Individualizing the selection of long-acting bronchodilator therapy for patients with COPD: considerations in primary care.

Chronic obstructive pulmonary disease (COPD) is a common condition encountered in primary care settings. COPD remains the third leading cause of death in the United States and carries a significant burden to both patients and the healthcare system. COPD is a chronic, progressive, irreversible lung disease associated with high morbidity and mortality. Proper assessment and diagnosis requires spirometry which is currently underutilized in primary care. Management is focused on adequate symptom control, improving quality of breathing and quality of life, and preventing exacerbations and hospitalizations. However, many patients are not receiving long-acting bronchodilator maintenance therapy as recommended in current clinical guidelines. Even when patients receive appropriate therapy, real-world issues such as a patient's health literacy, physical and cognitive limitations, and therapy nonadherence limit the effectiveness of prescribed inhaled medications. Primary care providers are well situated to ensure that prescribed therapies and long-term management goals are matched to the individual needs of patients with COPD.

Pulmonary rehabilitation: WHAT WE KNOW AND WHAT WE NEED TO KNOW.

The multidisciplinary treatment of pulmonary rehabilitation (PR), which includes exercise training, self-management education, and psychosocial and nutritional intervention, is now a standard of care for chronic obstructive pulmonary disease (COPD) and has been incorporated into major guidelines. We must now focus efforts on improving its impact and widening its applicability. What is the direction of PR; where does it fit in the comprehensive care of the COPD patient; and how can clinicians best apply this important intervention? This was the charge of the roundtable discussion, Pulmonary Rehabilitation: Moving Forward, involving 20 experts from North America and Europe, which was convened in Fort Lauderdale, Florida, in early 2008. It is not meant to be an exhaustive review; rather, this report summarizes the roundtable proceedings, while providing direction to best position PR into the continuum of COPD care. By consensus, it was agreed upon that although PR is effective for other chronic respiratory diseases, the discussion focus was COPD since most of the evidence base and patient referral are for this disease. These proceedings provide insight into 3 broad areas appropriate for investigation or implementation: positioning PR in an integrated care model for COPD patients; improving the effectiveness of this intervention; and expanding the recognition, application, and accessibility to PR. It is the hope that this document will provide a catalyst for clinicians, investigators, and healthcare policy makers to help realize these goals as well as serve to suggest important areas for future research and development in PR.

The use of hypertonic saline for fluid resuscitation in sepsis: a review.

Early volume resuscitation of a patient with sepsis has been shown to reduce morbidity, mortality, and healthcare resource consumption. Hypertonic saline offers a theoretically viable option for volume resuscitation. This article reviews the current information available regarding fluid resuscitation in patients with sepsis, with emphasis on the use of hypertonic saline.