classified in accordance with the Global Initiative for Chronic Obstructive Lung Disease criteria for the determination of the level of scientific evidence (grade of recommendation A, B, or C). Of the 84 articles selected, 40 (47.6%), 18 (21.4%), and 26 (31.0%) were classified as grades A, B, and C, respectively. Of the 420 analyses made in these articles, 236 were regarding the comparison between medications and placebos. Among these 236 analyses, the most commonly studied medications (in 66, 48, and 42 analyses, respectively) were long-acting anticholinergics; the combination of long-acting β(2) agonists and inhaled corticosteroids; and inhaled corticosteroids in isolation. Pulmonary function, adverse effects, and symptoms as outcomes generated 58, 54, and 35 analyses, respectively. The majority of the studies showed that the medications evaluated provided symptom relief; improved the quality of life and pulmonary function of patients; and prevented exacerbations. Few studies analyzed mortality as an outcome, and the role that pharmacological treatment plays in this outcome has yet to be fully defined. The medications studied are safe to use in the management of COPD and have few adverse effects.
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Affiliation(s)
- Ana Maria Baptista Menezes
- Graduate Program in Epidemiology, Department of Social Medicine, Federal University of Pelotas School of Medicine, Pelotas, Brazil.
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Abstract
The randomized controlled trial is the fundamental study design to evaluate the effectiveness of medications and receive regulatory approval. Observational studies, on the other hand, are essential to address post-marketing drug safety issues but have also been used to uncover new indications or new benefits for already marketed drugs. Hormone replacement therapy (HRT) for instance, effective for menopausal symptoms, was reported in several observational studies during the 1980s and 1990s to also significantly reduce the incidence of coronary heart disease. This claim was refuted in 2002 by the large-scale Women's Health Initiative randomized trial. An example of a new indication for an old drug is that of metformin, an anti-diabetic medication, which is being hailed as a potential anti-cancer agent, primarily on the basis of several recent observational studies that reported impressive reductions in cancer incidence and mortality with its use. These observational studies have now sparked the conduct of large-scale randomized controlled trials currently ongoing in cancer. We show in this paper that the spectacular effects on new indications or new outcomes reported in many observational studies in chronic obstructive pulmonary disease (COPD), HRT, and cancer are the result of time-related biases, such as immortal time bias, that tend to seriously exaggerate the benefits of a drug and that eventually disappear with the proper statistical analysis. In all, while observational studies are central to assess the effects of drugs, their proper design and analysis are essential to avoid bias. The scientific evidence on the potential beneficial effects in new indications of existing drugs will need to be more carefully assessed before embarking on long and expensive unsubstantiated trials.
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Newton R, Leigh R, Giembycz MA. Pharmacological strategies for improving the efficacy and therapeutic ratio of glucocorticoids in inflammatory lung diseases. Pharmacol Ther 2009; 125:286-327. [PMID: 19932713 DOI: 10.1016/j.pharmthera.2009.11.003] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2009] [Accepted: 11/02/2009] [Indexed: 10/20/2022]
Abstract
Glucocorticoids are widely used to treat various inflammatory lung diseases. Acting via the glucocorticoid receptor (GR), they exert clinical effects predominantly by modulating gene transcription. This may be to either induce (transactivate) or repress (transrepress) gene transcription. However, certain individuals, including those who smoke, have certain asthma phenotypes, chronic obstructive pulmonary disease (COPD) or some interstitial diseases may respond poorly to the beneficial effects of glucocorticoids. In these cases, high dose, often oral or parental, glucocorticoids are typically prescribed. This generally leads to adverse effects that compromise clinical utility. There is, therefore, a need to enhance the clinical efficacy of glucocorticoids while minimizing adverse effects. In this context, a long-acting beta(2)-adrenoceptor agonist (LABA) can enhance the clinical efficacy of an inhaled corticosteroid (ICS) in asthma and COPD. Furthermore, LABAs can augment glucocorticoid-dependent gene expression and this action may account for some of the benefits of LABA/ICS combination therapies when compared to ICS given as a monotherapy. In addition to metabolic genes and other adverse effects that are induced by glucocorticoids, there are many other glucocorticoid-inducible genes that have significant anti-inflammatory potential. We therefore advocate a move away from the search for ligands of GR that dissociate transactivation from transrepression. Instead, we submit that ligands should be functionally screened by virtue of their ability to induce or repress biologically-relevant genes in target tissues. In this review, we discuss pharmacological methods by which selective GR modulators and "add-on" therapies may be exploited to improve the clinical efficacy of glucocorticoids while reducing potential adverse effects.
