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OBJECTIVE: To describe the pathogenesis of chronic obstructive pulmonary disease (COPD) and mechanisms of benefit, formulations available, drug costs, pharmacokinetic profiles, and pertinent clinical studies for long-acting β2-agonists.DATA SOURCES: A MEDLINE search was conducted from July 1966 through October 2002.STUDY SELECTION AND DATA EXTRACTION: Pertinent articles related to COPD and long-acting β2-agonists.DATA SYNTHESIS: The incidence and subsequent morbidity and mortality of COPD have increased during the last 4 decades, prompting worldwide initiatives to formulate guidelines to decrease the burden of this disease. COPD is a progressive, irreversible disease state characterized by chronic cough, dyspnea, sputum production, and wheezing, in which no medication has been shown to decrease mortality, excluding oxygen supplementation. Bronchodilators have been a mainstay of COPD treatment through their ability to work by both smooth- and non–smooth-muscle mechanisms. Long-acting β2-agonists (i.e., formoterol, salmeterol) dosed twice daily provide more convenient dosing than 4-times-daily regimens of traditional short-acting bronchodilators. Both formoterol and salmeterol have acceptable adverse event profiles when used at recommended doses. There have been no direct clinical outcome studies comparing formoterol and salmeterol, but both have shown some benefits over ipratropium and theophylline in improving the symptoms, spirometric indices, exacerbations, and quality of life of patients with COPD.CONCLUSIONS: Based on current evidence, long-acting β2-agonists are acceptable first-line agents for patients with COPD.

Steel is a universal material and has reached a high level of sophistication in applications and recycling potential. Rules are indicated for maintaining the sustainability of recycling (DfR concept). Consumer goods should be designed so as to maximize metal utilization, which is the only economical solution to meet ambitious recycling levels. The present level reached by recycling in France is compared to those targets in order to identify how much more progress has to be made.

The impact of noninvasive positive‐pressure ventilation (NIPPV) on pulmonary function studies, quality of life, and survival was assessed in patients with amyotrophic lateral sclerosis. NIPPV did not change the rate of decline of the forced vital capacity (FVC) and forced expiratory volume in the first second (FEV1) (2.31 and 2.09 percent‐predicted points per month, respectively). NIPPV resulted in a drop of FEV1by 5.94 percent‐predicted points (P= 0.07), and of maximal inspiratory pressure by 6.33 percent‐predicted points (P= 0.11). The change in FEV1and FVC pre‐ and postintervention correlated with the corresponding change in maximal inspiratory pressure. Fatigue and mastery scores were improved by NIPPV. Median survivals in patients intolerant and tolerant of NIPPV were 5 and 20 months, respectively (P= 0.002). Although NIPPV has no impact on the rate of decline of lung function and may have deleterious effects on spirometric measures, it may improve quality of life and survival. © 2001 John Wiley & Sons, Inc. Muscle Nerve 24: 403–409, 2001.

The hepatopulmonary syndrome is a triad of liver disease, increased alveolar–arterial oxygen gradient and intrapulmonary vascular dilatations. Manifestations include orthodeoxia, platypnoea and hyperdynamic circulation. Intrapulmonary vascular abnormalities, perhaps mediated by nitric oxide, cause hypoxaemia by shunting, a perfusion–diffusion defect, and ventilation–perfusion mismatching. Contrast-enhanced echocardiography is the method of choice for demonstrating pulmonary vascular abnormalities, although perfusion lung scanning is a more specific and sensitive test. Angiography is best reserved for patients with poor response to 100% oxygen and defines whether vascular dilatations are of the diffuse ‘spongy’ type or, less commonly, discrete arteriovenous communications amenable to embolization. About 80% of patients with the hepatopulmonary syndrome eventually have improved oxygenation after liver transplantation, thereby making worsening hypoxaemia the primary indication for transplantation in many instances. Nevertheless, severe hypoxaemia carries a peri-operative mortality of 30% and reliable predictors of successful outcome after transplantation remain to be determined.

To prospectively study the utility of four clinical prediction models for either predicting the presence of obstructive sleep apnea (OSA, apnea-hypopnea index [AHI] > or = 10/hour), or prioritizing patients for a split-night protocol (AHI(3)20/hour).

The prevalence of acute methotrexate pneumonitis is up to 5.5. Its presentation is often difficult to distinguish from opportunistic infections such as Pneumocystis carinii, nocardia, and cryptococcus or from interstitial infiltrates from the underlying rheumatic disease. Its recognition rests on the presence of cough, dyspnea, fever, new pulmonary function test abnormalities, and acute infiltrates on chest radiograph. The diagnosis ultimately rests on histologic confirmation and exclusion of infection. Bronchoalveolar lavage for cultures, and special staining of lavage and transbronchial histopathology specimens, often allows identification of opportunistic pathogens. Transbronchial biopsy may provide sufficient material for the diagnosis of either methotrexate pneumonitis of rheumatoid lung, particularly when correlated with the clinical presentation. Open lung biopsy should be considered if a diagnosis cannot be obtained on bronchoscopy. Despite a mortality of up to 10, methotrexate pneumonitis usually responds to discontinuation of the drug and trial of corticosteroids.

We sought to determine whether preoperative fiberoptic pharyngoscopy (FOP) with Müller's maneuver (dynamic FOP) could be used to establish a subgroup of obstructive sleep apnea (OSA) patients with better outcome after uvulopalatopharyngoplasty (UPPP).

Upper airway obstruction is a potentially fatal condition that requires prompt diagnosis and treatment. Common causes include foreign body aspiration, infections (even in the adult population) and sequelae of intubation, tracheostomy, and transtracheal oxygen catheters. Spirometry is an insensitive test for diagnosing upper airway obstruction and reflects the functional, rather than anatomic, severity of an obstruction. Although simple tomography still plays an important role, CT and magnetic resonance imaging scans are useful additions to our diagnostic armamentarium. Advances in laser technology, surgery, and bronchoscopy have broadened treatment options but require further evaluation.

The current national coverage determinations (NCDs) for noninvasive ventilation for patients with thoracic restrictive disorders, COPD, and hypoventilation syndromes were formulated in 1998. New original research, updated formal practice guidelines, and current consensus expert opinion have accrued that are in conflict with the existing NCDs. Some inconsistencies in the NCDs have been noted, and the diagnostic and therapeutic technology has also advanced in the last quarter century. Thus, these and related NCDs relevant to bilevel positive airway pressure for the treatment of OSA and central sleep apnea need to be updated to ensure the optimal health of patients with these disorders. To that end, the American College of Chest Physicians organized a multisociety (American Thoracic Society, American Academy of Sleep Medicine, and American Association for Respiratory Care) effort to engage experts in the field to: (1) identify current barriers to optimal care; (2) highlight compelling scientific evidence that would justify changes from current policies incorporating best evidence and practice; and (3) propose suggestions that would form the basis for a revised NCD in each of these 5 areas (thoracic restrictive disorders, COPD, hypoventilation syndromes, OSA, and central sleep apnea). The expert panel met during a 2-day virtual summit in October 2020 and subsequently crafted written documents designed to achieve provision of “the right device to the right patient at the right time.” These documents have been endorsed by the participating societies following peer review and publication in CHESTand will be used to inform efforts to revise the current NCDs.