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Fibrinous Uremic Pleuritis: A Surgical Entity
Fibrinous Uremic Pleuritis: A Surgical Entity Lawrence GillJert, M.D., F.C.C.P.; 0 Seymour Rihot, M.D.; 00 Hou:ard Frankel, M.D.;t Martin ]acohs, M.D., F.C.C.P.;t and Barry/. Mankotcitz, M.D.§
Fibrosing uremic pleuritis is a newly recognized late complication of uremia. Extreme incarceration of the lining and chest waH can occur with disabling restriction of
pulmonary function. Decortication of the chest wall and the lung can be carried out safely with minimal bleeding and restoration of pulmonary function.
uremic pleuritis is a little known and seemingly unimportant complication of uremia. Its association with uremic pneumonia was alluded to in 1954 hy Hopps and Wissler. 1 ~1ore recently, Nidus and co-workers 2 increased interest in uremic pleuritis by describing its presence as an entity independent of pneumonia, still without major clinical significance. We report a case of bilateral uremic pleuritis so progressive in its course that remarkable, totally incapacitating pulmonary restriction occurred which required surgical intervention.
mesothelial cells with a specific gravity of 1.015. Culture of the aspirate yielded no growth of pathogens, acid-fast bacilli or mycotic organisms. There were no episodes of traumatic bleeding or infection. A needle biopsy showed a fibrinous pleuritis. In December of 1969, the patient was admitted with severe dyspnea and now was found to have extensive bilateral pleural involvement (Fig 1 ). Improvement in respiration was only obtained by frequent thoracentesis of the right pleural cavity.
CASE REPORT
During her hospitalization, the BUN and electrolytes were controlled with dialysis (Table 1). In preparation for surgery, her hemoglobin and hematocrit levels were gradually raised
A 32-year-old housewife was admitted to the Newark Beth Israel Medical Center on January 16, 1970 for incapacitating, relentless dyspnea. She ha~ known uremia secondary to pyelonephritis and has required hemodialysis three times per week for the pa~t two and one-half years. Hemodialysis was conducted with a Kiil dialyzer, each treatment for ten hours' duration with Aow rates of 200 ml per minute. Weight change hetween dialyses was usually less than three pounds. In May of 1969, she required pericardiocentesis for pericardia! effusion. At this time a moderate left plemal effusion was noted. By October 1969, the left plemal effusion had advanced to obliterate three-quarters of the left chest and a beginning haziness was noted in the right costophrenic angle. Frequent left thoracenteses were required for control. The pleural Auid cell block showed leukocytes, macrophages and Director, Thoracic and Cardiac Surgery, 1\:ewark Beth Israel Medical Center; Associate Professor of Surgery, Thoracic, New Jersey Colle!(e of Medicine and Dentistry, Newark. 00 Direetor of Nephrolo!t}'. Newark Beth Israel Medical Center: Assistant Clinical Professor of Medicine, New Jersey College of \ledicine and Dentistry. +Associate Director of Nephrology, Newark Beth Israel Medical Center; Clinical Assistant Professor of \fedicine, New Jersey College of \ledicine and Dentistry. !Clinical Assistant Professor of l\ledicine, New Jersey College of Medicine and Dentistry, 1\:ewark; Director of Nephrology, St. Barnabas Medical Center, Livingston, N.J. §lnstmetor in Surgery, New Jersey College of Medicine and Dentistrv. l\lanuscript received Febmary 16, 1972; revision accepted June 17. Reprir1t requests: Dr. Gilbert, 201 Lyons Avenue, Neu:ark, Nerc ]erscy071 12
Laboratory Data
Admission laboratory data are shown in Table 1. Course in Hospital
0
CHEST, 67: 1, JANUARY, 1975
FH;L"nE l. Chest roent~~:enogram, January 1970 ( preoperation) showing advanced bilateral pleural involvement.
