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High-intensity non-invasive positive pressure ventilation for stable hypercapnic COPD

Wolfram Windisch, Moritz Haenel, Jan H Storre, Michael Dreher


Department of Pneumology, University Hospital Freiburg, Germany

Abstract
Background: The objective of the present analysis is to describe the outcomes of high-intensity non-invasive positive pressure ventilation (NPPV) aimed at maximally decreasing PaCO2 as an alternative to conventional NPPV with lower ventilator settings in stable hypercapnic COPD patients. Methods: Physiological parameters, exacerbation rates and long-term survival

were assessed in 73 COPD patients (mean FEV1 3012 %predicted) who were established on highintensity NPPV due to chronic hypercapnic respiratory failure between March 1997 and May 2006. Results: Controlled NPPV with breathing frequencies of 213 breath/min and mean inspiratory/expiratory positive airway pressures of 285/51 cmH2O led to significant improvements in blood gases, lung function

and hematocrit after two months. Only sixteen patients (22%) required hospitalisation due to exacerbation during the first year, with anaemia increasing the risk for exacerbation. Two- and five-year survival rates of all patients were 82% and 58%, respectively. The five year survival rate was 32% and 83% in patients with low (39%) and high (55%) hematocrit, respectively.

Conclusion: High-intensity NPPV improves blood gases, lung function and hematocrit, and is also associated with low exacerbation rates and a favourable long-term outcome. The current report strongly emphasises the need for randomised controlled trials evaluating the role of high-intensity NPPV in stable hypercapnic COPD patients. Keywords: COPD, exacerbation, hematocrit,

non-invasive ventilation, survival

Trends in Chronic Obstructive Pulmonary Disease Prevalence, Incidence, and Mortality in

Ontario, Canada, 1996 to 2007A PopulationBased StudyFREE


Andrea S. Gershon, MD, MSc, FRCPC; Chengning Wang, MD, MSc; Andrew S. Wilton, MSc; Roxana Raut, MSc; Teresa To, PhD [+] Author Affiliations

ABSTRACT

ABSTRACT | METHODS | RESULTS | COMMENT | AUTHOR INFORMATION | REFERENCES

Background Chronic
obstructive pulmonary disease (COPD) is a preventable and treatable disease with a prevalence of more than 10% worldwide among adults 40 years and older. Whether this amount has been increasing, decreasing, or stable over time remains unknown.

Methods A longitudinal
cohort study using populationbased, health administrative data from 1991 to 2007 was conducted in Ontario, Canada. Individuals with COPD were identified using a previously validated health administrative case definition of COPD. Annual COPD prevalence, incidence, and all-cause mortality rates were estimated from 1996 to 2007.

Results The prevalence of


COPD increased by 64.8% between 1996 and 2007. The age- and sex-standardized COPD prevalence rate increased from 7.8% to 9.5%, representing a relative increase of 23.0% (P < .001). The age- and sexstandardized incidence decreased from 11.8 per 1000 adults to 8.5 per 1000 adults, representing a relative decrease of 28.3% (P < .001). Finally, the age- and sex-standardized allcause mortality rate decreased

from 5.7% to 4.3%, representing a relative decrease of 24.0% (P < .001).

Conclusions Our findings


indicate a substantial increase in COPD prevalence in the last decade, with more of the burden being shifted from men to women. Effective clinical and public health strategies are needed to prevent COPD and manage the increasing number of people living longer with this disease.

Congestive heart failure in dialysis patients: Prevalence, incidence, prognosis and risk factors
John D Harnett1, Robert N Foley1, Gloria M Kent1, Paul E Barre1, David Murray1 and Patrick S Parfrey1
1

Division of Nephrology and Clinical Epidemiology, Memorial University of Newfoundland and the Division of Nephrology, McGill University, Montreal, Canada Correspondence: Dr JD Harnett, Associate Professor of Medicine, Division of Nephrology, Health Sciences Centre, St. John's, Newfoundland, Canada A1B 3V6. Received 8 August 1994; Revised 3 October 1994; Accepted 3 October 1994. Top of page

ABSTRACT
Congestive heart failure in dialysis patients: Prevalence, incidence, prognosis and risk factors. Cardiovascular disease is the most common cause of death in dialysis subjects. Congestive heart failure (CHF) is a common presenting symptom of cardiovascular disease in the dialysis population. Information regarding prevalence, incidence, risk factors and prognosis is crucial for planning rational interventional studies. A prospective multicenter cohort study of 432 dialysis patients followed for a mean of 41 months was carried out. Prospective information on a variety of risk factors was collected. Annual echocardiography and clinical assessment was performed. Major endpoints included death and the development of morbid cardiovascular events. One hundred and thirty-three (31%) subjects had CHF at the time of initiation of dialysis therapy. Multivariate analysis showed that the following risk factors were significantly and independently associated with CHF at baseline: systolic dysfunction, older age, diabetes mellitus and ischemic heart disease. Seventy-six of 299 subjects (25%) who did not have baseline CHF subsequently developed CHF during their course on dialysis. Compared to those subjects who never developed CHF (N = 218) multivariate analysis identified the following risk factors for the development of CHF: older age, anemia during dialysis therapy, hypoalbuminemia, hypertension during dialysis therapy, and systolic dysfunction. Seventy-five of the 133 (56%) subjects with CHF at baseline had recurrent CHF during follow-up. Independent and significant risk factors for CHF recurrence were ischemic heart disease and systolic dysfunction, anemia during dialysis therapy and hypoalbuminemia. The median survival of subjects with CHF at baseline was 36 months compared to 62 months in subjects without CHF. In this study the prevalence of CHF on starting ESRD therapy and the subsequent annual incidence was high. CHF was a strong, independent, adverse prognostic indicator. Risk factors for CHF include older age, pre-existing cardiac diseases (systolic dysfunction and ischemic heart disease), and potentially reversible abnormalities related to chronic uremia (anemia, hypertension and hypoalbuminemia).

http://www.nature.com/ki/journal/v47/n3/abs/ki1995132a.html http://jco.ascopubs.org/content/early/2011/01/04/JCO.2010.31.9129.abstract http://aje.oxfordjournals.org/content/160/7/628.abstract

Pacing in congestive heart failure


Jayne A Morris-Thurgood and Michael P Frenneaux*

Abstract
Despite the major advances in medical drug therapy, heart failure remains a syndrome associated with high mortality and morbidity. Biventricular or left ventricular (LV) short atrioventricular (AV) delay pacing is being tested in congestive heart failure patients with left bundle branch block. The aim is to resynchronise the dyscoordinate LV contraction. A number of studies are underway, but it is clear that while some patients respond remarkably, this is highly variable. Accurate identification of patients likely to benefit will be crucial. The mechanism of benefit is unclear. A greater understanding of the physiological consequences of pacing will be necessary to accurately identify these patients.

Keywords:
bundle branch block; haemodynamics; heart failure; pacing