Kronik Obstrüktif Akciğer Hastalığında Noktürnal Noninvaziv Pozitif Basınçlı Ventilasyon
Yıl 2022,
Cilt: 31 Sayı: 2, 71 - 77, 30.06.2022
Özlem Özkan Kuşcu
,
Pınar Ergenoğlu
Öz
Kronik obstrüktif akciğer hastalığı (KOAH), zararlı gaz ve partiküllerin akciğerde yol açtığı inflamasyon nedeniyle hava yollarında ve alveollerde daralma ve solunum problemlerinin geliştiği, ilerleyici, kalıcı ve geri dönüşü olmayan bir hastalıktır. Önemli bir halk sağlığı sorunu olmaya devam etmesine rağmen tanı ve tedavi basamakları geliştirilmeye muhtaçtır.
Noninvaziv pozitif basınçlı ventilasyonun KOAH alevlenmesindeki rolü ve faydaları literatürde iyi tanımlanmıştır. Stabil ilerlemiş KOAH hastalarında noktürnal NPPV kullanımı ise tartışmalı bir konu olmaya devam etmekte ve bununla ilgili literatürde henüz yeterli veri ve kanıt bulunmamaktadır. Bu derlemede stabil ilerlemiş KOAH hastalarında noktürnal NPPV kullanımının etkilerinin değerlendirilmesi amaçlandı.
Kaynakça
- Referans 1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2013;380(9859):2095-128
- Referans 2. Halpin DMG, Criner GJ, Papi A, Singh D, Anzueto A, Martinez FJ, et al. Global Initiative for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease. The 2020 GOLD Science Committee Report on COVID-19 and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2021 Jan 1;203(1):24-36. doi: 10.1164/rccm.202009-3533SO. PMID: 33146552; PMCID: PMC7781116.
- Referans 3. Fan VS, Gaziano JM, Lew R, Bourbeau J, Adams SG, Leatherman S, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med. 2012 May 15;156(10):673-83. doi: 10.7326/0003-4819-156-10-201205150-00003. PMID: 22586006.
- Referans 4. Akashiba T, Ishikawa Y, Ishihara H, Imanaka H, Ohi M, Ochiai R, et al. The Japanese respiratory society noninvasive positive pressure ventilation (NPPV) guidelines. Respiratory investigation. 2017;55(1):83-92.
- Referans 5. Krachman SL, Berger TJ, Quaranta A, Cfiner GJ. Effects of noninvasive positive pressure ventilation on gas exchange and sleep in COPD patients. Chest. 1997;112(3):623-8.,
- Referans 6. Elliott M, Simonds A, Carroll M, Wedzicha J, Branthwaite M. Domiciliary nocturnal nasal intermittent positive pressure ventilation in hypercapnic respiratory failure due to chronic obstructive lung disease: effects on sleep and quality of life. Thorax. 1992;47(5):342-8.
- Referans 7. Casanova C, Celli BR, Tost L, Soriano E, Abreu J, Velasco V, et al. Long-term controlled trial of nocturnal nasal positive pressure ventilation in patients with severe COPD. CHEST Journal. 2000;118(6):1582-90
- Referans 8. Diaz O, Begin P, Andresen M, Prieto M, Castillo C, Jorquera J, et al. Physiological and clinical effects of diurnal noninvasive ventilation in hypercapnic COPD. European Respiratory Journal. 2005;26(6):1016-23.
- Referans 9. Liu Y, Dai B, Su J, Peng Y, Tan W, Zhao H. Effect of home noninvasive positive pressure ventilation on patients with severe stable chronic obstructive pulmonary disease: a meta-analysis. Zhonghua jie he he hu xi za zhi= Zhonghua jiehe he huxi zazhi= Chinese journal of tuberculosis and respiratory diseases. 2017;40(5):354.
- Referans 10. Budweiser S, Heinemann F, Fischer W, Dobroschke J, Pfeifer M. Long-term reduction of hyperinflation in stable COPD by non-invasive nocturnal home ventilation. Respiratory medicine. 2005;99(8):976-84.