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Affiliation(s)
- Robert Newton
- Department of Cell Biology and Anatomy, Airway Inflammation Group, Institute of Infection, Immunity and Inflammation, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Abstract
Chronic obstructive pulmonary disease (COPD) is a multi-component disease characterised by airflow limitation and airway inflammation. Exacerbations of COPD have a considerable impact on the quality of life, daily activities and general well-being of patients and are a great burden on the health system. Thus, the aims of COPD management include not only relieving symptoms and preventing disease progression but also preventing and treating exacerbations. Attention towards the day-to-day burden of the disease is also required in light of evidence that suggests COPD may be variable throughout the day with morning being the time when symptoms are most severe and patients' ability to perform regular morning activities the most problematic. While available therapies improve clinical symptoms and decrease airway inflammation, they do not unequivocally slow long-term progression or address all disease components. With the burden of COPD continuing to increase, research into new and improved treatment strategies to optimise pharmacotherapy is ongoing - in particular, combination therapies, with a view to their complementary modes of action enabling multiple components of the disease to be addressed. Evidence from recent clinical trials indicates that triple therapy, combining an anticholinergic with an inhaled corticosteroid and a long-acting beta(2)-agonist, may provide clinical benefits additional to those associated with each treatment alone in patients with more severe COPD. This article reviews the evidence for treatment strategies used in COPD with a focus on combination therapies and introduces the 3-month CLIMB study (Evaluation of Efficacy and Safety of Symbicort as an Add-on Treatment to Spiriva in Patients With Severe COPD) which investigated the potential treatment benefits of combining tiotropium with budesonide/formoterol in patients with COPD with regard to lung function, exacerbations, symptoms and morning activities.
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Affiliation(s)
- T Welte
- Department of Respiratory Medicine, Hannover Medical School, Carl-Neuberg-Strasse 1, Hannover, Germany.
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Suissa S. Controverses méthodologiques sur les essais thérapeutiques dans la bronchopneumopathie chronique obstructive. Presse Med 2009; 38:445-51. [DOI: 10.1016/j.lpm.2008.12.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Accepted: 12/31/2008] [Indexed: 12/19/2022] Open
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Identifying COPD patients at increased risk of mortality: Predictive value of clinical study baseline data. Respir Med 2008; 102:1615-24. [DOI: 10.1016/j.rmed.2008.05.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2007] [Revised: 05/08/2008] [Accepted: 05/12/2008] [Indexed: 11/20/2022]
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Abstract
Systemic and local inflammation is central to the pathophysiology of chronic obstructive pulmonary disease (COPD). Increased levels of inflammation have been linked to a more progressive course in COPD and have been shown to be present during an exacerbation. Decreases in inflammatory cytokines, C-reactive protein, and inflammatory cells have been observed with corticosteroid use, suggesting a possible mechanism for a therapeutic benefit of steroids. No available data support the routine use of systemic corticosteroids in stable COPD; however, short courses during exacerbations are likely to improve length of hospitalization, lung function, and relapse rate. Inhaled corticosteroids (ICS) decrease the rate of exacerbation and may improve the response to bronchodilators and decrease dyspnea in stable COPD. No study shows that ICS reduce the loss of lung function; however, recent data suggest a possible survival benefit when combined with long-acting beta agonists. There are limited data on the use of ICS in the treatment of acute exacerbations of COPD, and its role in this setting must be more clearly defined. The empiric use of systemic corticosteroids perioperatively represents another area of uncertainty. The role of pharmacogenetics in the metabolism of corticosteroids in COPD is evolving but may be partially responsible for the observed variability in patient responsiveness. The potential benefits of systemic or inhaled corticosteroid use must be weighed against the risk of known toxicities.
