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June 16, 1989, Vol 261, No. 23 >
ARTICLE | June 16, 1989

Acute on Chronic Respiratory Failure: Title and subTitle BreakAssessment and Management of Patients With COPD in the Emergent Setting FREE

Gregory A. Schmidt, MD; Jesse B. Hall, MD
[+] Author Affiliations

Reprint requests to Department of Medicine, Box 83, The University of Chicago, 5841 S Maryland Ave, Chicago, IL 60637 (Dr Schmidt).


JAMA. 1989;261(23):3444-3453. doi:10.1001/jama.1989.03420230098035
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References

Patients with acute on chronic respiratory failure exhibit severe pulmonary impairment as a baseline characteristic. Additional minor insults can precipitate cardiopulmonary failure that requires hospital admission and possibly mechanical ventilation. Our approach to these patients emphasizes evaluation of the imbalance between neuromuscular competence and mechanical load on the respiratory system. In this way, reversible factors can be identified and corrected before they progress to inspiratory muscle fatigue and respiratory failure. For cases in which deterioration is inexorable, guidelines for mechanical ventilation are given and approaches to eventual liberation from the ventilator are reviewed.

(JAMA. 1989;261:3444-3453)

REFERENCES

1 +
Current Estimates From the National Health Review Survey . Washington, DC: National Center for Health Statistics; 1985;. Series 10, No. (160) .
2 +
Higgins M:  Epidemiology of COPD: state of the art . Chest. 1984;;85( (suppl) ):3S-8S.
3 +
Fletcher C, Peto R.  The natural history of chronic airflow obstruction . Br Med J. 1977;;1:1645-1648.
4 +
American Thoracic Society:  Chronic bronchitis, asthma, and pulmonary emphysema: a statement by the Committee on Diagnostic Standards for Nontuberculous Respiratory Diseases . Am Rev Respir Dis. 1962;;85:762-768.
5 +
Chronic Obstructive Lung Disease: The Health Consequences of Smoking—A Report of the Surgeon General . Rockville, Md: US Dept of Health and Human Services; 1984;. Public Health Service publication 84-50205.
6 +
Silverberg E.  Cancer statistics . CA. 1985;;35:19-35.
7 +
Himelman RB, Struve SN, Brown JK, et al.  Improved recognition of cor pulmonale in patients with severe chronic obstructive pulmonary disease . Am J Med. 1988;;84:891-898.
8 +
Kline LE, Crawford MH, MacDonald WJ, et al.  Noninvasive assessment of left ventricular performance in patients with chronic obstructive pulmonary disease . Chest. 1977;;72:558-564.
9 +
Fletcher CM, Peto R, Tinker C, et al. The Natural History of Chronic Bronchitis and Emphysema: An Eight-Year Study of Early Chronic Obstructive Lung Disease in Working Men in London . New York, NY: Oxford University Press; 1976;:272.
10 +
Smith CB, Golden CA, Kanner RE.  Association of viral and Mycoplasma pneumoniae infections with acute respiratory illness in patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1980;;121:225-232.
11 +
Edwards RHT.  Physiological analysis of skeletal muscle weakness and fatigue . Clin Sci Mol Med. 1978;;54:463-470.
12 +
Roussos CS, Macklem PT.  Diaphragmatic fatigue in man . J Appl Physiol. 1977;;43:189-197.
13 +
Roussos C, Fixley M, Gross D, et al.  Fatigue of the inspiratory muscles and their synergic behavior . J Appl Physiol. 1979;;46:897-904.
14 +
Roussos C, Macklem PT.  Inspiratory muscle fatigue . In: Fishman AP, ed. Handbook of Physiology: The Respiratory System . Bethesda, Md: American Physiological Society; 1985;;3(pt (2) ):511.
15 +
Leith DE, Bradley M.  Ventilatory muscle strength and endurance training . J Appl Physiol. 1973;;41:508-516.
16 +
Roussos C, Macklem PT.  The respiratory muscles . N Engl J Med. 1982;;307:786-797.
17 +
Grassino A, Macklem PT.  Respiratory muscle fatigue and ventilatory failure . Annu Rev Med. 1984;;35:625-647.
18 +
Hall JB, Wood LDH.  Liberation of the patient from mechanical ventilation . JAMA. 1987;;257: 1621-1628.
19 +
Hall J, Keamy MF.  Artificial airways in the critically ill patient . Pulmonary Crit Care Update. 1986;;2:2-8.
20 +
Anthonisen NR, Wright EC, IPPB Trial Group.  Bronchodilator response in chronic obstructive pulmonary disease . Am Rev Respir Dis. 1986;;133:814-819.
21 +
Gross NJ.  COPD: a disease of reversible airflow obstruction . Am Rev Respir Dis. 1986;;133: 725-726.
22 +
Albert RK, Martin TR, Lewis SW.  Controlled clinical trial of methylprednisolone in patients with chronic bronchitis and acute respiratory insufficiency . Ann Intern Med. 1980;;92:753-758.
23 +
Pepe PE, Marini JJ.  Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction . Am Rev Respir Dis. 1982;;126:166-170.
24 +
Fleury B, Murciano D, Talamo C, et al.  Work of breathing in patients with chronic obstructive pulmonary disease in acute respiratory failure . Am Rev Respir Dis. 1985;;131:822-827.
25 +
Cherniack RM.  The physical properties of the lung in chronic obstructive pulmonary emphysema . J Clin Invest. 1956;;35:394-404.
26 +
Braun NMT, Rochester DF, Arora NS.  Respiratory muscle strength in chronic obstructive lung disease . Am Rev Respir Dis. 1979;;119(pt (2) ):151-154.
27 +
Rochester DF, Arora NS, Braun NMT, et al.  The respiratory muscles in chronic obstructive pulmonary disease (COPD) . Bull Eur Physiopathol Respir. 1979;;15:951-975.
28 +
Broseghini C, Brandolese R, Poggi R, et al.  Respiratory mechanics during the first day of mechanical ventilation in patients with pulmonary edema and chronic airway obstruction . Am Rev Respir Dis. 1988;;138:355-361.
