[Therapy of chronic respiratory insufficiency]

In patients with chronic respiratory insufficiency the treatment of the underlying pulmonary disease is of primary importance. However, many patients often also need symptomatic management to recompensate or stabilize impaired pulmonary gas exchange. The most suitable measures for this purpose are (1) ventilatory support by periodic intermittent positive pressure breathing (IPPB), (2) long-term oxygen administration and (3) respiratory stimulant drugs. IPPB provides good results if restricted to well defined indications (paO2 below 60 mm Hg, paCO2 above 45 mm Hg, forced expiratory volume [FEV1] below 40% of vital capacity or below 1000 ml). Long-term domiciliary oxygen therapy for at least 15 h daily prevents the early decompensation of cor pulmonale and improves physical performance. With the introduction of industrial O2-concentrators this form of therapy becomes more practicable and less expensive compared with the conventional method delivering compressed oxygen. However, the indication should be confined to patients with chronic and severe hypoxemia (paO2 below 50 mm Hg), pulmonary hypertension and secondary polycythemia. Respiratory stimulant drugs are useful in protecting patients from central respiratory depression during oxygen breathing. Aminophylline seems to be the most suitable drug simultaneously acting as a bronchodilator and vasodilator in the pulmonary circulation. To achieve a potent stimulant effect, serum theophylline levels above 10 microgram/ml through repeated intravenous administrations of aminophylline are required. Individual differences in the pharmacokinetic action of theophylline may sometimes need drug monitoring to prevent toxic side effects.