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Abstract
Mortality due to chronic obstructive pulmonary disease continues to rise, whereas mortality rates related to cardiovascular disease appear to be slowing, or even declining. This is due at least in part to more widespread use of preventative therapies that have been shown to reduce cardiovascular mortality, raising the question of whether appropriate use of therapies for chronic obstructive pulmonary disease which potentially reduce mortality could have a similar impact. This article discusses approaches used successfully in managing heart disease and considers whether these can be applied to chronic obstructive pulmonary disease and whether a better understanding of the strongest predictors of mortality in chronic obstructive pulmonary disease is needed. It reviews the role of inhaled corticosteroids, both alone and in combination with long-acting beta(2)-agonists, in individuals with chronic obstructive pulmonary disease, including the role of combination therapy with inhaled corticosteroids/long-acting beta(2)-agonists (budesonide/formoterol or salmeterol/fluticasone propionate) in decreasing exacerbations and improving health status, potentially providing survival benefits in chronic obstructive pulmonary disease. This review also discusses the potential impact of treatments indicated for cardiovascular disease on chronic obstructive pulmonary disease and possible links between the two diseases.
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Affiliation(s)
- David Halpin
- Royal Devon & Exeter Hospital Barrack Road Exeter EX2 5DW, UK.
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12
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One hundred years of respiratory medicine chronic obstructive pulmonary disease (COPD)—Republished article. ACTA ACUST UNITED AC 2008. [DOI: 10.1016/j.rmedu.2007.11.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Giembycz MA, Kaur M, Leigh R, Newton R. A Holy Grail of asthma management: toward understanding how long-acting beta(2)-adrenoceptor agonists enhance the clinical efficacy of inhaled corticosteroids. Br J Pharmacol 2007; 153:1090-104. [PMID: 18071293 DOI: 10.1038/sj.bjp.0707627] [Citation(s) in RCA: 107] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
There is unequivocal evidence that the combination of an inhaled corticosteroid (ICS) -- i.e. glucocorticoid -- and an inhaled long-acting beta(2)-adrenoceptor agonist (LABA) is superior to each component administered as a monotherapy alone in the clinical management of asthma. Moreover, Calverley and colleagues (Lancet 2003, 361: 449-456; N Engl J Med 2007, 356: 775-789) reporting for the 'TRial of Inhaled STeroids ANd long-acting beta(2)-agonists (TRISTAN)' and 'TOwards a Revolution in COPD Health (TORCH)' international study groups also demonstrated the superior efficacy of LABA/ICS combination therapies over ICS alone in the clinical management of chronic obstructive pulmonary disease. This finding has been independently confirmed indicating that the therapeutic benefit of LABA/ICS combination therapies is not restricted to asthma and may be extended to other chronic inflammatory diseases of the airways. Despite the unquestionable benefit of LABA/ICS combination therapies, there is a vast gap in our understanding of how these two drugs given together deliver superior clinical efficacy. In this article, we review the history of LABA/ICS combination therapies and critically evaluate how these two classes of drugs might interact at the biochemical level to suppress pro-inflammatory responses. Understanding the molecular basis of this fundamental clinical observation is a Holy Grail of current respiratory diseases research as it could permit the rational exploitation of this effect with the development of new 'optimized' LABA/ICS combination therapies.
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Affiliation(s)
- M A Giembycz
- Department of Pharmacology and Therapeutics, Institute of Infection, Immunity and Inflammation, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada.