- Referans 11. Elliott M, Mulvey D, Moxham J, Green M, Branthwaite M. Domiciliary nocturnal nasal intermittent positive pressure ventilation in COPD: mechanisms underlying changes in arterial blood gas tensions. European Respiratory Journal. 1991;4(9):1044-52.
- Referans 12. Leger P, Bedicam JM, Cornette A, Reybet-Degat O, Langevin B, Robert D, et al. Nasal intermittent positive pressure ventilation: long-term follow-up in patients with severe chronic respiratory insufficiency. Chest. 1994;105(1):100-5.
- Referans 13. Sivasothy P, Smith I, Shneerson J. Mask intermittent positive pressure ventilation in chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease. European Respiratory Journal. 1998;11(1):34-40.
- Referans 14. Jones S, Packham S, Hebden M, Smith A. Domiciliary nocturnal intermittent positive pressure ventilation in patients with respiratory failure due to severe COPD: long term follow up and effect on survival. Thorax. 1998;53(6):495-8.
- Referans 15. Ambrosino N, Nava S, Bertone P, Fracchia C, Rampulla C. Physiologic evaluation of pressure support ventilation by nasal mask in patients with stable COPD. Chest. 1992;101(2):385-91.
- Referans 16. Liu Y, Dai B, Su J, Peng Y, Tan W, Zhao H. Effect of home noninvasive positive pressure ventilation on patients with severe stable chronic obstructive pulmonary disease: a meta-analysis. Zhonghua jie he he hu xi za zhi= Zhonghua jiehe he huxi zazhi= Chinese journal of tuberculosis and respiratory diseases. 2017;40(5):354.
- Referans 17. Budweiser S, Heinemann F, Fischer W, Dobroschke J, Pfeifer M. Long-term reduction of hyperinflation in stable COPD by non-invasive nocturnal home ventilation. Respiratory medicine. 2005;99(8):976-84.
- Referans 18. Elliott M, Mulvey D, Moxham J, Green M, Branthwaite M. Domiciliary nocturnal nasal intermittent positive pressure ventilation in COPD: mechanisms underlying changes in arterial blood gas tensions. European Respiratory Journal. 1991;4(9):1044-52.
- Referans 19. Leger P, Bedicam JM, Cornette A, Reybet-Degat O, Langevin B, Robert D, et al. Nasal intermittent positive pressure ventilation: long-term follow-up in patients with severe chronic respiratory insufficiency. Chest. 1994;105(1):100-5.
- Referans 20. Sivasothy P, Smith I, Shneerson J. Mask intermittent positive pressure ventilation in chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease. European Respiratory Journal. 1998;11(1):34-40.
- Referans 21. Jones S, Packham S, Hebden M, Smith A. Domiciliary nocturnal intermittent positive pressure ventilation in patients with respiratory failure due to severe COPD: long term follow up and effect on survival. Thorax. 1998;53(6):495-8.
- Referans 22. Ambrosino N, Nava S, Bertone P, Fracchia C, Rampulla C. Physiologic evaluation of pressure support ventilation by nasal mask in patients with stable COPD. Chest. 1992;101(2):385-91.
- Referans 23. Bégin P, Grassino A. Inspiratory muscle dysfunction and chronic hypercapnia in chronic obstructive pulmonary disease. Am Rev Respir Dis. 1991;143(5 Pt 1):905-12.
- Referans 24. Rochester DF, Arora NS. Respiratory muscle failure. Med Clin North Am. 1983 May;67(3):573-97. doi: 10.1016/s0025-7125(16)31190-7. PMID: 6341727.
- Referans 25. Carrey Z, Gottfried SB, Levy RD. Ventilatory muscle support in respiratory failure with nasal positive pressure ventilation. Chest. 1990;97(1):150-8.
- Referans 26. Nava S, Ambrosino N, Rubini F, Fracchia C, Rampulla C, Torri G, et al. Effect of nasal pressure support ventilation and external PEEP on diaphragmatic activity in patients with severe stable COPD. Chest. 1993;103(1):143-50.
