There are 2 major goals in the treatment of pulmonary disease. The first goal is to favorably alter the natural history of the disease. The second is to improve the patient’s symptoms and functional status and minimize associated problems.
Smoking cessation is the single most efficacious and cost-effective intervention in reducing the risk of COPD and slowing its progression. Ophthalmologists should not underestimate the power of even a brief discussion with a patient about the impact of smoking and the beneficial effects of smoking cessation.
Similarly, avoiding precipitants of airway obstruction is important in ameliorating asthmatic conditions. In patients with severe pulmonary hypertension and cor pulmonale, use of supplemental oxygen to maintain an arterial oxygen pressure above 60 mm Hg confers a modest reduction in pulmonary hypertension and improved survival rates. However, a patient receiving supplemental oxygen must be carefully monitored because such treatment may decrease the body’s respiratory drive to eliminate carbon dioxide, aggravating respiratory acidosis and possibly leading to carbon dioxide narcosis. Breathing exercises and postoperative chest physiotherapy have demonstrable short-term effects in improving respiratory function.
Noninvasive pressure support ventilation can be used to deliver increased airway pressure. Continuous positive airway pressure (CPAP) throughout the ventilation cycle improves alveolar oxygen exchange. In CPAP therapy, a tight, well-fitting mask is placed either over the patient’s mouth and nose or just over the nose. Noninvasive pressure support ventilation is recommended for patients with respiratory failure who are expected to quickly respond to medical therapy. Intubation and standard ventilation are preferred for patients who require total ventilatory support, because the mask may slip, and effective ventilation may cease.
Currently, the most effective treatment for OSA is CPAP; the positive pressure acts as a pneumatic splint to maintain airway patency. Treatment of OSA with CPAP therapy has been shown to improve daytime sleepiness, health-related quality of life, and mood and attendance at work, as well as reduce the risk of developing cardiovascular disease, refractory hypertension, coronary artery disease, congestive heart failure, arrhythmias, and stroke. Despite these proven benefits, a recent meta-analysis found that CPAP therapy did not reduce the risk of major cardiovascular events (acute coronary events, stroke, or vascular death) or all-cause mortality. In addition, although there are now over 100 different mask options to help optimize patient comfort and adherence to mask use, patient adherence to this treatment option is low due to discomfort; some patients still find the mask cumbersome to wear.
McEvoy RD, Antic NA, Heeley E, et al; SAVE Investigators and Coordinators. CPAP for prevention of cardiovascular events in obstructive sleep apnea. N Engl J Med. 2016;375(10):919–931.
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Yu J, Zhou Z, McEvoy RD, Anderson CS, Rodgers A, Perkovic V, Neal B. Association of positive airway pressure with cardiovascular events and deaths in adults with sleep apnea: a systematic review and meta-analysis. JAMA. 2017;318(2):156–166.
Excerpted from BCSC 2020-2021 series: Section 1 - Update on General Medicine. For more information and to purchase the entire series, please visit https://www.aao.org/bcsc.