Domiciliary noninvasive ventilatory support

Morbidity and mortality due to chronic obstructive pulmonary disease (COPD) vary dramatically between industrialized countries (1). These variations have been attributed to different exposure to risk factors such as tobacco use, atopy, occupational hazards, genetic factors, and air pollution (2), but other elements such as nonuniform classification of disease codes and differences in death certification and autopsy reports may play a role (3). Nevertheless COPD-related mortality rates have been increasing both in North America and in the rest of the world (4). A study focused on mortality trends in the United States from 1950 to 1986 showed that the only death rates that did not decline were those of COPD and malignant neoplasm (5). With regards to COPD, both age-adjusted death rate and proportionate mortality increased dramatically, from 0.5% in 1950 to 3.3% in 1986, while the rate per 100,000 population rose from 4.4 to 18.8 (5). The increase in smoking, especially among women (4), and in air pollution (2) and, additionally, the failure of pharmaco-814 Nava and Navalesi logical treatments to mitigate the decline in lung function when COPD is established (6,7) may explain these results. Bronchodilators, β2-agonists and anticholinergics, and corticosteroids, while seeming to improve exercise tolerance and quality of life, do not affect the rate of decline in FEV1 and mortality (8-10). Only smoking cessation (6) and long-term oxygen therapy in hypoxic patients have been demonstrated to be effective strategies for increasing survival (11,12). Recently, novel surgical therapeutic approaches have aroused enthusiasm. Unfortunately, lung transplantation has recently been shown not to confer a survival benefit to patients with emphysema at a 2-year follow-up (13), and no data are presently available to evaluate the impact on long-term survival and medical costs of lung volume reduction surgery (14,15).