- Referans 27. Renston JP, DiMarco AF, Supinski GS. Respiratory muscle rest using nasal BiPAP ventilation in patients with stable severe COPD. Chest. 1994;105(4):1053-60.
- Referans 28. Belman MJ, Hoo GWS, Kuei JH, Shadmehr R. Efficacy of positive vs negative pressure ventilation in unloading the respiratory muscles. Chest. 1990;98(4):850-6.
- Referans 29. Schols AM, Soeters PB, Dingemans AM, Mostert R, Frantzen PJ, Wouters EF. Prevalence and characteristics of nutritional depletion in patients with stable COPD eligible for pulmonary rehabilitation. Am Rev Respir Dis. 1993 May;147(5):1151-6. doi: 10.1164/ajrccm/147.5.1151. PMID: 8484624.
- Referans 30. Creutzberg EC, Wouters EF, Mostert R, Weling-Scheepers CA, Schols AM. Efficacy of nutritional supplementation therapy in depleted patients with chronic obstructive pulmonary disease. Nutrition. 2003 Feb;19(2):120-7. doi: 10.1016/s0899-9007(02)00841-9. PMID: 12591542.
- Referans 31. Layec G, Haseler LJ, Hoff J, Richardson RS. Evidence that a higher ATP cost of muscular contraction contributes to the lower mechanical efficiency associated with COPD: preliminary findings. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology. 2011;300(5):R1142-R7.
- Referans 32. Budweiser S, Heinemann F, Meyer K, Wild PJ, Pfeifer M. Weight gain in cachectic COPD patients receiving noninvasive positive-pressure ventilation. Respiratory care. 2006;51(2):126-32.
- Referans 33. Sin DD, Wong E, Mayers I, Lien DC, Feeny D, Cheung H, et al. Effects of nocturnal noninvasive mechanical ventilation on heart rate variability of patients with advanced COPD. Chest. 2007;131(1):156-63.
- Referans 34. Dreher M, Storre JH, Windisch W. Noninvasive ventilation during walking in patients with severe COPD: a randomised cross-over trial. European Respiratory Journal. 2007;29(5):930-6.
- Referans 35. Garrod R, Mikelsons C, Paul EA, Wedzicha JA. Randomized controlled trial of domiciliary noninvasive positive pressure ventilation and physical training in severe chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine. 2000;162(4):1335-41.
- Referans 36. Testa MA, Simonson DC. Assessment of quality-of-life outcomes. New England journal of medicine. 1996;334(13):835-40.
- Referans 37. Windisch W. Impact of home mechanical ventilation on health-related quality of life. European respiratory journal. 2008;32(5):1328-36.
- Referans 38. Clini E, Sturani C, Rossi A, Viaggi S, Corrado A, Donner C, et al. The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease patients. European Respiratory Journal. 2002;20(3):529-38.
- Referans 39. Vogelmeier CF, Criner GJ, Martínez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. Erratum to" Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary"[Arch Bronconeumol. 2017; 53: 128-49]. Archivos de bronconeumologia. 2017;53(7):411.
- Referans 40. Tuggey J, Plant P, Elliott M. Domiciliary non-invasive ventilation for recurrent acidotic exacerbations of COPD: an economic analysis. Thorax. 2003;58(10):867-71.
- Referans 41. Budweiser S, Hitzl A, Jörres R, Heinemann F, Arzt M, Schroll S, et al. Impact of noninvasive home ventilation on long‐term survival in chronic hypercapnic COPD: a prospective observational study. International journal of clinical practice. 2007;61(9):1516-22.
- Referans 42. Richards GN, Cistulli PA, Ungar RG, Berthon-Jones M, Sullivan CE. Mouth leak with nasal continuous positive airway pressure increases nasal airway resistance. Am J Respir Crit Care Med. 1996 Jul;154(1):182-6. doi: 10.1164/ajrccm.154.1.8680678. PMID: 8680678.
