Pulmonary emphysema is a disease which develops because of a localized imbalance between endogenous proteinase inhibitors and proteinases leaking from neurophils during phagocytosis at inflammatory foci within the lung. This volume not only reviews at a biochemical level what is known about the natural inhibitors and proteinases involved in connective tissue destruction within the lung, but also suggests novel methodologies for reestablishing proper enzyme-inhibitor balance, including the use of natural or synthetic inhibitors for supplementation or gene therapy.

The workshops that have been held over the past few years and the volumes published in their wake have proved highly successful and have prompted us to press on with our initial plans. Our basic aim was to tackle certain very important problems in respiratory rehabilitation and then discuss the various issues with people from all over the wodd engaged in the updating of experience and know ledge in this field. We therefore firmly believe that this ongoing effort is of fundamental importance. Hyperinflation, which is still a poody defined c1inical and physiopatho logical condition, is the focal point ofthis present study, which is aimed at discussing and weighing up the physiopathological mechanisms, c1inical consequences, and rehabilitation possibilities in a disease in which, until relatively recently, rehabilitation had seemed almost totally ineffective. The present contributions, however, show us how very important and versatile rehabilitation may be in its treatment. Perhaps, if we consider this branch of medicine as one which now no longer simply draws upon other sciences, but make an active contribution in its own right, we will have touched upon the most important aspect of this study. If I may, I would just like to add how very pleasing it is for me to acknow ledge how much this joint effort has contributed, in terms of true insights and above all VI results, to finding solutions to the problems addressed in reeent years.

This monograph comprises 17 papers written by prominent authors in the field, each of whom presents his most recent experiences. The papers were not specially selected so that this work is far from being a comprehensive textbook covering all aspects of right ventricular hypertrophy and failure in chronic lung disease. Perhaps some of the papers dealing with more strictly physiological problems and experimental models will be somewhat difficult to relate directly to former modes of thinking of both cardiologists and pneumologists. Nevertheless, we hope and expect that this book will provide the reader with, an in-depth appreciation of the situation of present research in different laboratories and countries. Occasionally contradictions between different papers may be noticed. We have not tried to remove these, since each contradiction reflects current areas of dispute or uncertainty in this developing field. We wish finally to acknowledge the continuing support of the Clinica del Lavoro Foundation for projects aimed at promoting education in all fields related to medical rehabilitation. Vlastimil Jdek Mario Morpurgo Roberto Tramarin Foreword This volume is the sixth issue in the Series "Current Topics in Rehabilitation", which was ftrst conceived in 1987 with the aim of offering updated indications as to functional comprehensive evaluation strategies and rehabilitation programmes.

In his review of the Proceedings of the First International Workshop on Respiratory Muscles in Chronic Obstructive Pulmonary Disease, organized in Montescano in 1986, Thomas K. Aldrich stated that "there is little information on nutrition". We felt that the need to supplement the evaluation of respiratory muscles by studying nutritional problems was an important enough matter to justify producing a specific study on the subject. This book is the result of the efforts made in this direction. Since 1986, many of the problems associated with nutrition and ventilatory function have been elucidated, and we hope that the contents of this book may contribute towards spreading interest and knowledge in this sector, particularly among those working in the field of respiratory rehabilitation. The physiological and clinical aspects of nutritional problems and the therapeutic approaches adopted in different disease conditions are dealt with in these pages by some of the best-known researchers in the field, providing abundant evidence, if any should be needed, that rehabilitation is not merely exercise. The picture strongly emerging over these last few years is that rehabilitation is not merely a matter of knowledge of lung or respiratory muscles, but also of heart-lung interaction, metabolic equilibrium and nutrition. So much for recent developments, but what does the future hold in store? May 1992 RENATO CORSICO Preface Nutrition and ventilation are inextricably related.

Respiratory rehabilitation can be defined as long term evaluation and therapy. This definition has evolved considerably from earlier and more restrictive attempts to delineate the discipline. Currently, respiratory rehabilitation involves evaluation techniques and treatment strategies which utilize the benefits gained from exercises, but without being limited to it. Respiratory muscle training, non-invasive mechanical ventilation, bronchodilator drugs, and metabolic balance and maintenance of nutrition are just a few of the topics covered in this book. The editors have organized the text to provide an updated review of the topic and indicate many areas in need of development and exploration in the years ahead. The information provided is easily accessible to a broad spectrum of readers, including clinicians, researchers, pharmacologists, technicians and therapists.