29 +
Rossi A, Gottfried SB, Zocchi L, et al.  Measurement of static compliance of total respiratory system in patients with acute respiratory failure during mechanical ventilation . Am Rev Respir Dis. 1985;;131:672-678.
30 +
Murciano D, Aubier M, Bussi S, et al.  Comparison of esophageal, tracheal, and mouth occlusion pressure in patients with chronic obstructive pul monary disease during acute respiratory failure . Am Rev Respir Dis. 1982;;126:837-841.
31 +
Aubier M, Murciano D, Fournier M, et al.  Central respiratory drive in acute respiratory failure of patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1980;;122:191-199.
32 +
Aubier M, Murciano D, Fournier M, et al.  Effects of the administration of O2 on ventilation and blood gases in patients with chronic obstructive pulmonary disease during acute respiratory failure . Am Rev Respir Dis. 1980;;122:747-754.
33 +
Sassoon CSH, Hassell KT, Mahutte CK.  Hyperoxic-induced hypercapnia in stable chronic obstructive pulmonary disease . Am Rev Respir Dis. 1987;;135:907-911.
34 +
Pittinger C, Adamson R.  Antibiotic blockade of neuromuscular function . Ann Rev Pharmacol. 1972;;12:169-184.
35 +
Scharf SM, Bark H, Einhorn S, et al.  Blood flow to the canine diaphragm during hemorrhagic shock . Am Rev Respir Dis. 1986;;133:205-211.
36 +
Hussain SNA, Graham R, Rutledge F, et al.  Respiratory muscle energetics during endotoxic shock in dogs . J Appl Physiol. 1986;;60:486-493.
37 +
Pardy RL, Bye PTP.  Diaphragmatic fatigue in normoxia and hyperoxia . J Appl Physiol. 1985;; 58:738-742.
38 +
Aubier M, Viires N, Piquet J, et al.  Effects of hypocalcemia on diaphragmatic strength generation . J Appl Physiol. 1985;;58:2054-2061.
39 +
Aubier M, Murciano D, Lecocguic Y, et al.  Effect of hypophosphatemia on diaphragmatic contractility in patients with acute respiratory failure . N Engl J Med. 1985;;313:420-424.
40 +
Dhingra S, Solven F, Wilson A, et al.  Hypomagnesemia and respiratory muscle power . Am Rev Respir Dis. 1984;;129:497-498.
41 +
Rogers RM, Dauber JH, Sanders MH, et al.  Nutrition and COPD. State-of-the-art minireview . Chest. 1984;;85( (suppl) ):63S-66S.
42 +
Sharp JT.  The respiratory muscles in chronic obstructive pulmonary disease . Am Rev Respir Dis. 1986;;134:1089-1091.
43 +
Juan G, Calverley P, Talamo C, et al.  Effect of carbon dioxide on diaphragmatic function in human beings . N Engl J Med. 1984;;310:874-879.
44 +
Jardim J, Farkas G, Prefaut C, et al.  The failing inspiratory muscles under normoxic and hypoxic conditions . Am Rev Respir Dis. 1981;;124:274-279.
45 +
Fishman AP.  Chronic cor pulmonale . Am Rev Respir Dis. 1976;;114:775-794.
46 +
Minh VD, Lee HM, Dolan GF, et al.  Hypoxemia during exercise in patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1979;;120:787-794.
47 +
Matthay RA, Berger HJ.  Cardiovascular function in cor pulmonale . Clin Chest Med. 1983;;4:269-295.
48 +
Hall JB.  The cardiopulmonary failure of sleepdisordered breathing . JAMA. 1986;;255:930-933.
49 +
Hall JB, Wood LDH.  Acute hypoxic respiratory failure . Med Grand Rounds. 1984;;3:183-195.
50 +
Dantzker DR.  Mechanisms of hypoxemia and hypercapnia . In: Bone RC, ed. Critical Care: A Comprehensive Approach . Park Ridge, Ill: American College of Chest Physicians; 1984;:1-14.
51 +
Campbell EJM.  The J. Burns Amberson Lecture: the management of acute respiratory failure in chronic bronchitis and emphysema . Am Rev Respir Dis . 1967;;96:626-639.
52 +
Lee J, Read J.  Effect of oxygen breathing on distribution of pulmonary blood flow in chronic obstructive lung disease . Am Rev Respir Dis. 1967;;96:1173-1180.
53 +
Degaute JP, Domenighetti G, Naeije R, et al.  Oxygen delivery in acute exacerbations of chronic obstructive pulmonary disease . Am Rev Respir Dis. 1981;;124:26-30.
54 +
Fishman AP.  The pulmonary circulation . In: Fishman AP, Fisher AB, eds. Handbook of Physiology: The Respiratory System . Bethesda, Md: American Physiological Society; 1985;:142.
55 +
Eliasson O, Degraff AC.  The use of criteria for reversibility and obstruction toto define patient groups for bronchodilator trials . Am Rev Respir Dis. 1985;;132:858-864.
56 +
Richer C, Mathieu M, Bah H.  Theophylline kinetics and ventilatory flow in bronchial asthma and chronic airflow obstruction: influence of erythromycin . Clin Pharmacol Ther. 1983;;31:579-586.
57 +
Barclay J, Whiting B, Merideth PA, et al.  Theophylline-salbutamol interaction: bronchodilator response to salbutamol at maximally effective theophylline concentrations . Br J Clin Pharmacol. 1981;;11:203-208.
58 +
Filuk RB, Easton PA, Anthonisen NR.  Responses to large doses of salbutamol and theophylline in patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1985;;132:871-874.
59 +
Jenne JW.  Theophylline as a bronchodilator in COPD and its combination with inhaled β-adrenergic drugs . Chest. 1987;;92( (suppl) ):75-145.
60 +
Rice KL, Leatherman JW, Duane PG, et al.  Aminophylline for acute exacerbations of chronic obstructive pulmonary disease . Ann Intern Med. 1987;;107:305-309.
61 +
Bukowskyj M, Nakatsu K, Munt PW.  Theophylline reassessed . Ann Intern Med. 1984;;101:63-73.
62 +
Jacobs MH, Senior RM, Kessler G.  Clinical experience with theophylline . JAMA. 1976;; 235:1983-1986.