Nocturnal Noninvasive Positive Pressure Ventilation in Stable Severe Chronic Obstructive Pulmonary Disease
Yıl 2022,
Cilt: 31 Sayı: 2, 71 - 77, 30.06.2022
Özlem Özkan Kuşcu
,
Pınar Ergenoğlu
Öz
Chronic Obstructive Pulmonary Disease is characterized as a progressive and irreversible inflammatory response in the airways and alveoli because of exposure to noxious particles or gases. Excessive inflammation causes progressive, persistent, and not fully reversible structural changes and airflow limitation. Although COPD is a significant public health problem, diagnosis and treatment stages need to be improved.
Nocturnal Noninvasive Positive Pressure Ventilation is one of the treatment modalities of choice for COPD exacerbation, and the role and benefits of NPPV in COPD exacerbation are well defined, but the use of nocturnal NPPV on stable severe COPD individuals is controversial, and the evidence is not sufficient yet. This review evaluates the effects of nocturnal NPPV on stable COPD patients.
Kaynakça
- Referans 1. Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet. 2013;380(9859):2095-128
- Referans 2. Halpin DMG, Criner GJ, Papi A, Singh D, Anzueto A, Martinez FJ, et al. Global Initiative for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease. The 2020 GOLD Science Committee Report on COVID-19 and Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med. 2021 Jan 1;203(1):24-36. doi: 10.1164/rccm.202009-3533SO. PMID: 33146552; PMCID: PMC7781116.
- Referans 3. Fan VS, Gaziano JM, Lew R, Bourbeau J, Adams SG, Leatherman S, et al. A comprehensive care management program to prevent chronic obstructive pulmonary disease hospitalizations: a randomized, controlled trial. Ann Intern Med. 2012 May 15;156(10):673-83. doi: 10.7326/0003-4819-156-10-201205150-00003. PMID: 22586006.
- Referans 4. Akashiba T, Ishikawa Y, Ishihara H, Imanaka H, Ohi M, Ochiai R, et al. The Japanese respiratory society noninvasive positive pressure ventilation (NPPV) guidelines. Respiratory investigation. 2017;55(1):83-92.
- Referans 5. Krachman SL, Berger TJ, Quaranta A, Cfiner GJ. Effects of noninvasive positive pressure ventilation on gas exchange and sleep in COPD patients. Chest. 1997;112(3):623-8.,
- Referans 6. Elliott M, Simonds A, Carroll M, Wedzicha J, Branthwaite M. Domiciliary nocturnal nasal intermittent positive pressure ventilation in hypercapnic respiratory failure due to chronic obstructive lung disease: effects on sleep and quality of life. Thorax. 1992;47(5):342-8.
- Referans 7. Casanova C, Celli BR, Tost L, Soriano E, Abreu J, Velasco V, et al. Long-term controlled trial of nocturnal nasal positive pressure ventilation in patients with severe COPD. CHEST Journal. 2000;118(6):1582-90
- Referans 8. Diaz O, Begin P, Andresen M, Prieto M, Castillo C, Jorquera J, et al. Physiological and clinical effects of diurnal noninvasive ventilation in hypercapnic COPD. European Respiratory Journal. 2005;26(6):1016-23.
- Referans 9. Liu Y, Dai B, Su J, Peng Y, Tan W, Zhao H. Effect of home noninvasive positive pressure ventilation on patients with severe stable chronic obstructive pulmonary disease: a meta-analysis. Zhonghua jie he he hu xi za zhi= Zhonghua jiehe he huxi zazhi= Chinese journal of tuberculosis and respiratory diseases. 2017;40(5):354.
- Referans 10. Budweiser S, Heinemann F, Fischer W, Dobroschke J, Pfeifer M. Long-term reduction of hyperinflation in stable COPD by non-invasive nocturnal home ventilation. Respiratory medicine. 2005;99(8):976-84.
- Referans 11. Elliott M, Mulvey D, Moxham J, Green M, Branthwaite M. Domiciliary nocturnal nasal intermittent positive pressure ventilation in COPD: mechanisms underlying changes in arterial blood gas tensions. European Respiratory Journal. 1991;4(9):1044-52.
