Conservative and Aggressive Treatment of Acute Severe Respiratory Insufficiency in Patients with Chronic Non-Specific Lung Disease (C.N.S.L.D.)

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Abstract
A survey is given of the treatment of severe acute respiratory insufficiency in patients with CNSLD in the Respiration Unit of the Groningen State University Hospital. Eighty-eight patients were admitted 104 times. Details are given about the routine clinical and laboratory investigations in these patients. The indication to admit the patient to the Unit was failure of conservative treatment in other hospitals and an immediate threat to life. More than half of the patients were comatose or stuporose on admission, overt pulmonary heart failure was present in 67 patients. Treatment consisted of a combination of conservative and aggressive treatment. Conservative treatment included antibiotics, aminophylline, oxygen, physiotherapy, corticosteroids and central nervous system stimulants. Aggressive treatment included endo-tracheal intubation, tracheotomy and artificial ventilation. Complications of respiratory insufficiency (eg pulmonary heart failure, cerebral vasodilatation, acute gastric dilatation) responded favorably to correction of the respiratory insufficiency. Complications of treatment included rib fractures, hemoptysis, bronchopneumonia, esophago-tracheal fistula. Rapid correction of hypercapnia may lead to post-hypercapneic hypotension and residual metabolic alkalosis (hypopotassemia, digitalis intoxication). The alkalosis may reach dangerous levels in patients with coexisting primary metabolic alkalosis (resulting from potassium- and chloride-depletion following diuretics, corticosteroids or low-sodium diet). The importance of correcting this metabolic alkalosis (by means of acetazolamide, potassium chloride) is emphasized. Seventy (70)% of the patients with CNSLD survived their first admission. Within one year after discharge another 39 patients died, 7 of these during readmission to the Respiration Unit. "Intractable respiratory insufficiency" proved to be the major cause of death in patients dying in the Unit. The rationale of cardiac therapy (low-sodium diet, digitalis, diuretics) in patients with pulmonary heart failure, in whom the respiratory insufficiency can be relieved, is seriously challenged.