FIBRINOUS UREMIC PLEURITIS 53
Table 1-Biood Chemidry and Peripheral Blood J1 alue• at Key Stale• of Management 32-year-old woman, 5'3", 85 lbs., 1.34 M 2 Chemistries Time
Dialysis Status
Blood BUN
CR
Na
K
CL
C02
Hb
Ht
6.2
19
Admission
Pre
83
9.9
132
5.6
90
21.9
Pre-op day
Post
25
3.6
142
2.3
98
24
10.2
31
Day of surg.
None
41
133
4.1
93.3
1st PO day
None
49
7
140
4
94
21
10.6
33
2nd PO day
Pre
59
9.6
136
4.5
93
16
2nd PO day
Post
28
140
3.3
101
Blood urea nitrogen (BUN) and creatinine (CR)
ar~
24.9
expressed in mg %. Serum electrolytes are expressed in milliequivalents.
by transfusions to 10.2 and 31 percent respectively. The last hemodialysis was carried out the afternoon and evening prior to surgery.
ACD blood drawn fresh the same morning. The thoracic cavity was drained with two No. 36 French thoracostomy tubes. The chest wall was reconstructed and maintained in anatomic layers.
Pulmonary Function Studies
Postoperative Course
There was severe reduction of the vital capacity associated with remarkable restrictive lung disease (Table 2).
This was routine and unremarkable. The first hemodialysis was carried out on the second postoperative day employing regional heparization and on a routine three times per week thereafter. The chest tubes were removed on the third postoperative day. At this time, an x-ray picture of the chest showed full expansion of the left lung with good delineation of the costophrenic angle. The wound healed per prim urn. Pulmonary function studies carried out on the tenth postoperative day showed considerable improvement (Table 2 ) . The patient was discharged from the hospital on the lith postsurgical day.
Smgery On the tenth hospital day, left thoracotomy was performed through a standard posterolateral incision. The seventh and eighth ribs were shingled. The pleural cavity was then entered to determine the extent of pleural disease. Total decortication was carried out separating the thick pleura from the chest wall, lung surface and pericardium. Blood loss was surprisingly minimal and was replaced with
Table 2-Chronologie Pulmonary Funelion Studiea lllualraling Sequence o/lmprtnJemenl 32-year-old woman, 5'3", 85 lbs., 1.34 M 2
Tidal volume
Predicted
Before Surgery
10 Days Postoperation
Normals
12/31/69
350-550 ml
Respiratory rate Minute volumes
Liters/minute
Oxygen uptake
250 ml
Vital capacity
2.97 liters
%predicted Timed vital cap.
83%
Max expiratory flow
Liters/minute
Max breathing cap.
77 L/M
'1o predicted Frnetional uptake Carbon monoxide
'7o of predicted
54 GILBERT ET AL
10.5-28 mi/M/mm Hg
2 Mos. PO
9 Mos. PO
2/5/70
3/24/70
10/19/70
297
315
360
345
21
19
16
13
6.5 200
6.0
225
200
.900
.850
5.75
1.200
4.5 250 1.600
29
31
41
55
91
92
87
90
114
156
156
168
20
30
36
42
26
39
47
53
5 29
6.7 39
6.9 41
46
CHEST, 67: 1, JANUARY, 1975
FIGURE 3. Chest roentgenogram, January 1971, one year after operation with relatively normal left hemithorax and resorbing right pleural effusion.
