Although medical treatment of COPD has advanced, nonadherence to medication regimens poses a significant barrier to optimal management. Underuse, overuse, and improper use continue to be the most common causes of poor adherence to therapy. An average of 40%–60% of patients with COPD adheres to the prescribed regimen and only 1 out of 10 patients with a metered dose inhaler performs all essential steps correctly. Adherence to therapy is multifactorial and involves both the patient and the primary care provider. The effect of patient instruction on inhaler adherence and rescue medication utilization in patients with COPD does not seem to parallel the good results reported in patients with asthma. While use of a combined inhaler may facilitate adherence to medications and improve efficacy, pharmacoeconomic factors may influence patient’s selection of both the device and the regimen. Patient’s health beliefs, experiences, and behaviors play a significant role in adherence to pharmacological therapy. This manuscript reviews important aspects associated with medication adherence in patients with COPD and identifies some predictors of poor adherence.

When the upper airway is bypassed during invasive mechanical ventilation, humidification is necessary to prevent hypothermia, disruption of the airway epithelium, bronchospasm, atelectasis, and airway obstruction. In severe cases, inspissation of airway secretions may cause occlusion of the endotracheal tube. 1 While there is not clear consensus on whether or not additional heat and humidity are always necessary when the upper airway is not bypassed, such as in noninvasive mechanical ventilation (NIV), active humidification is highly suggested to improve comfort. [2][3][4][5][6][7] Two systems, active humidification through a heated humidifier (HH) and passive humidification through a heat and moisture exchanger (HME), are available for warming and humidifying gases delivered to mechanically ventilated patients. There are 3 types of HME or artificial nose: hydrophobic, hygroscopic, and a filtered HME.Heated humidifiers operate actively to increase the heat and water vapor content of inspired gas. 8 HMEs operate passively by storing heat and moisture from the patient's exhaled gas and releasing it to the inhaled gas. 9 The upper airway provides 75% of the heat and moisture supplied to the alveoli. When bypassed, the humidifier needs to supply this missing heat and moisture. Since The authors have disclosed a relationship with Teleflex Medical, which manufactures humidification devices.

We searched the MEDLINE, CINAHL, and Cochrane Library databases for articles published between January 1995 and April 2011. The update of this clinical practice guideline is the result of reviewing a total of 54 clinical trials and systematic reviews on incentive spirometry. The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) scoring system. 1: Incentive spirometry alone is not recommended for routine use in the preoperative and postoperative setting to prevent postoperative pulmonary complications. 2: It is recommended that incentive spirometry be used with deep breathing techniques, directed coughing, early mobilization, and optimal analgesia to prevent postoperative pulmonary complications. 3: It is suggested that deep breathing exercises provide the same benefit as incentive spirometry in the preoperative and postoperative setting to prevent postoperative pulmonary complications. 4: Routine use of incentive spirometry to prevent atelectasis in patients after upper-abdominal surgery is not recommended. 5: Routine use of incentive spirometry to prevent atelectasis after coronary artery bypass graft surgery is not recommended. 6: It is suggested that a volume-oriented device be selected as an incentive spirometry device.

An electronic literature search for articles published between January 1990 and September 2011 was conducted by using the PubMed, CINAHL, SCOPUS, and Cochrane Library databases. The update of this clinical practice guideline is the result of reviewing a total of 124 articles: 3 randomized controlled trials, 103 prospective trials, 1 retrospective study, 3 case studies, 11 review articles, 2 surveys and 1 consensus paper on transcutaneous monitoring (TCM) for P(tcO(2)) and P(tcCO(2)). The following recommendations are made following the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) criteria: (1) Although P(tcCO(2)) has a good correlation with P(aCO(2)) and is a reliable method to evaluate plasma CO(2) levels, it is recommended that arterial blood gas values be compared to transcutaneous readings taken at the time of arterial sampling, in order to verify the transcutaneous values, and periodically as dictated by the patient's clinical condition. (2) It is suggested that P(tcCO(2)) may be used in clinical settings where monitoring the adequacy of ventilation is indicated. (3) It is suggested that P(tcO(2)) and P(tcCO(2)) may be used in determining the adequacy of tissue perfusion and monitoring of reperfusion. (4) It is suggested that TCM should be avoided in the presence of increased thickness or edema of the skin and/or subcutaneous tissue where the sensor is applied. (5) It is recommended that sites used for a TCM be changed as often as necessary and that they be alternated and observed to avoid thermal injury. Manufacturer recommendations should be followed.

Current guidelines recommend inhalation therapy as the preferred route of drug administration for treating chronic obstructive pulmonary disease (COPD). Previous systematic reviews in COPD patients found similar clinical outcomes for drugs delivered by handheld inhalers - pressurized metered-dose inhalers (pMDIs), dry powder inhalers (DPIs) - and nebulizers, provided the devices were used correctly. However, in routine clinical practice critical errors in using handheld inhalers are highly prevalent and frequently result in inadequate symptom relief. In comparison with pMDIs and DPIs, effective drug delivery with conventional pneumatic nebulizers requires less intensive patient training. Moreover, by design, newer nebulizers are more portable and more efficient than traditional jet nebulizers. The current body of evidence regarding nebulizer use for maintenance therapy in patients with moderate-to-severe COPD, including use during exacerbations, suggests that the efficacy of long-term nebulizer therapy is similar, and in some respects superior, to that with pMDI/DPIs. Therefore, despite several known drawbacks associated with nebulized therapy, we recommend that maintenance therapy with nebulizers should be employed in elderly patients, those with severe disease and frequent exacerbations, and those with physical and/or cognitive limitations. Likewise, financial concerns and individual preferences that lead to better compliance may favor nebulized therapy over other inhalers. For some patients, using both nebulizers and pMDI/DPI may provide the best combination of efficacy and convenience. The impact of maintenance nebulizer treatment on other relevant clinical outcomes in patients with COPD, especially the progressive decline in lung function and frequency of exacerbations, needs further investigation.