A medical approach to nicotine addiction treatment.

Smoking cessation is a complex process, not a simple event. The cues that cause a smoker to light up, the life-style, and the fallacies of each smoker are helpful information for the practicing physician. Behavioral modification aimed at eliminating cues that initiate smoking together with the systematic use of pharmacologic replacement therapy can help some patients quit. Transdermal nicotine replacement appears particularly promising, and additional pharmacologic agents to deal with nicotine withdrawal may be worth trying. Our advice to practitioners who would like to get involved in smoking cessation is to (1) set up your own smoking cessation clinic; (2) be systematic; (3) don't be discouraged; (4) follow your patients until they either quit smoking or quit coming to your office; and (5) keep abreast of new developments in smoking cessation strategies.

Nicotine dependency treatment: a role for the nurse practitioner.

Most patients who continue to smoke are nicotine dependent. By developing a standard procedure for identifying patients who smoke, encouraging cessation on each visit, teaching relapse prevention skills, and following up, NPs can help ease the withdrawal symptoms that accompany the cessation process. Methods that combine the proper use of pharmacological therapy (in the form of nicotine replacement) and behavioral counseling are most effective.

Urinary levels of bombesin-like peptides in asymptomatic cigarette smokers: a potential risk marker for smoking-related diseases.

Bombesin-like peptides (BLP) produced by pulmonary neuroendocrine cells have many physiological actions which are relevant to the pathobiology of cigarette smoking. The objectives of this study were to determine whether cigarette smokers excrete increased levels of BLP in their urine compared with nonsmokers, to determine the relationship between BLP levels in urine and bronchoalveolar lavage (BAL) fluid, and whether urinary BLP levels are merely a reflection of exposure to cigarette smoke. Simultaneous BAL fluid and urine samples were obtained from ten clinically normal smokers and 22 normal nonsmoker volunteers. Urine samples were also obtained from 39 normal smokers and 30 normal nonsmokers who did not have BAL performed. BLP levels were measured in urine and BAL fluid using an enzyme-linked immunoassay. Expired air content of carbon monoxide, which reflects recent exposure to cigarette smoke, was determined in 34 of the clinically normal smokers and correlated with urinary BLP levels. We found that, in addition to having increased BLP levels in BAL fluid (P = 0.04), asymptomatic cigarette smokers also have increased BLP levels in their urine compared with normal nonsmokers (P = 0.007). Of note, a subgroup of smokers have markedly increased BLP levels which do not overlap with the nonsmokers. Urinary BLP levels correlated with expired air content of carbon monoxide (r = 0.49, P less than 0.01). However, not all smokers with increased expired air content of carbon monoxide exhibited increased BLP levels. Finally, all smokers with detectable BLP levels in BAL fluid had detectable urinary BLP levels, and there was a positive correlation between BLP levels in urine and BAL fluid (r = 0.625, P less than 0.001). We conclude that a subgroup of asymptomatic cigarette smokers exhibited increased BLP levels, measurable in both urine and BAL fluid, which precede the onset of clinically detectable disease and which are not strictly dependent on smoking intensity. We speculate that smokers with increased BLP levels may have a greater risk for smoking-related diseases.

The physician's role in smoking cessation. A present and future agenda.

Medical views in the United States on the effects of smoking have shifted dramatically since the published evidence in 1958 established the link between smoking and fatal disease. Today's physician should be a nonsmoking role model, whose workplace both directly and indirectly teaches smoking cessation skills. Publications on smoking cessation techniques from the National Institutes of Health along with intervention tools such as patient smoking history questionnaires are available free of charge to physicians. Patient histories are critical to the intervention process, for they provide essential clues and information about which stage in cessation of smoking the patient has already reached: precontemplation, contemplation, action, and maintenance. Different approaches and techniques are required at each stage. The most important objective for the physician with a patient at the stage of contemplating quitting is to initiate a conversation leading to a directive to quit, with benefits of quitting stressed as reinforcement. Actively motivated patients committed to quit dates may need both educational and pharmacologic support; issues such as nicotine dependence and withdrawal symptoms must be addressed. Pharmacologic therapy at this time may consist of substitution of nicotine-containing gum (nicotine polacrilex) for cigarettes. Used in sufficient, regular dosages, the nicotine gum has been found to help diminish withdrawal symptoms following smoking cessation. Other drug therapies are currently under study. For now, nicotine replacement therapy (where indicated) is to be used for at least three months, the period of greatest chance of relapse. The physician should continue to encourage patients who have quit smoking to forestall relapses, while tacitly understanding that the incidence of relapse is high in first-time quitters. Hospital inpatients provide an opportunity to initiate bedside smoking cessation programs. The hope is that, in the future, hospitals will involve the entire health team in comprehensive smoking cessation programs.

Criteria for weaning from prolonged mechanical ventilation.

We retrospectively studied 11 instances of patients requiring prolonged mechanical ventilation. Their spontaneous ventilatory measurements were not useful in judging their ability to wean, since these measurements did not change from the period of unsuccessful weaning to the period of progressive weaning from the ventilator. An adverse factor score and a ventilator score were created to evaluate underlying medical and respiratory problems related to ability to wean. Each score and the sum of the two scores separated patients between unsuccessful and successful weaning periods. We also found that the course and the duration of the entire weaning process could be predicted once progressive weaning had begun. We conclude that the adverse factor score and ventilator score correlate with the ability of patients receiving prolonged mechanical ventilation to wean.

The history of long-term oxygen therapy.

Early investigators of oxygen therapy reported an overall clinical improvement in persons with chronic lung disease who received oxygen. Later American and British studies showed that oxygen therapy could decrease pulmonary vascular pressures and red cell mass in some patients with pulmonary hypertension and polycythemia secondary to severe hypoxemia. The British Research Council Study showed that survival rates were significantly higher in patients receiving 15 hours of oxygen than in those receiving no oxygen. The Nocturnal Oxygen Therapy Trial showed that survival rates for persons receiving continuous oxygen therapy has also been shown to improve exercise tolerance and neuropsychiatric function. Further advances in the administration of long-term oxygen therapy and studies in the criteria for its use are needed.

Quality of life for the chronic lung disease patient.

For more than 14 years, Dr. Thomas Petty and Louise Nett have set up rehabilitation programs for people with emphysema and chronic bronchitis. "An organized rehabilitation program dealing with shortness of breath, disability, and despair clearly improves the quality of life," they state. The authors outline the basics of a self-care program which can make the patient more self-sufficient.

Outpatient oxygen therapy in chronic obstructive pulmonary disease. A review of 13 years' experience and an evaluation of modes of therapy.

Thirteen years' experience with home oxygen for patients with advanced chronic obstructive pulmonary disease are reviewed. Home oxygen is safe and relieves pulmonary hypertension and elevated RBC mass in some, but not all patients. Marked clinical improvement is the most important result of long-term home oxygen use, including reduced hospitalizations and return to gainful employment for a few patients. Chronic compensated carbon dioxide retention is well tolerated and adaptive in cases of severe chronic airflow obstruction. New oxygen concentrators are effective in correcting hypoxemia and may make home oxygen administration more convenient and less expensive.

Intensive respiratory care unit. Review of ten years' experience.

In ten years' experience in the respiratory care units serving both medical and surgical patients, 18,077 consecutive patients received ventilatory support for 24 hours or more. The overall survival rate including all patients was 75.2%. Survival rate has not changed appreciably during the past five years. The respiratory care unit provides technical assistance and consultation to primary physicians of the medical and surgical services. This system of intensive respiratory care is flexible and applicable to general hospitals that treat large numbers of patients with acute respiratory respiratory failure.