2. Photo~raph showing the pleural cavitary surface of the peel with the thoracic aspect split longitudinally. FIGURE
Pathology
The specimen consisted of a broad sheet of thickened pleura measuring 14 X 14.5 ern. The thickness varied from 1.5 em at its thickest portion, and averaged .5 to .6 ern throughout ( Fig 2). Collagenous thickening, remote hemorrhage, mild chronic inflammation and hyalinized fibrin were demonstrated throughout. Follou.:-up
In the following 20 month period, repeated pulmonary function studies showed steady improvement (Table 2) and chest roentgenograms (Fig 3) continued to show further clearing of the lun~ fields with much unexpected spontaneous resolution of the right pleural effusion. At present, this active housewife is undergoing home hemodialysis three times a week and disclaims any disability or discomfort due to pulmonary function. DISCUSSION
The longer life span uremic patients on dialysis now enjoy permits living with altered levels of body chemicals, known and unknown, associated with the uremic state. These alterations probably have an etiologic relationship to complicating pathology, the importance and extent of which is growing in relation to the increased life span of patients with end stage renal disease. Fibrosing pleuritis is the newest of these important complications. Many factors were of concern in the management of this patient: extremely poor pulmonary function; wound healing; and the possibility of excessive bleeding created by the decortication. CHEST, 67: 1, JANUARY, 1975
Pulmonary function could be only temporarily improved by repeated right thoracentesis. On the left side, attempted thoracentesis during the last admission repeatedly failed and also indicated the thickness and induration of the parietal pleura, with incarceration of the left lung. For these reasons, it was elected to decorticate the left hemithorax because it was the only procedure that realistically could improve function. Wound healing in these patients has proved to be reasonably good if associated with proper surgery and management. Hampers and co-workers 3 detailed the successful management of a large group of uremics undergoing major surgery. In our own experience with mitral valve replacement4 as well as 25 fenestration pericardotomies5 in hemodialysis dependent patients, wound healing has not been a problem. By our plan, the patient is brought into optimal chemical and acid-base balance by frequent hemodialysis, the last being the afternoon prior to surgery, and the hemoglobin and hematocrit levels are raised to a minimum of 10 gm and 30 percent respectively. The tendency for uremics to bleed is a well-recognized clinical phenomenon. 6 In this regard, the decortication concerned us, for we had no way of knowing the pathologic extent of invasion of the lung and parietes by the uremic fibrinous process. Acid citrate dextrose blood, drawn fresh the morning of surgery, was prepared to replace blood loss and to combat any excessive capillary oozing. At surgery, the parietal peel was decorticated without excessive bleeding. The pulmonary peel, much to FIBRINOUS UREMIC PLEURITIS 55
our surprise, separated with gratifying ease in a perfect plane, causing no surface lung tear or bleeding. In a similar manner, the costophrenic sulcus was cleared easily. There was no tissue in-
vasion of the lung by the uremic fibrinous pleural process. REFERENCES
Hopps HC, Wissler RW: Uremic pneumonitis. Am J Path 31:261-267, 1955 2 Nidus BD, Matalon R, Cantacuzino D, et al: Uremic
3 4
5 6
pleuritis-a clinicopathological entity. N Eng! ] Med 281: 255-256, 1969 Hampers CL, Bailey GL, Hager ES, et al: Major surgery in patients on maintenance hemodialysis. Am J Surg 115: 747-754, 1968 Ribot S, Gilbert L, Rothfeld EL, et al: Bacterial endocarditis with pulmonary edema necessitating mitral valve replacement in a hemodialysis dependent patient. ] Thorac Cardiovasc Surg 62:59-62, 1971 Ribot S, Gilbert L, Frankel HJ, et al: Treatment of uremic pericarditis. Clin Nephrol (in press) Horowitz HI: Uremic toxins and platelet function. Arch Intern Med 125:823, 1970