- Referans 12. Leger P, Bedicam JM, Cornette A, Reybet-Degat O, Langevin B, Robert D, et al. Nasal intermittent positive pressure ventilation: long-term follow-up in patients with severe chronic respiratory insufficiency. Chest. 1994;105(1):100-5.
- Referans 13. Sivasothy P, Smith I, Shneerson J. Mask intermittent positive pressure ventilation in chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease. European Respiratory Journal. 1998;11(1):34-40.
- Referans 14. Jones S, Packham S, Hebden M, Smith A. Domiciliary nocturnal intermittent positive pressure ventilation in patients with respiratory failure due to severe COPD: long term follow up and effect on survival. Thorax. 1998;53(6):495-8.
- Referans 15. Ambrosino N, Nava S, Bertone P, Fracchia C, Rampulla C. Physiologic evaluation of pressure support ventilation by nasal mask in patients with stable COPD. Chest. 1992;101(2):385-91.
- Referans 16. Liu Y, Dai B, Su J, Peng Y, Tan W, Zhao H. Effect of home noninvasive positive pressure ventilation on patients with severe stable chronic obstructive pulmonary disease: a meta-analysis. Zhonghua jie he he hu xi za zhi= Zhonghua jiehe he huxi zazhi= Chinese journal of tuberculosis and respiratory diseases. 2017;40(5):354.
- Referans 17. Budweiser S, Heinemann F, Fischer W, Dobroschke J, Pfeifer M. Long-term reduction of hyperinflation in stable COPD by non-invasive nocturnal home ventilation. Respiratory medicine. 2005;99(8):976-84.
- Referans 18. Elliott M, Mulvey D, Moxham J, Green M, Branthwaite M. Domiciliary nocturnal nasal intermittent positive pressure ventilation in COPD: mechanisms underlying changes in arterial blood gas tensions. European Respiratory Journal. 1991;4(9):1044-52.
- Referans 19. Leger P, Bedicam JM, Cornette A, Reybet-Degat O, Langevin B, Robert D, et al. Nasal intermittent positive pressure ventilation: long-term follow-up in patients with severe chronic respiratory insufficiency. Chest. 1994;105(1):100-5.
- Referans 20. Sivasothy P, Smith I, Shneerson J. Mask intermittent positive pressure ventilation in chronic hypercapnic respiratory failure due to chronic obstructive pulmonary disease. European Respiratory Journal. 1998;11(1):34-40.
- Referans 21. Jones S, Packham S, Hebden M, Smith A. Domiciliary nocturnal intermittent positive pressure ventilation in patients with respiratory failure due to severe COPD: long term follow up and effect on survival. Thorax. 1998;53(6):495-8.
- Referans 22. Ambrosino N, Nava S, Bertone P, Fracchia C, Rampulla C. Physiologic evaluation of pressure support ventilation by nasal mask in patients with stable COPD. Chest. 1992;101(2):385-91.
- Referans 23. Bégin P, Grassino A. Inspiratory muscle dysfunction and chronic hypercapnia in chronic obstructive pulmonary disease. Am Rev Respir Dis. 1991;143(5 Pt 1):905-12.
- Referans 24. Rochester DF, Arora NS. Respiratory muscle failure. Med Clin North Am. 1983 May;67(3):573-97. doi: 10.1016/s0025-7125(16)31190-7. PMID: 6341727.
- Referans 25. Carrey Z, Gottfried SB, Levy RD. Ventilatory muscle support in respiratory failure with nasal positive pressure ventilation. Chest. 1990;97(1):150-8.
- Referans 26. Nava S, Ambrosino N, Rubini F, Fracchia C, Rampulla C, Torri G, et al. Effect of nasal pressure support ventilation and external PEEP on diaphragmatic activity in patients with severe stable COPD. Chest. 1993;103(1):143-50.
- Referans 27. Renston JP, DiMarco AF, Supinski GS. Respiratory muscle rest using nasal BiPAP ventilation in patients with stable severe COPD. Chest. 1994;105(4):1053-60.