63 +
Aubier M.  Pharmacotherapy of respiratory muscles . Clin Chest Med. 1988;;9:311-324.
64 +
Moxham J.  Aminophylline and the respiratory muscles: an alternative view . Clin Chest Med. 1988;;9:325-336.
65 +
Jones DA, Howell S, Roussos C, et al.  Low-frequency fatigue in isolated skeletal muscles and the effects of methylxanthines . Clin Sci. 1982;; 63:161-167.
66 +
Aubier M, De Troyer A, Sampson M, et al.  Aminophylline improves diaphragmatic contractility . N Engl J Med. 1981;;305:249-252.
67 +
Murciano D, Aubier M, Lecocguic Y, et al.  Effects of theophylline on diaphragmatic strength and fatigue in patients with chronic obstructive pulmonary disease . N Engl J Med. 1984;;311:349-353.
68 +
Murciano D, Aubier M, Lecocguic Y, et al.  Effect of aminophylline on diaphragmatic strength and fatigue in patients with chronic obstructive pulmonary disease . Bull Eur Physiopathol Respir. 1983;;19:64P.
69 +
Cooper CB, Davidson AC, Cameron IR.  Aminophylline, respiratory muscle strength and exercise tolerance in chronic obstructive airways disease . Bull Eur Physiopathol Respir. 1987;;23:15-22.
70 +
Kongragunta VR, Druz WS, Sharp JT.  Dyspnea and diaphragmatic fatigue in patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1988;;137:662-667.
71 +
Aubier M, Viires N, Murciano D, et al.  Effects of digoxin on diaphragmatic strength generation . J Appl Physiol. 1986;;61:1767-1774.
72 +
Aubier M, Murciano D, Menu Y, et al.  Dopamine effects on diaphragmatic strength during acute respiratory failure in chronic obstructive pulmonary disease . Ann Intern Med. 1989;;110:17-23.
73 +
Kolbeck RC, Speir WA.  Diltiazem, verapamil, and nifedipine inhibit theophylline-enhanced diaphragmatic contractility . Am Rev Respir Dis. 1989;;139:139-145.
74 +
Astin TW.  Reversibility of airway obstruction in chronic obstruction . Clin Sci. 1971;;42:725-732.
75 +
Dull WL, Alexander MR, Sadoul P, et al.  The efficacy of isoproterenol inhalation for predicting the response to orally administered theophylline in chronic obstructive pulmonary disease . Am Rev Respir Dis. 1982;;126:656-659.
76 +
Goldberg IS, Lourenco RV.  Deposition of aerosols in pulmonary disease . Arch Intern Med. 1973;;131:88-91.
77 +
The Intermittent Positive Pressure Breathing Trial Group:  Intermittent positive pressure breathing therapy of chronic obstructive pulmonary disease . Ann Intern Med. 1983;;99:612-620.
78 +
Pierson DJ, Hudson LD, Stark K, et al.  Cardiopulmonary effects of terbutaline and a bronchodilator combination in chronic obstructive pulmonary disease . Chest. 1980;;77:176-182.
79 +
Gross NJ.  Ipratropium bromide . N Engl J Med. 1988;;319:486-494.
80 +
Rebuck AS, Chapman KR, Abboud R, et al.  Nebulized anticholinergic and sympathomimetic treatment of asthma and chronic obstructive airways disease in the emergency room . Am J Med. 1987;;82:59-64.
81 +
Backman R, Hellstrom P-E.  Fenoterol and ipratropium bromide in respirator treatment of patients with chronic bronchitis . Curr Ther Res. 1985;;38:135-140.
82 +
Miller WF, Geumei AM.  Respiratory and pharmacological therapy in COPD . In: Petty TL, ed. Chronic Obstructive Pulmonary Disease . 2nd ed. New York, NY: Marcel Dekker Inc; 1985;:205-338.
83 +
Stoller JK.  Systemic corticosteroids in stable chronic obstructive pulmonary disease: do they work? Chest. 1987;;91:155-156.
84 +
Eliasson O, Hoffman J, Trueb D, et al.  Corticosteroids in COPD: a clinical trial and reassessment of the literature . Chest. 1986;;89:484-490.
85 +
Albert RK, Martin TR, Lewis SW.  Controlled clinical trial of methylprednisone in patients with chronic bronchitis and acute respiratory insufficiency . Ann Intern Med. 1980;;92:753-758.
86 +
Shih HT, Webb CR, Conway WA, et al.  Frequency and significance of cardiac arrhythmias in chronic obstructive lung disease . Chest. 1988;;94:44-48.
87 +
Brashear RE.  Arrhythmias in patients with chronic obstructive pulmonary disease . Med Clin North Am. 1984;;68:969-981.
88 +
Williams DO, Tatelbaum R, Most AS.  Effective treatment of supraventricular arrhythmias with acebutolol . Am J Cardiol. 1979;;44:521-525.
89 +
Amsterday EA, Lee G, Morrison S, et al.  Efficacy of cardioselective beta adrenergic blockade with intravenously administered tolamolol in the treatment of cardiac arrhythmias . Am J Cardiol. 1976;;38:195-199.
90 +
Marchlinski FE, Miller JM.  Atrial arrhythmias exacerbated by theophylline: response to verapamil and evidence for triggered activity in man . Chest. 1985;;88:931-934.
91 +
Salerno DM, Anderson B, Sharkey PJ, et al.  Intravenous verapamil for treatment of multifocal atrial tachycardia with and without calcium pretreatment . Ann Intern Med. 1987;;107:623-628.
92 +
Tager I, Speizer FE.  Role of infection in chronic bronchitis . N Engl J Med. 1975;;292:563-571.
93 +
Nicotra MB, Rivera M, Awe RJ.  Antibiotic therapy of acute exacerbations of chronic bronchitis . Ann Intern Med. 1982;;97:18-21.
94 +
Anthonisen NR, Manfreda J, Warren CPW, et al.  Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease . Ann Intern Med. 1987;;106:196-204.
95 +
Fanta CH, Wright TC, McFadden ER.  Differentiation of recurrent pulmonary emboli from chronic obstructive lung disease as a cause of cor pulmonale . Chest. 1981;;79:92-95.