Rehabilitation of Patients with Chronic Obstructive Pulmonary Diseases Most communities today are seriously deficient in the essential medical resources required for the optimal longterm treatment of patients with obstructive puhnonary diseases such as bronchitis and emphysema, according to a report published by the Inter-Society Commission for Heart Disease Resources ( ICHD). To help alleviate this problem, ICHD has developed an approach it feels will result in increased patient access to excellent cardiopulmonary care during the da·ades ahead. The full report, entitled "Community Resources for Rehabilitation of Patients with Chronic Obstructive Pulmonary Diseases and Cor Puhnonale," is available from chapters and affiliates of the American Heart Association and the American Lung Association. Th~ report outlines the basic principles of rehabilitation and then recommends a stratified system of care for organizing community resources. Stratified care means that medical facilities within a community or region should be organized into a layered system where each has a defined and complementary-not duplicativefunction based on community need. Three levels of care are identified: ( 1) the primary physician's office or group practice, ( 2) the community hospital rehabilitation unit, and ( 3) the regional reference center. Stressing the importance of the hospital unit the report states: "Though the primary physician should retain responsibility for supervision of the patient's medical care, it is essential that the community provide him with certain supporting services that are often required by these patients because of the multiple problems associated with chronic cardiopulmonary disease. The principal supporting service is an organized and professionally directed community hospital respiratory rehabilitation unit. As required, patients can be referred to this unit for
56 GILBERT ET AL
consultation and evaluation and through its coordinated team approach for the entire range of ancillary services necessary for optimal care. Without such an organized approach, most physicians will find it extremely difficult to provide the kind of comprehensive rehabilitation and long-term management necessary for the well being of these patients. It is, therefore, recommended that communities and regions develop such a physician and patient support system as an essential medical resource for the care of respiratory patients." For optimal care, ICHD recommends services that should be provided by these units: patient and family instruction, chest physiotherapy, inhalation therapy, pulmonary function studies, bacteriology and blood gas analysis laboratories, home nursing care, psychiatric consultation, exercise prescription and training, vocational counseling, retraining and placement, social services including homemaker services, family and financial counseling and direction to community resources, programs to help patients stop smoking and patient transportation services. In appendices the report then gives detailed descriptions of three model programs tailored to meet the needs of large cities, suburban communities and sparsely populated rural areas. The report also stresses the need for early identification of patients with chronic obstructive pulmonary diseases because of the prevalence of significant undetected COPD in our population and because early recognition may serve to motivate young patients at risk to stop smoking. ICHD, composed of experts in cardiovascular disease who represent 29 medical and nursing organizations, was formed under a contract with the federal Regional Medical Programs Service.
CHEST, 67: 1, JANUARY, 1975
Fibrosing uremic pleuritis is a newly recognized late complication of uremia. Extreme incarceration of the lining and chest waH can occur with disabling restriction of
pulmonary function. Decortication of the chest wall and the lung can be carried out safely with minimal bleeding and restoration of pulmonary function.
uremic pleuritis is a little known and seemingly unimportant complication of uremia. Its association with uremic pneumonia was alluded to in 1954 hy Hopps and Wissler. 1 ~1ore recently, Nidus and co-workers 2 increased interest in uremic pleuritis by describing its presence as an entity independent of pneumonia, still without major clinical significance. We report a case of bilateral uremic pleuritis so progressive in its course that remarkable, totally incapacitating pulmonary restriction occurred which required surgical intervention.
mesothelial cells with a specific gravity of 1.015. Culture of the aspirate yielded no growth of pathogens, acid-fast bacilli or mycotic organisms. There were no episodes of traumatic bleeding or infection. A needle biopsy showed a fibrinous pleuritis. In December of 1969, the patient was admitted with severe dyspnea and now was found to have extensive bilateral pleural involvement (Fig 1 ). Improvement in respiration was only obtained by frequent thoracentesis of the right pleural cavity.