- Referans 28. Belman MJ, Hoo GWS, Kuei JH, Shadmehr R. Efficacy of positive vs negative pressure ventilation in unloading the respiratory muscles. Chest. 1990;98(4):850-6.
- Referans 29. Schols AM, Soeters PB, Dingemans AM, Mostert R, Frantzen PJ, Wouters EF. Prevalence and characteristics of nutritional depletion in patients with stable COPD eligible for pulmonary rehabilitation. Am Rev Respir Dis. 1993 May;147(5):1151-6. doi: 10.1164/ajrccm/147.5.1151. PMID: 8484624.
- Referans 30. Creutzberg EC, Wouters EF, Mostert R, Weling-Scheepers CA, Schols AM. Efficacy of nutritional supplementation therapy in depleted patients with chronic obstructive pulmonary disease. Nutrition. 2003 Feb;19(2):120-7. doi: 10.1016/s0899-9007(02)00841-9. PMID: 12591542.
- Referans 31. Layec G, Haseler LJ, Hoff J, Richardson RS. Evidence that a higher ATP cost of muscular contraction contributes to the lower mechanical efficiency associated with COPD: preliminary findings. American Journal of Physiology-Regulatory, Integrative and Comparative Physiology. 2011;300(5):R1142-R7.
- Referans 32. Budweiser S, Heinemann F, Meyer K, Wild PJ, Pfeifer M. Weight gain in cachectic COPD patients receiving noninvasive positive-pressure ventilation. Respiratory care. 2006;51(2):126-32.
- Referans 33. Sin DD, Wong E, Mayers I, Lien DC, Feeny D, Cheung H, et al. Effects of nocturnal noninvasive mechanical ventilation on heart rate variability of patients with advanced COPD. Chest. 2007;131(1):156-63.
- Referans 34. Dreher M, Storre JH, Windisch W. Noninvasive ventilation during walking in patients with severe COPD: a randomised cross-over trial. European Respiratory Journal. 2007;29(5):930-6.
- Referans 35. Garrod R, Mikelsons C, Paul EA, Wedzicha JA. Randomized controlled trial of domiciliary noninvasive positive pressure ventilation and physical training in severe chronic obstructive pulmonary disease. American journal of respiratory and critical care medicine. 2000;162(4):1335-41.
- Referans 36. Testa MA, Simonson DC. Assessment of quality-of-life outcomes. New England journal of medicine. 1996;334(13):835-40.
- Referans 37. Windisch W. Impact of home mechanical ventilation on health-related quality of life. European respiratory journal. 2008;32(5):1328-36.
- Referans 38. Clini E, Sturani C, Rossi A, Viaggi S, Corrado A, Donner C, et al. The Italian multicentre study on noninvasive ventilation in chronic obstructive pulmonary disease patients. European Respiratory Journal. 2002;20(3):529-38.
- Referans 39. Vogelmeier CF, Criner GJ, Martínez FJ, Anzueto A, Barnes PJ, Bourbeau J, et al. Erratum to" Global Strategy for the Diagnosis, Management, and Prevention of Chronic Obstructive Lung Disease 2017 Report: GOLD Executive Summary"[Arch Bronconeumol. 2017; 53: 128-49]. Archivos de bronconeumologia. 2017;53(7):411.
- Referans 40. Tuggey J, Plant P, Elliott M. Domiciliary non-invasive ventilation for recurrent acidotic exacerbations of COPD: an economic analysis. Thorax. 2003;58(10):867-71.
- Referans 41. Budweiser S, Hitzl A, Jörres R, Heinemann F, Arzt M, Schroll S, et al. Impact of noninvasive home ventilation on long‐term survival in chronic hypercapnic COPD: a prospective observational study. International journal of clinical practice. 2007;61(9):1516-22.
- Referans 42. Richards GN, Cistulli PA, Ungar RG, Berthon-Jones M, Sullivan CE. Mouth leak with nasal continuous positive airway pressure increases nasal airway resistance. Am J Respir Crit Care Med. 1996 Jul;154(1):182-6. doi: 10.1164/ajrccm.154.1.8680678. PMID: 8680678.