The authors would like to acknowledge David A. Miller for his contributions that remain unchanged from the first edition.
RATIONALE
I. Therapy of lung and respiratory dysfunction relies on an understanding of the pathophysiologic basis of the underlying condition.
A. Asthma is believed to result from episodic inflammatory changes within the airways due to inhaled pollen, dusts, and other irritants.
1. Hence, anti-inflammatory agents are the first-line drugs of choice.
a. Corticosteroids
b. Leukotriene-receptor antagonists
2. Other medications targeted at controlling infection, bronchospasm, and mucous plugging are used as needed.
B. Chronic obstructive pulmonary disease (COPD) is the result of more persistent inflammatory changes, usually caused by inhalation of tobacco smoke.
1. The resultant increase in cholinergic effects causes an increase in airway mucus and in bronchial smooth muscle tone.
2. Hence, anticholinergic therapy is indicated first.
4. Improvement in skeletal muscle endurance, specifically, of the diaphragm and the chest wall, may be the primary effect of theophylline.
5. Note that a polypharmacotherapeutic approach is often employed.
6. In addition, antimicrobial agents are used when infection is also present.
C. Acute respiratory distress syndrome (ARDS) may result from any severe inflammatory injury, including bacteremia, burns, pancreatitis, and trauma.
1. As a restrictive ventilatory defect, ARDS results in a reduction in pulmonary compliance.
2. The primary therapy for the condition remains the treatment of its cause. This primary treatment may involve the following:
a. Antimicrobials
b. Surgery
c. Correction of additional dysfunction
i. Hyperglycemia
ii. Azotemia
iii. Encephalopathy
3. Supportive care often involves the use of mechanical ventilatory assistance, it is hoped temporarily, to sustain the patient during treatment of the underlying condition.
D. Similarly, other restrictive ventilatory defects (e.g., interstitial pulmonary fibrosis [IPF], sarcoidosis, vasculitis) require treatment of the underlying cause of the defect, if any possible reduction in the degree of restriction is to be achieved.
II. Respiratory dysfunction requires an integrated approach to sustain the supply of oxygen to the patient and the removal of carbon dioxide.
A. It is equally important to consider nutrition as a primary treatment modality.
B. Respiratory disease requires the consumption of energy to sustain the work of breathing.
C. Extra nutritional resources must be available to provide the substrate that, with oxygen, will restore energy stores.
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