CASE REPORT
During her hospitalization, the BUN and electrolytes were controlled with dialysis (Table 1). In preparation for surgery, her hemoglobin and hematocrit levels were gradually raised
A 32-year-old housewife was admitted to the Newark Beth Israel Medical Center on January 16, 1970 for incapacitating, relentless dyspnea. She ha~ known uremia secondary to pyelonephritis and has required hemodialysis three times per week for the pa~t two and one-half years. Hemodialysis was conducted with a Kiil dialyzer, each treatment for ten hours' duration with Aow rates of 200 ml per minute. Weight change hetween dialyses was usually less than three pounds. In May of 1969, she required pericardiocentesis for pericardia! effusion. At this time a moderate left plemal effusion was noted. By October 1969, the left plemal effusion had advanced to obliterate three-quarters of the left chest and a beginning haziness was noted in the right costophrenic angle. Frequent left thoracenteses were required for control. The pleural Auid cell block showed leukocytes, macrophages and Director, Thoracic and Cardiac Surgery, 1\:ewark Beth Israel Medical Center; Associate Professor of Surgery, Thoracic, New Jersey Colle!(e of Medicine and Dentistry, Newark. 00 Direetor of Nephrolo!t}'. Newark Beth Israel Medical Center: Assistant Clinical Professor of Medicine, New Jersey College of \ledicine and Dentistry. +Associate Director of Nephrology, Newark Beth Israel Medical Center; Clinical Assistant Professor of \fedicine, New Jersey College of \ledicine and Dentistry. !Clinical Assistant Professor of l\ledicine, New Jersey College of Medicine and Dentistry, 1\:ewark; Director of Nephrology, St. Barnabas Medical Center, Livingston, N.J. §lnstmetor in Surgery, New Jersey College of Medicine and Dentistrv. l\lanuscript received Febmary 16, 1972; revision accepted June 17. Reprir1t requests: Dr. Gilbert, 201 Lyons Avenue, Neu:ark, Nerc ]erscy071 12
Laboratory Data
Admission laboratory data are shown in Table 1. Course in Hospital
0
CHEST, 67: 1, JANUARY, 1975
FH;L"nE l. Chest roent~~:enogram, January 1970 ( preoperation) showing advanced bilateral pleural involvement.
FIBRINOUS UREMIC PLEURITIS 53
Table 1-Biood Chemidry and Peripheral Blood J1 alue• at Key Stale• of Management 32-year-old woman, 5'3", 85 lbs., 1.34 M 2 Chemistries Time
Dialysis Status
Blood BUN
CR
Na
K
CL
C02
Hb
Ht
6.2
19
Admission
Pre
83
9.9
132
5.6
90
21.9
Pre-op day
Post
25
3.6
142
2.3
98
24
10.2
31
Day of surg.
None
41
133
4.1
93.3
1st PO day
None
49
7
140
4
94
21
10.6
33
2nd PO day
Pre
59
9.6
136
4.5
93
16
2nd PO day
Post
28
140
3.3
101
Blood urea nitrogen (BUN) and creatinine (CR)
ar~
24.9
expressed in mg %. Serum electrolytes are expressed in milliequivalents.
by transfusions to 10.2 and 31 percent respectively. The last hemodialysis was carried out the afternoon and evening prior to surgery.
ACD blood drawn fresh the same morning. The thoracic cavity was drained with two No. 36 French thoracostomy tubes. The chest wall was reconstructed and maintained in anatomic layers.
Pulmonary Function Studies
Postoperative Course
There was severe reduction of the vital capacity associated with remarkable restrictive lung disease (Table 2).
This was routine and unremarkable. The first hemodialysis was carried out on the second postoperative day employing regional heparization and on a routine three times per week thereafter. The chest tubes were removed on the third postoperative day. At this time, an x-ray picture of the chest showed full expansion of the left lung with good delineation of the costophrenic angle. The wound healed per prim urn. Pulmonary function studies carried out on the tenth postoperative day showed considerable improvement (Table 2 ) . The patient was discharged from the hospital on the lith postsurgical day.