96 +
Lippmann M, Fein A.  Pulmonary embolism in the patient with chronic obstructive pulmonary disease: a diagnostic dilemma . Chest. 1981;;79:39-42.
97 +
Sharma GVRK, Sasahara AA.  Diagnosis of pulmonary embolism in patients with chronic obstructive pulmonary disease . J Chronic Dis. 1975;;28:253-257.
98 +
Alderson PO, Biello DR, Sachariah G, et al.  Scintigraphic detection of pulmonary embolism in patients with obstructive pulmonary disease . Radiology. 1981;;138:661-666.
99 +
Smith R, Ellis K, Alderson PO.  Role of chest radiography in predicting the extent of airway disease in patients with suspected pulmonary embolism . Radiology. 1986;;159:391-394.
100 +
Mills SR, Jackson DC, Older RA, et al.  The incidence, etiologies, and avoidance of complications of pulmonary angiography in a large series . Radiology. 1980;;136:295-299.
101 +
Goodman PC.  Pulmonary angiography . Clin Chest Med. 1984;;5:465-477.
102 +
Perlmutt LM, Braun SD, Newman GE, et al.  Pulmonary arteriography in the high-risk patient . Radiology. 1987;;162:187-189.
103 +
Dalen JE, Alpert JS.  Natural history of pulmonary embolism . Prog Cardiovasc Dis. 1975;; 17:259-270.
104 +
UPET Study Group.  Urokinase pulmonary embolism trial . JAMA. 1970;;214:2163-2172.
105 +
Hirsh J.  Treatment of pulmonary embolism . Ann Rev Med. 1987;;38:91-105.
106 +
D'Alonzo GE.  Deep venous thrombosis and pulmonary embolism . In: Dantzker DR, ed. Cardiopulmonary Critical Care . New York, NY: Grune & Stratton; 1986;:680.
107 +
George RB, Herbert SJ, Shames JM, et al.  Pneumothorax complicating pulmonary emphysema . JAMA. 1975;;234:389-393.
108 +
Christensen EE, Dietz GW.  Subpulmonic pneumothorax in patients with chronic obstructive pulmonary disease . Radiology. 1976;;121:33-37.
109 +
Videm V, Pillgram-Larsen J, Ellingsen O, et al.  Spontaneous pneumothorax in chronic obstructive pulmonary disease: complications, treatment and recurrences . Eur J Respir Dis. 1987;;71:365-371.
110 +
Rahn H, Otis AB, Chadwick LE, et al.  The pressure-volume diagram of the thorax and lung . Am J Physiol. 1946;;146:161-178.
111 +
Light RW.  Thoracentesis (diagnostic and therapeutic) and pleural biopsy . In: Pleural Diseases . Philadelphia, Pa: Lea & Febiger; 1983;:237.
112 +
Estenne M, Yernault JC, De Troyer A.  Mechanism of relief of dyspnea after thoracocentesis in patients with large pleural effusions . Am J Med. 1983;;74:813-819.
113 +
Dittmann M, Steenblock U, Kranzlin M, et al.  Epidural analgesia or mechanical ventilation for multiple rib fractures? Intensive Care Med. 1982;;8:89-92.
114 +
Rotman HH, Liss HP, Weg JG.  Diagnosis of upper airway obstruction by pulmonary function testing . Chest. 1975;;68:796-799.
115 +
Lavelle TF, Rotman HH, Weg JG.  Isoflowvolume curves in the diagnosis of upper airway obstruction . Am Rev Respir Dis. 1978;;117:845-852.
116 +
Gelb AF, Tashkin DP, Epstein JD, et al.  NdYAG laser surgery for severe tracheal stenosis physiologically and clinically masked by severe diffuse obstructive pulmonary disease . Chest. 1987;;91:166-170.
117 +
Wilson RH, Borden CW, Ebert RV, et al.  A comparison of the effect of voluntary hyperventilation in normal persons, patients with pulmonary emphysema, and patients with cardiac disease . J Lab Clin Med. 1950;;36:119-126.
118 +
Gilbert R, Keighley J, Auchincloss JH.  Mechanisms of chronic carbon dioxide retention in patients with obstructive pulmonary disease . Am J Med. 1965;;38:217-225.
119 +
Bickerman HA, Chusid EL.  The case against the use of respiratory stimulants . Chest. 1970;; 58:53-56.
120 +
Moser KM, Luchsinger PC, Adamson JS, et al.  Respiratory stimulation with intravenous doxapram in respiratory failure . N Engl J Med. 1973;;288:427-431.
121 +
Martin JG, Shore S, Engel LA.  Effect of continuous positive airway pressure on respiratory mechanics and pattern of breathing in induced asthma . Am Rev Respir Dis. 1982;;126:812-817.
122 +
O'Donnell DE, Sanii R, Younes M.  Improvement in exercise endurance in patients with chronic airflow limitation using continuous positive airway pressure . Am Rev Respir Dis. 1988;;138:1510-1514.
123 +
Kaelin RM, Assimacopoulos A, Chevrolet JC.  Failure to predict six-month survival of patients with COPD requiring mechanical ventilation by analysis of simple indices . Chest. 1987;;92:971-978.
124 +
Martin TR, Lewis SW, Albert RK.  The prognosis of patients with chronic obstructive pulmonary disease after hospitalization for acute respiratory failure . Chest. 1982;;82:310-314.
125 +
Tobin MJ, Guenther SM, Perez W, et al.  Konno-Mead analysis of ribcage-abdominal motion during successful and unsuccessful trials of weaning from mechanical ventilation . Am Rev Respir Dis. 1987;;135:1320-1328.
126 +
Tobin MJ, Perez W, Guenther SM, et al.  Does rib cage-abdominal paradox signify respiratory muscle fatigue? J Appl Physiol. 1987;;63:851-860.
127 +
Connors AF, McCaffree DR, Gray BA.  Effect of inspiratory flow rate on gas exchange during mechanical ventilation . Am Rev Respir Dis. 1981;;124:537-543.
128 +
Lawson NW, Butler GH, Ray CT.  Alkalosis and cardiac arrythmias . Anesth Analg. 1973;; 52:951-964.
