Excerpted from the ACPNet Quality Improvement Project on COPD, this chapter provides an overview of the following topics:

• Managing patients' nutritional status
• Assessing for GERD symptoms
• Assessing for disordered sleep
• Assessing for anxiety and depression

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Noninvasive positive-pressure ventilation (NPPV) consists of the provision of positive-pressure ventilation without the need for an invasive airway. Consisting of a ventilator that delivers pressurized gas to the upper airway via tubing attached to a mask strapped to the face, NPPV has assumed an important role in the management of acute and chronic respiratory failure. Although not a form of assisted ventilation because it does not actively assist inhalation, CPAP alone, administered noninvasively, reduces the work of breathing in COPD, thereby counterbalancing intrinsic (auto-) PEEP and effectively reducing or even eliminating the inspiratory threshold load (Figure 10). By increasing airway pressure during inspiration, pressure support alone also reduces work of breathing in COPD. However, the combination of pressure support and PEEP reduces the work of breathing in patients with COPD more than either modality alone.

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Volume-limited or pressure-limited modes can be used, but volume-limited assist/control is the most frequent initial choice. The challenge in ventilating COPD patients is to avoid excessive minute volume that contributes to dynamic hyperinflation (auto-PEEP) and alkalemia that results from the compensatory metabolic alkalosis for chronic hypercarbia. Tidal volume should be kept small (for example, 5-7 mL/kg ideal body weight) and backup respiratory rate should be set between 10 and 14/min. A lower rate increases the cycle time, which permits more time for exhalation and emptying of the lung. Shortening inspiratory time is another way to increase expiratory time, accomplished by increasing the inspiratory flow rate. This strategy is not as fruitful as lowering respiratory rate because substantial increases in flow rate result in only minor increases in expiratory time, and flow rates above 60 L/min may add to patient discomfort.

Note: Subscription to MKSAP 14 is required to view this material. For more information, visit www.acponline.org.

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Joseph W. Stubbs, MD, FACP, president of the American College of Physicians (ACP) and a practicing internist, knows all too well that the number of people who get vaccinated against the flu typically drops after November. But flu viruses can circulate into February -- even into the spring and summer.

Between April and November 2009, the H1N1 virus infected more than 45 million Americans, resulting in more than 200,000 hospitalizations and nearly 10,000 deaths.

Pregnant women, health care and emergency medical service providers, children, young adults under the age of 25, and adults between the ages of 25 to 64 with an underlying chronic medical condition are at higher risk for serious H1N1 flu complications. It also is important for people who live with or provide care for infants less than 6 months old to be vaccinated.

Complications of H1N1 flu can include bacterial pneumonia, dehydration, and worsening of chronic medical conditions, such as congestive heart failure, asthma, or diabetes.

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Question
In patients with stable chronic obstructive pulmonary disease (COPD), how effective and safe is the combination of inhaled long-acting β2-agonists (LABAs) plus inhaled corticosteroids (ICSs) compared with LABAs alone?

Conclusion
In patients with stable chronic obstructive pulmonary disease, the combination of inhaled long-acting β2-agonists (LABAs) plus inhaled corticosteroids is not more effective than LABAs alone.

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Question
Which patient- and procedure-related factors and test results predict postoperative pulmonary complications (PPCs) after noncardiothoracic surgery?

Conclusion
Certain surgical sites (especially abdominal aortic aneurysm repair, thoracic surgery, and abdominal surgery) and patient characteristics (such as advanced age and presence of comorbid conditions) are associated with increased risk for postoperative pulmonary complications after noncardiothoracic surgery.

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Postoperative pulmonary complications play an important role in the risk for patients undergoing noncardiothoracic surgery. Postoperative pulmonary complications are as prevalent as cardiac complications and contribute similarly to morbidity, mortality, and length of stay. Pulmonary complications may even be more likely than cardiac complications to predict long-term mortality after surgery. The purpose of this guideline is to provide guidance to clinicians on clinical and laboratory predictors of perioperative pulmonary risk before noncardiothoracic surgery. It also evaluates strategies to reduce the perioperative pulmonary risk and focuses on atelectasis, pneumonia, and respiratory failure. The target audience for this guideline is general internists or other clinicians involved in perioperative management of surgical patients. The target patient population is all adult persons undergoing noncardiothoracic surgery.

*This paper, written by Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Nick Fitterman, MD; E. Rodney Hornbake, MD; Valerie A. Lawrence, MD; Gerald W. Smetana, MD; Kevin Weiss, MD, MPH; and Douglas K. Owens, MD, MS, was developed for the Clinical Efficacy Assessment Subcommittee of the American College of Physicians (ACP): Douglas K. Owens, MD, MS (Chair); Mark Aronson, MD; Patricia Barry, MD, MPH; Donald E. Casey Jr., MD, MPH, MBA; J. Thomas Cross Jr., MD, MPH; Nick Fitterman, MD; E. Rodney Hornbake, MD; Katherine D. Sherif, MD; and Kevin B. Weiss, MD, MPH (Immediate Past Chair). Approved by the ACP Board of Regents on 21 January 2006.

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Background:

The importance of clinical risk factors for postoperative pulmonary complications and the value of preoperative testing to stratify risk are the subject of debate.

Purpose:

To systematically review the literature on preoperative pulmonary risk stratification before noncardiothoracic surgery.

Data Sources:

MEDLINE search from 1 January 1980 through 30 June 2005 and hand search of the bibliographies of retrieved articles.

Study Selection:

English-language studies that reported the effect of patient- and procedure-related risk factors and laboratory predictors on postoperative pulmonary complication rates after noncardiothoracic surgery and that met predefined inclusion criteria.

Data Extraction:

The authors used standardized abstraction instruments to extract data on study characteristics, hierarchy of research design, study quality, risk factors, and laboratory predictors.

Data Synthesis:

The authors determined random-effects pooled estimate odds ratios and, when appropriate, trim-and-fill estimates for patient- and procedure-related risk factors from studies that used multivariable analyses. They assigned summary strength of evidence scores for each factor. Good evidence supports patient-related risk factors for postoperative pulmonary complications, including advanced age, American Society of Anesthesiologists class 2 or higher, functional dependence, chronic obstructive pulmonary disease, and congestive heart failure. Good evidence supports procedure-related risk factors for postoperative pulmonary complications, including aortic aneurysm repair, nonresective thoracic surgery, abdominal surgery, neurosurgery, emergency surgery, general anesthesia, head and neck surgery, vascular surgery, and prolonged surgery. Among laboratory predictors, good evidence exists only for serum albumin level less than 30 g/L. Insufficient evidence supports preoperative spirometry as a tool to stratify risk.

Limitations:

For certain risk factors and laboratory predictors, the literature provides only unadjusted estimates of risk. Prescreening, variable selection algorithms, and publication bias limited reporting of risk factors among studies using multivariable analysis.

Conclusions:

Selected clinical and laboratory factors allow risk stratification for postoperative pulmonary complications after noncardiothoracic surgery.

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