Smgery On the tenth hospital day, left thoracotomy was performed through a standard posterolateral incision. The seventh and eighth ribs were shingled. The pleural cavity was then entered to determine the extent of pleural disease. Total decortication was carried out separating the thick pleura from the chest wall, lung surface and pericardium. Blood loss was surprisingly minimal and was replaced with
Table 2-Chronologie Pulmonary Funelion Studiea lllualraling Sequence o/lmprtnJemenl 32-year-old woman, 5'3", 85 lbs., 1.34 M 2
Tidal volume
Predicted
Before Surgery
10 Days Postoperation
Normals
12/31/69
350-550 ml
Respiratory rate Minute volumes
Liters/minute
Oxygen uptake
250 ml
Vital capacity
2.97 liters
%predicted Timed vital cap.
83%
Max expiratory flow
Liters/minute
Max breathing cap.
77 L/M
'1o predicted Frnetional uptake Carbon monoxide
'7o of predicted
54 GILBERT ET AL
10.5-28 mi/M/mm Hg
2 Mos. PO
9 Mos. PO
2/5/70
3/24/70
10/19/70
297
315
360
345
21
19
16
13
6.5 200
6.0
225
200
.900
.850
5.75
1.200
4.5 250 1.600
29
31
41
55
91
92
87
90
114
156
156
168
20
30
36
42
26
39
47
53
5 29
6.7 39
6.9 41
46
CHEST, 67: 1, JANUARY, 1975
FIGURE 3. Chest roentgenogram, January 1971, one year after operation with relatively normal left hemithorax and resorbing right pleural effusion.
2. Photo~raph showing the pleural cavitary surface of the peel with the thoracic aspect split longitudinally. FIGURE
Pathology
The specimen consisted of a broad sheet of thickened pleura measuring 14 X 14.5 ern. The thickness varied from 1.5 em at its thickest portion, and averaged .5 to .6 ern throughout ( Fig 2). Collagenous thickening, remote hemorrhage, mild chronic inflammation and hyalinized fibrin were demonstrated throughout. Follou.:-up
In the following 20 month period, repeated pulmonary function studies showed steady improvement (Table 2) and chest roentgenograms (Fig 3) continued to show further clearing of the lun~ fields with much unexpected spontaneous resolution of the right pleural effusion. At present, this active housewife is undergoing home hemodialysis three times a week and disclaims any disability or discomfort due to pulmonary function. DISCUSSION
The longer life span uremic patients on dialysis now enjoy permits living with altered levels of body chemicals, known and unknown, associated with the uremic state. These alterations probably have an etiologic relationship to complicating pathology, the importance and extent of which is growing in relation to the increased life span of patients with end stage renal disease. Fibrosing pleuritis is the newest of these important complications. Many factors were of concern in the management of this patient: extremely poor pulmonary function; wound healing; and the possibility of excessive bleeding created by the decortication. CHEST, 67: 1, JANUARY, 1975
Pulmonary function could be only temporarily improved by repeated right thoracentesis. On the left side, attempted thoracentesis during the last admission repeatedly failed and also indicated the thickness and induration of the parietal pleura, with incarceration of the left lung. For these reasons, it was elected to decorticate the left hemithorax because it was the only procedure that realistically could improve function. Wound healing in these patients has proved to be reasonably good if associated with proper surgery and management. Hampers and co-workers 3 detailed the successful management of a large group of uremics undergoing major surgery. In our own experience with mitral valve replacement4 as well as 25 fenestration pericardotomies5 in hemodialysis dependent patients, wound healing has not been a problem. By our plan, the patient is brought into optimal chemical and acid-base balance by frequent hemodialysis, the last being the afternoon prior to surgery, and the hemoglobin and hematocrit levels are raised to a minimum of 10 gm and 30 percent respectively. The tendency for uremics to bleed is a well-recognized clinical phenomenon. 6 In this regard, the decortication concerned us, for we had no way of knowing the pathologic extent of invasion of the lung and parietes by the uremic fibrinous process. Acid citrate dextrose blood, drawn fresh the morning of surgery, was prepared to replace blood loss and to combat any excessive capillary oozing. At surgery, the parietal peel was decorticated without excessive bleeding. The pulmonary peel, much to FIBRINOUS UREMIC PLEURITIS 55
our surprise, separated with gratifying ease in a perfect plane, causing no surface lung tear or bleeding. In a similar manner, the costophrenic sulcus was cleared easily. There was no tissue in-