129 +
Braun NMT, Faulkner J, Hughes RL, et al.  When should respiratory muscles be exercised? Chest. 1983;;84:76-84.
130 +
Sassoon CSH, Te TT, Mahutte CK, et al.  Airway occlusion pressure: an important indicator for successful weaning in patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1987;;135:107-113.
131 +
Pourriat JL.  Diaphragmatic fatigue and breathing pattern during weaning from mechanical ventilation in COPD patients . Chest. 1986;;90:703-707.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Current Estimates From the National Health Review Survey . Washington, DC: National Center for Health Statistics; 1985;. Series 10, No. (160) .
2 +
Higgins M:  Epidemiology of COPD: state of the art . Chest. 1984;;85( (suppl) ):3S-8S.
3 +
Fletcher C, Peto R.  The natural history of chronic airflow obstruction . Br Med J. 1977;;1:1645-1648.
4 +
American Thoracic Society:  Chronic bronchitis, asthma, and pulmonary emphysema: a statement by the Committee on Diagnostic Standards for Nontuberculous Respiratory Diseases . Am Rev Respir Dis. 1962;;85:762-768.
5 +
Chronic Obstructive Lung Disease: The Health Consequences of Smoking—A Report of the Surgeon General . Rockville, Md: US Dept of Health and Human Services; 1984;. Public Health Service publication 84-50205.
6 +
Silverberg E.  Cancer statistics . CA. 1985;;35:19-35.
7 +
Himelman RB, Struve SN, Brown JK, et al.  Improved recognition of cor pulmonale in patients with severe chronic obstructive pulmonary disease . Am J Med. 1988;;84:891-898.
8 +
Kline LE, Crawford MH, MacDonald WJ, et al.  Noninvasive assessment of left ventricular performance in patients with chronic obstructive pulmonary disease . Chest. 1977;;72:558-564.
9 +
Fletcher CM, Peto R, Tinker C, et al. The Natural History of Chronic Bronchitis and Emphysema: An Eight-Year Study of Early Chronic Obstructive Lung Disease in Working Men in London . New York, NY: Oxford University Press; 1976;:272.
10 +
Smith CB, Golden CA, Kanner RE.  Association of viral and Mycoplasma pneumoniae infections with acute respiratory illness in patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1980;;121:225-232.
11 +
Edwards RHT.  Physiological analysis of skeletal muscle weakness and fatigue . Clin Sci Mol Med. 1978;;54:463-470.
12 +
Roussos CS, Macklem PT.  Diaphragmatic fatigue in man . J Appl Physiol. 1977;;43:189-197.
13 +
Roussos C, Fixley M, Gross D, et al.  Fatigue of the inspiratory muscles and their synergic behavior . J Appl Physiol. 1979;;46:897-904.
14 +
Roussos C, Macklem PT.  Inspiratory muscle fatigue . In: Fishman AP, ed. Handbook of Physiology: The Respiratory System . Bethesda, Md: American Physiological Society; 1985;;3(pt (2) ):511.
15 +
Leith DE, Bradley M.  Ventilatory muscle strength and endurance training . J Appl Physiol. 1973;;41:508-516.
16 +
Roussos C, Macklem PT.  The respiratory muscles . N Engl J Med. 1982;;307:786-797.
17 +
Grassino A, Macklem PT.  Respiratory muscle fatigue and ventilatory failure . Annu Rev Med. 1984;;35:625-647.
18 +
Hall JB, Wood LDH.  Liberation of the patient from mechanical ventilation . JAMA. 1987;;257: 1621-1628.
19 +
Hall J, Keamy MF.  Artificial airways in the critically ill patient . Pulmonary Crit Care Update. 1986;;2:2-8.
20 +
Anthonisen NR, Wright EC, IPPB Trial Group.  Bronchodilator response in chronic obstructive pulmonary disease . Am Rev Respir Dis. 1986;;133:814-819.
21 +
Gross NJ.  COPD: a disease of reversible airflow obstruction . Am Rev Respir Dis. 1986;;133: 725-726.
22 +
Albert RK, Martin TR, Lewis SW.  Controlled clinical trial of methylprednisolone in patients with chronic bronchitis and acute respiratory insufficiency . Ann Intern Med. 1980;;92:753-758.
23 +
Pepe PE, Marini JJ.  Occult positive end-expiratory pressure in mechanically ventilated patients with airflow obstruction . Am Rev Respir Dis. 1982;;126:166-170.
24 +
Fleury B, Murciano D, Talamo C, et al.  Work of breathing in patients with chronic obstructive pulmonary disease in acute respiratory failure . Am Rev Respir Dis. 1985;;131:822-827.
25 +
Cherniack RM.  The physical properties of the lung in chronic obstructive pulmonary emphysema . J Clin Invest. 1956;;35:394-404.
26 +
Braun NMT, Rochester DF, Arora NS.  Respiratory muscle strength in chronic obstructive lung disease . Am Rev Respir Dis. 1979;;119(pt (2) ):151-154.
27 +
Rochester DF, Arora NS, Braun NMT, et al.  The respiratory muscles in chronic obstructive pulmonary disease (COPD) . Bull Eur Physiopathol Respir. 1979;;15:951-975.
28 +
Broseghini C, Brandolese R, Poggi R, et al.  Respiratory mechanics during the first day of mechanical ventilation in patients with pulmonary edema and chronic airway obstruction . Am Rev Respir Dis. 1988;;138:355-361.
29 +
Rossi A, Gottfried SB, Zocchi L, et al.  Measurement of static compliance of total respiratory system in patients with acute respiratory failure during mechanical ventilation . Am Rev Respir Dis. 1985;;131:672-678.
30 +
Murciano D, Aubier M, Bussi S, et al.  Comparison of esophageal, tracheal, and mouth occlusion pressure in patients with chronic obstructive pul monary disease during acute respiratory failure . Am Rev Respir Dis. 1982;;126:837-841.
31 +
Aubier M, Murciano D, Fournier M, et al.  Central respiratory drive in acute respiratory failure of patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1980;;122:191-199.