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Abstract
BACKGROUND Chronic obstructive pulmonary disease (COPD) is a common multi-component disease that imposes an enormous burden on the patient, the healthcare professional and the society in terms of morbidity, mortality, healthcare resource utilisation and cost. Despite the availability of several comprehensive treatment guidelines, COPD is both under-diagnosed and misdiagnosed. Some of the factors contributing to this are a poor knowledge and low adherence to guideline recommendations, on the part of some healthcare professionals, and a lack of understanding of the significance and severity of the disease, on the part of patients. However, evidence suggests that COPD is both preventable and treatable when it is diagnosed early and treated effectively. Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines suggest that the key to early diagnosis is the recognition of the clinical features of persistent cough, chronic sputum production, breathlessness on exertion and a history of exposure to tobacco smoke. Primary care clinicians can play a crucial role in early diagnosis of at-risk subjects. They can educate patients to recognise the early symptoms of COPD, avoid the risk factors, such as smoking, and encourage early presentation to a primary care professional. Similarly, evidence suggests that effective implementation of non-pharmacological and pharmacological interventions can improve the management of COPD patients at the primary care level. OBJECTIVES The aim of this review is to discuss the role of the primary care team in the early diagnosis and effective management of COPD, and to outline education initiatives and management strategies that can be implemented in primary care.
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Affiliation(s)
- D Bellamy
- Bournemouth and Poole PCT, Bournemouth, UK.
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Sin DD, Man SFP. Do chronic inhaled steroids alone or in combination with a bronchodilator prolong life in chronic obstructive pulmonary disease patients? Curr Opin Pulm Med 2007; 13:90-7. [PMID: 17255798 DOI: 10.1097/mcp.0b013e3280142021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Inhaled corticosteroids with or without long-acting beta2 adrenergic agonists are commonly used to treat patients with chronic obstructive pulmonary disease to attenuate symptoms and to prevent exacerbations. Whether these medications prolong survival is uncertain. RECENT FINDINGS Inhaled corticosteroids attenuate airway and systemic inflammation, reduce airway hyperreactivity, improve patient symptoms and prevent exacerbations in chronic obstructive pulmonary disease patients. The data on mortality are mixed. A pooled analysis of published randomized controlled trials indicated that inhaled corticosteroids reduced mortality by around 25%; however other studies have failed to show a beneficial effect on mortality. The addition of long-acting beta2 adrenergic agonists to inhaled corticosteroids enhances the clinical effectiveness of these medications and confers incremental mortality benefits to patients. Interestingly, these medications appear to be especially beneficial in reducing cardiovascular morbidity and mortality, though large randomized controlled trials powered specifically on these endpoints are needed to confirm these early findings. SUMMARY Inhaled corticosteroids, especially with long-acting beta2 adrenergic agonists, reduce airway inflammation and appear to prolong survival in chronic obstructive pulmonary disease patients. They may be particularly effective in reducing cardiovascular morbidity and mortality of patients, pending confirmation by additional clinical studies powered specifically on these endpoints.
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Affiliation(s)
- Don D Sin
- The University of British Columbia (Respiratory Division), Vancouver, British Columbia, Canada.
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Abstract
Chronic obstructive pulmonary disease (COPD) is an increasing health problem and one of the leading causes of morbidity and mortality worldwide, but knowledge about its pathogenesis has increased substantially in recent years. The disease results from interaction between individual risk factors (like enzymatic deficiencies) and environmental exposures to noxious agents, like cigarette smoking, occupational dusts, air pollution and infections in childhood. The main mechanisms that may contribute to airflow limitation in COPD are fixed narrowing of small airways, emphysema and luminal obstruction with mucus secretions. COPD is characterised by a chronic inflammatory process in the pulmonary tissue, with a pattern different from bronchial asthma, associated with extrapulmonary effects and is considered now a complex, systemic disease. Optimal therapeutic targeting of COPD depends on a clear understanding of the precise mechanisms of these complex processes and on early and correct evaluation of disease severity. A combination of pharmacological and non-pharmacological approaches is used to treat COPD. Bronchodilators are the mainstay of COPD treatment and can be combined with inhaled corticosteroids for greater efficacy and fewer side effects. The use of LTOT for hypoxemic patients has resulted in increased survival, and expanded drug therapy options have effectively improved dyspnoea and quality of life. Recent studies have documented the benefits of pulmonary rehabilitation. In addition, non-invasive mechanical ventilation offers new alternatives for patients with acute or chronic failure.
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Affiliation(s)
- Mario Cazzola
- Department of Internal Medicine, Unit of Respiratory Diseases, University of Rome Tor Vergata, Rome, Italy.
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