vasion of the lung by the uremic fibrinous pleural process. REFERENCES
Hopps HC, Wissler RW: Uremic pneumonitis. Am J Path 31:261-267, 1955 2 Nidus BD, Matalon R, Cantacuzino D, et al: Uremic
3 4
5 6
pleuritis-a clinicopathological entity. N Eng! ] Med 281: 255-256, 1969 Hampers CL, Bailey GL, Hager ES, et al: Major surgery in patients on maintenance hemodialysis. Am J Surg 115: 747-754, 1968 Ribot S, Gilbert L, Rothfeld EL, et al: Bacterial endocarditis with pulmonary edema necessitating mitral valve replacement in a hemodialysis dependent patient. ] Thorac Cardiovasc Surg 62:59-62, 1971 Ribot S, Gilbert L, Frankel HJ, et al: Treatment of uremic pericarditis. Clin Nephrol (in press) Horowitz HI: Uremic toxins and platelet function. Arch Intern Med 125:823, 1970
Rehabilitation of Patients with Chronic Obstructive Pulmonary Diseases Most communities today are seriously deficient in the essential medical resources required for the optimal longterm treatment of patients with obstructive puhnonary diseases such as bronchitis and emphysema, according to a report published by the Inter-Society Commission for Heart Disease Resources ( ICHD). To help alleviate this problem, ICHD has developed an approach it feels will result in increased patient access to excellent cardiopulmonary care during the da·ades ahead. The full report, entitled "Community Resources for Rehabilitation of Patients with Chronic Obstructive Pulmonary Diseases and Cor Puhnonale," is available from chapters and affiliates of the American Heart Association and the American Lung Association. Th~ report outlines the basic principles of rehabilitation and then recommends a stratified system of care for organizing community resources. Stratified care means that medical facilities within a community or region should be organized into a layered system where each has a defined and complementary-not duplicativefunction based on community need. Three levels of care are identified: ( 1) the primary physician's office or group practice, ( 2) the community hospital rehabilitation unit, and ( 3) the regional reference center. Stressing the importance of the hospital unit the report states: "Though the primary physician should retain responsibility for supervision of the patient's medical care, it is essential that the community provide him with certain supporting services that are often required by these patients because of the multiple problems associated with chronic cardiopulmonary disease. The principal supporting service is an organized and professionally directed community hospital respiratory rehabilitation unit. As required, patients can be referred to this unit for
56 GILBERT ET AL
consultation and evaluation and through its coordinated team approach for the entire range of ancillary services necessary for optimal care. Without such an organized approach, most physicians will find it extremely difficult to provide the kind of comprehensive rehabilitation and long-term management necessary for the well being of these patients. It is, therefore, recommended that communities and regions develop such a physician and patient support system as an essential medical resource for the care of respiratory patients." For optimal care, ICHD recommends services that should be provided by these units: patient and family instruction, chest physiotherapy, inhalation therapy, pulmonary function studies, bacteriology and blood gas analysis laboratories, home nursing care, psychiatric consultation, exercise prescription and training, vocational counseling, retraining and placement, social services including homemaker services, family and financial counseling and direction to community resources, programs to help patients stop smoking and patient transportation services. In appendices the report then gives detailed descriptions of three model programs tailored to meet the needs of large cities, suburban communities and sparsely populated rural areas. The report also stresses the need for early identification of patients with chronic obstructive pulmonary diseases because of the prevalence of significant undetected COPD in our population and because early recognition may serve to motivate young patients at risk to stop smoking. ICHD, composed of experts in cardiovascular disease who represent 29 medical and nursing organizations, was formed under a contract with the federal Regional Medical Programs Service.
CHEST, 67: 1, JANUARY, 1975