32 +
Aubier M, Murciano D, Fournier M, et al.  Effects of the administration of O2 on ventilation and blood gases in patients with chronic obstructive pulmonary disease during acute respiratory failure . Am Rev Respir Dis. 1980;;122:747-754.
33 +
Sassoon CSH, Hassell KT, Mahutte CK.  Hyperoxic-induced hypercapnia in stable chronic obstructive pulmonary disease . Am Rev Respir Dis. 1987;;135:907-911.
34 +
Pittinger C, Adamson R.  Antibiotic blockade of neuromuscular function . Ann Rev Pharmacol. 1972;;12:169-184.
35 +
Scharf SM, Bark H, Einhorn S, et al.  Blood flow to the canine diaphragm during hemorrhagic shock . Am Rev Respir Dis. 1986;;133:205-211.
36 +
Hussain SNA, Graham R, Rutledge F, et al.  Respiratory muscle energetics during endotoxic shock in dogs . J Appl Physiol. 1986;;60:486-493.
37 +
Pardy RL, Bye PTP.  Diaphragmatic fatigue in normoxia and hyperoxia . J Appl Physiol. 1985;; 58:738-742.
38 +
Aubier M, Viires N, Piquet J, et al.  Effects of hypocalcemia on diaphragmatic strength generation . J Appl Physiol. 1985;;58:2054-2061.
39 +
Aubier M, Murciano D, Lecocguic Y, et al.  Effect of hypophosphatemia on diaphragmatic contractility in patients with acute respiratory failure . N Engl J Med. 1985;;313:420-424.
40 +
Dhingra S, Solven F, Wilson A, et al.  Hypomagnesemia and respiratory muscle power . Am Rev Respir Dis. 1984;;129:497-498.
41 +
Rogers RM, Dauber JH, Sanders MH, et al.  Nutrition and COPD. State-of-the-art minireview . Chest. 1984;;85( (suppl) ):63S-66S.
42 +
Sharp JT.  The respiratory muscles in chronic obstructive pulmonary disease . Am Rev Respir Dis. 1986;;134:1089-1091.
43 +
Juan G, Calverley P, Talamo C, et al.  Effect of carbon dioxide on diaphragmatic function in human beings . N Engl J Med. 1984;;310:874-879.
44 +
Jardim J, Farkas G, Prefaut C, et al.  The failing inspiratory muscles under normoxic and hypoxic conditions . Am Rev Respir Dis. 1981;;124:274-279.
45 +
Fishman AP.  Chronic cor pulmonale . Am Rev Respir Dis. 1976;;114:775-794.
46 +
Minh VD, Lee HM, Dolan GF, et al.  Hypoxemia during exercise in patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1979;;120:787-794.
47 +
Matthay RA, Berger HJ.  Cardiovascular function in cor pulmonale . Clin Chest Med. 1983;;4:269-295.
48 +
Hall JB.  The cardiopulmonary failure of sleepdisordered breathing . JAMA. 1986;;255:930-933.
49 +
Hall JB, Wood LDH.  Acute hypoxic respiratory failure . Med Grand Rounds. 1984;;3:183-195.
50 +
Dantzker DR.  Mechanisms of hypoxemia and hypercapnia . In: Bone RC, ed. Critical Care: A Comprehensive Approach . Park Ridge, Ill: American College of Chest Physicians; 1984;:1-14.
51 +
Campbell EJM.  The J. Burns Amberson Lecture: the management of acute respiratory failure in chronic bronchitis and emphysema . Am Rev Respir Dis . 1967;;96:626-639.
52 +
Lee J, Read J.  Effect of oxygen breathing on distribution of pulmonary blood flow in chronic obstructive lung disease . Am Rev Respir Dis. 1967;;96:1173-1180.
53 +
Degaute JP, Domenighetti G, Naeije R, et al.  Oxygen delivery in acute exacerbations of chronic obstructive pulmonary disease . Am Rev Respir Dis. 1981;;124:26-30.
54 +
Fishman AP.  The pulmonary circulation . In: Fishman AP, Fisher AB, eds. Handbook of Physiology: The Respiratory System . Bethesda, Md: American Physiological Society; 1985;:142.
55 +
Eliasson O, Degraff AC.  The use of criteria for reversibility and obstruction toto define patient groups for bronchodilator trials . Am Rev Respir Dis. 1985;;132:858-864.
56 +
Richer C, Mathieu M, Bah H.  Theophylline kinetics and ventilatory flow in bronchial asthma and chronic airflow obstruction: influence of erythromycin . Clin Pharmacol Ther. 1983;;31:579-586.
57 +
Barclay J, Whiting B, Merideth PA, et al.  Theophylline-salbutamol interaction: bronchodilator response to salbutamol at maximally effective theophylline concentrations . Br J Clin Pharmacol. 1981;;11:203-208.
58 +
Filuk RB, Easton PA, Anthonisen NR.  Responses to large doses of salbutamol and theophylline in patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1985;;132:871-874.
59 +
Jenne JW.  Theophylline as a bronchodilator in COPD and its combination with inhaled β-adrenergic drugs . Chest. 1987;;92( (suppl) ):75-145.
60 +
Rice KL, Leatherman JW, Duane PG, et al.  Aminophylline for acute exacerbations of chronic obstructive pulmonary disease . Ann Intern Med. 1987;;107:305-309.
61 +
Bukowskyj M, Nakatsu K, Munt PW.  Theophylline reassessed . Ann Intern Med. 1984;;101:63-73.
62 +
Jacobs MH, Senior RM, Kessler G.  Clinical experience with theophylline . JAMA. 1976;; 235:1983-1986.
63 +
Aubier M.  Pharmacotherapy of respiratory muscles . Clin Chest Med. 1988;;9:311-324.
64 +
Moxham J.  Aminophylline and the respiratory muscles: an alternative view . Clin Chest Med. 1988;;9:325-336.
65 +
Jones DA, Howell S, Roussos C, et al.  Low-frequency fatigue in isolated skeletal muscles and the effects of methylxanthines . Clin Sci. 1982;; 63:161-167.
66 +
Aubier M, De Troyer A, Sampson M, et al.  Aminophylline improves diaphragmatic contractility . N Engl J Med. 1981;;305:249-252.
67 +
Murciano D, Aubier M, Lecocguic Y, et al.  Effects of theophylline on diaphragmatic strength and fatigue in patients with chronic obstructive pulmonary disease . N Engl J Med. 1984;;311:349-353.
68 +
Murciano D, Aubier M, Lecocguic Y, et al.  Effect of aminophylline on diaphragmatic strength and fatigue in patients with chronic obstructive pulmonary disease . Bull Eur Physiopathol Respir. 1983;;19:64P.
69 +
Cooper CB, Davidson AC, Cameron IR.  Aminophylline, respiratory muscle strength and exercise tolerance in chronic obstructive airways disease . Bull Eur Physiopathol Respir. 1987;;23:15-22.
70 +
Kongragunta VR, Druz WS, Sharp JT.  Dyspnea and diaphragmatic fatigue in patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1988;;137:662-667.
71 +
Aubier M, Viires N, Murciano D, et al.  Effects of digoxin on diaphragmatic strength generation . J Appl Physiol. 1986;;61:1767-1774.
72 +
Aubier M, Murciano D, Menu Y, et al.  Dopamine effects on diaphragmatic strength during acute respiratory failure in chronic obstructive pulmonary disease . Ann Intern Med. 1989;;110:17-23.
73 +
Kolbeck RC, Speir WA.  Diltiazem, verapamil, and nifedipine inhibit theophylline-enhanced diaphragmatic contractility . Am Rev Respir Dis. 1989;;139:139-145.
74 +
Astin TW.  Reversibility of airway obstruction in chronic obstruction . Clin Sci. 1971;;42:725-732.
75 +
Dull WL, Alexander MR, Sadoul P, et al.  The efficacy of isoproterenol inhalation for predicting the response to orally administered theophylline in chronic obstructive pulmonary disease . Am Rev Respir Dis. 1982;;126:656-659.
76 +
Goldberg IS, Lourenco RV.  Deposition of aerosols in pulmonary disease . Arch Intern Med. 1973;;131:88-91.
77 +
The Intermittent Positive Pressure Breathing Trial Group:  Intermittent positive pressure breathing therapy of chronic obstructive pulmonary disease . Ann Intern Med. 1983;;99:612-620.
78 +
Pierson DJ, Hudson LD, Stark K, et al.  Cardiopulmonary effects of terbutaline and a bronchodilator combination in chronic obstructive pulmonary disease . Chest. 1980;;77:176-182.
79 +
Gross NJ.  Ipratropium bromide . N Engl J Med. 1988;;319:486-494.
80 +
Rebuck AS, Chapman KR, Abboud R, et al.  Nebulized anticholinergic and sympathomimetic treatment of asthma and chronic obstructive airways disease in the emergency room . Am J Med. 1987;;82:59-64.
81 +
Backman R, Hellstrom P-E.  Fenoterol and ipratropium bromide in respirator treatment of patients with chronic bronchitis . Curr Ther Res. 1985;;38:135-140.
82 +
Miller WF, Geumei AM.  Respiratory and pharmacological therapy in COPD . In: Petty TL, ed. Chronic Obstructive Pulmonary Disease . 2nd ed. New York, NY: Marcel Dekker Inc; 1985;:205-338.
83 +
Stoller JK.  Systemic corticosteroids in stable chronic obstructive pulmonary disease: do they work? Chest. 1987;;91:155-156.
84 +
Eliasson O, Hoffman J, Trueb D, et al.  Corticosteroids in COPD: a clinical trial and reassessment of the literature . Chest. 1986;;89:484-490.
85 +
Albert RK, Martin TR, Lewis SW.  Controlled clinical trial of methylprednisone in patients with chronic bronchitis and acute respiratory insufficiency . Ann Intern Med. 1980;;92:753-758.
86 +
Shih HT, Webb CR, Conway WA, et al.  Frequency and significance of cardiac arrhythmias in chronic obstructive lung disease . Chest. 1988;;94:44-48.
87 +
Brashear RE.  Arrhythmias in patients with chronic obstructive pulmonary disease . Med Clin North Am. 1984;;68:969-981.
88 +
Williams DO, Tatelbaum R, Most AS.  Effective treatment of supraventricular arrhythmias with acebutolol . Am J Cardiol. 1979;;44:521-525.
89 +
Amsterday EA, Lee G, Morrison S, et al.  Efficacy of cardioselective beta adrenergic blockade with intravenously administered tolamolol in the treatment of cardiac arrhythmias . Am J Cardiol. 1976;;38:195-199.
90 +
Marchlinski FE, Miller JM.  Atrial arrhythmias exacerbated by theophylline: response to verapamil and evidence for triggered activity in man . Chest. 1985;;88:931-934.
91 +
Salerno DM, Anderson B, Sharkey PJ, et al.  Intravenous verapamil for treatment of multifocal atrial tachycardia with and without calcium pretreatment . Ann Intern Med. 1987;;107:623-628.
92 +
Tager I, Speizer FE.  Role of infection in chronic bronchitis . N Engl J Med. 1975;;292:563-571.
93 +
Nicotra MB, Rivera M, Awe RJ.  Antibiotic therapy of acute exacerbations of chronic bronchitis . Ann Intern Med. 1982;;97:18-21.
94 +
Anthonisen NR, Manfreda J, Warren CPW, et al.  Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease . Ann Intern Med. 1987;;106:196-204.
95 +
Fanta CH, Wright TC, McFadden ER.  Differentiation of recurrent pulmonary emboli from chronic obstructive lung disease as a cause of cor pulmonale . Chest. 1981;;79:92-95.
96 +
Lippmann M, Fein A.  Pulmonary embolism in the patient with chronic obstructive pulmonary disease: a diagnostic dilemma . Chest. 1981;;79:39-42.
97 +
Sharma GVRK, Sasahara AA.  Diagnosis of pulmonary embolism in patients with chronic obstructive pulmonary disease . J Chronic Dis. 1975;;28:253-257.
98 +
Alderson PO, Biello DR, Sachariah G, et al.  Scintigraphic detection of pulmonary embolism in patients with obstructive pulmonary disease . Radiology. 1981;;138:661-666.
99 +
Smith R, Ellis K, Alderson PO.  Role of chest radiography in predicting the extent of airway disease in patients with suspected pulmonary embolism . Radiology. 1986;;159:391-394.
100 +
Mills SR, Jackson DC, Older RA, et al.  The incidence, etiologies, and avoidance of complications of pulmonary angiography in a large series . Radiology. 1980;;136:295-299.
101 +
Goodman PC.  Pulmonary angiography . Clin Chest Med. 1984;;5:465-477.
102 +
Perlmutt LM, Braun SD, Newman GE, et al.  Pulmonary arteriography in the high-risk patient . Radiology. 1987;;162:187-189.
103 +
Dalen JE, Alpert JS.  Natural history of pulmonary embolism . Prog Cardiovasc Dis. 1975;; 17:259-270.
104 +
UPET Study Group.  Urokinase pulmonary embolism trial . JAMA. 1970;;214:2163-2172.
105 +
Hirsh J.  Treatment of pulmonary embolism . Ann Rev Med. 1987;;38:91-105.
106 +
D'Alonzo GE.  Deep venous thrombosis and pulmonary embolism . In: Dantzker DR, ed. Cardiopulmonary Critical Care . New York, NY: Grune & Stratton; 1986;:680.
107 +
George RB, Herbert SJ, Shames JM, et al.  Pneumothorax complicating pulmonary emphysema . JAMA. 1975;;234:389-393.
108 +
Christensen EE, Dietz GW.  Subpulmonic pneumothorax in patients with chronic obstructive pulmonary disease . Radiology. 1976;;121:33-37.
109 +
Videm V, Pillgram-Larsen J, Ellingsen O, et al.  Spontaneous pneumothorax in chronic obstructive pulmonary disease: complications, treatment and recurrences . Eur J Respir Dis. 1987;;71:365-371.
110 +
Rahn H, Otis AB, Chadwick LE, et al.  The pressure-volume diagram of the thorax and lung . Am J Physiol. 1946;;146:161-178.
111 +
Light RW.  Thoracentesis (diagnostic and therapeutic) and pleural biopsy . In: Pleural Diseases . Philadelphia, Pa: Lea & Febiger; 1983;:237.
112 +
Estenne M, Yernault JC, De Troyer A.  Mechanism of relief of dyspnea after thoracocentesis in patients with large pleural effusions . Am J Med. 1983;;74:813-819.
113 +
Dittmann M, Steenblock U, Kranzlin M, et al.  Epidural analgesia or mechanical ventilation for multiple rib fractures? Intensive Care Med. 1982;;8:89-92.
114 +
Rotman HH, Liss HP, Weg JG.  Diagnosis of upper airway obstruction by pulmonary function testing . Chest. 1975;;68:796-799.
115 +
Lavelle TF, Rotman HH, Weg JG.  Isoflowvolume curves in the diagnosis of upper airway obstruction . Am Rev Respir Dis. 1978;;117:845-852.
116 +
Gelb AF, Tashkin DP, Epstein JD, et al.  NdYAG laser surgery for severe tracheal stenosis physiologically and clinically masked by severe diffuse obstructive pulmonary disease . Chest. 1987;;91:166-170.
117 +
Wilson RH, Borden CW, Ebert RV, et al.  A comparison of the effect of voluntary hyperventilation in normal persons, patients with pulmonary emphysema, and patients with cardiac disease . J Lab Clin Med. 1950;;36:119-126.
118 +
Gilbert R, Keighley J, Auchincloss JH.  Mechanisms of chronic carbon dioxide retention in patients with obstructive pulmonary disease . Am J Med. 1965;;38:217-225.
119 +
Bickerman HA, Chusid EL.  The case against the use of respiratory stimulants . Chest. 1970;; 58:53-56.
120 +
Moser KM, Luchsinger PC, Adamson JS, et al.  Respiratory stimulation with intravenous doxapram in respiratory failure . N Engl J Med. 1973;;288:427-431.
121 +
Martin JG, Shore S, Engel LA.  Effect of continuous positive airway pressure on respiratory mechanics and pattern of breathing in induced asthma . Am Rev Respir Dis. 1982;;126:812-817.
122 +
O'Donnell DE, Sanii R, Younes M.  Improvement in exercise endurance in patients with chronic airflow limitation using continuous positive airway pressure . Am Rev Respir Dis. 1988;;138:1510-1514.
123 +
Kaelin RM, Assimacopoulos A, Chevrolet JC.  Failure to predict six-month survival of patients with COPD requiring mechanical ventilation by analysis of simple indices . Chest. 1987;;92:971-978.
124 +
Martin TR, Lewis SW, Albert RK.  The prognosis of patients with chronic obstructive pulmonary disease after hospitalization for acute respiratory failure . Chest. 1982;;82:310-314.
125 +
Tobin MJ, Guenther SM, Perez W, et al.  Konno-Mead analysis of ribcage-abdominal motion during successful and unsuccessful trials of weaning from mechanical ventilation . Am Rev Respir Dis. 1987;;135:1320-1328.
126 +
Tobin MJ, Perez W, Guenther SM, et al.  Does rib cage-abdominal paradox signify respiratory muscle fatigue? J Appl Physiol. 1987;;63:851-860.
127 +
Connors AF, McCaffree DR, Gray BA.  Effect of inspiratory flow rate on gas exchange during mechanical ventilation . Am Rev Respir Dis. 1981;;124:537-543.
128 +
Lawson NW, Butler GH, Ray CT.  Alkalosis and cardiac arrythmias . Anesth Analg. 1973;; 52:951-964.
129 +
Braun NMT, Faulkner J, Hughes RL, et al.  When should respiratory muscles be exercised? Chest. 1983;;84:76-84.
130 +
Sassoon CSH, Te TT, Mahutte CK, et al.  Airway occlusion pressure: an important indicator for successful weaning in patients with chronic obstructive pulmonary disease . Am Rev Respir Dis. 1987;;135:107-113.
131 +
Pourriat JL.  Diaphragmatic fatigue and breathing pattern during weaning from mechanical ventilation in COPD patients . Chest. 1986;;90:703-707.

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