Chronic Respiratory Disease current issue

Integrated care for COPD. What exactly do we mean?

Morgan, M. — 2008-08-06

The implementation of Restoring Health - a chronic disease model of care to decrease acute health care utilization

Howard, R, Sanders, R, Lydall-Smith, S. — 2008-08-06

The Restoring Health Program, a multi-disciplinary model of care for patients with chronic lung diseases, heart failure, and diabetes, was established to improve the quality of life and function for patients with these target chronic diseases, while reducing their disproportionately high demand on acute health care services. Acute health care utilization at St Vincent's Hospital Melbourne for all patients recruited between February 2003 and June 2005 (n = 351) was analyzed using within-subjects paired sample t-tests to compare the 6 months of pre-recruitment with 6 months of post-recruitment. Analysis showed statistically significant decreases in emergency department presentations (P < 0.001), hospital admissions (P < 0.001), and length of stay (P < 0.001). This article describes the current model of care, the program's enablers, and its impact on health service demand after the first 4 years of implementation.

Noninvasive ventilation as ceiling of therapy in end-stage chronic obstructive pulmonary disease

Creagh-Brown, B., Shee, C. — 2008-08-06

The benefits of noninvasive ventilation (NIV) for acute hypercapnic respiratory failure caused by chronic obstructive pulmonary disease (COPD) are well recognized and consequently its use is widespread. Prognostication in advanced COPD is imperfect, limiting accurate identification of ‘end-stage' COPD. Decisions regarding withholding invasive ventilation are largely dependent upon prognostication. In patients where ‘invasive' ventilation is not considered to be in their best interests, NIV will be the ceiling of therapy. In this patient group, NIV is extremely valuable in reducing mortality and providing valuable symptomatic benefit. We discuss the use of NIV in the management of an acute exacerbation of ‘end-stage' COPD where NIV is the ceiling of therapy, the use of advanced directives and the implications of the Mental Capacity Act 2005 on decisions regarding end-of-life care. We highlight areas where further research would be useful.

Pulmonary rehabilitation and follow-on services: a Northern Ireland survey

O'Neill, B, Elborn, J., MacMahon, J, Bradley, J. — 2008-08-06

There should be a clear pathway through pulmonary rehabilitation and follow-on services. The aim of this survey was to determine the characteristics of the different components of the patient pathway, that is, pulmonary rehabilitation programs, ongoing exercise facilities, and support networks in Northern Ireland. Questionnaires were sent to current providers of pulmonary rehabilitation, providers of ongoing exercise, and support groups in Northern Ireland. Findings relating to the current status of pulmonary rehabilitation in Northern Ireland up to January 2007 are reported. There are currently 23 pulmonary rehabilitation programs in Northern Ireland. There appears to be a pathway through the short-term pulmonary rehabilitation program (6–8 weeks). Programs met standards for structure and format, except for the frequency of supervised exercise. Not all programs have links for the provision of ongoing exercise, but a range of exercise programs are available in leisure centers in Northern Ireland that include people with respiratory disease. There are 13 support groups for patients with respiratory disease in Northern Ireland and their function is diverse. Pulmonary rehabilitation is established in Northern Ireland, although not all patients are able to access these. Facilities for ongoing exercise and support groups are less developed. Improvements could be facilitated by better communication within the patient pathway and a strategic coordinated approach.

Procalcitonin in stable and unstable patients with bronchiectasis

Loebinger, M., Shoemark, A, Berry, M, Kemp, M, Wilson, R — 2008-08-06

Presently used markers of infection in bronchiectasis are inadequate to judge stability or make decisions about antibiotic treatment during bacterial exacerbations. Procalcitonin (PCT) is a new marker that has been used in community-acquired pneumonia and promises to allow much more specific and sensitive monitoring of patients with bacterial infections. This is the first study assessing its use in bronchiectasis. Thirty-eight consecutive inpatients and 63 consecutive outpatients were included in the study. All patients had PCT, other inflammatory markers, and a symptom score recorded. Inpatients had these values repeated at day 5 and 10 of their stay, while receiving intravenous antibiotics. Outpatients: PCT levels were generally low in the outpatient group. PCT was significantly correlated to C-reactive protein. Higher levels were associated with increased symptoms (P = 0.09) and an increased likelihood of antibiotic prescription (P = 0.007). Inpatients: As a group, inflammatory markers were significantly higher than in the outpatient group (P = 0.007). There was no correlation between the levels of PCT and the other inflammatory markers. PCT concentrations were generally low (as with other markers), which may reflect mucosal infection. Larger studies are needed, but PCT seems unlikely to be able to guide treatment of an exacerbation in bronchiectasis. PCT may offer more promise as a measure of stability.

Quality of life and inflammation in exacerbations of bronchiectasis

Courtney, J., Kelly, M., Watt, A, Garske, L, Bradley, J, Ennis, M, Elborn, J. — 2008-08-06

Patients with bronchiectasis often have impaired quality of life (QoL), which deteriorates with exacerbations. The aim of this study was to investigate changes in QoL and how these were influenced by changes in airway physiology and inflammation in patients with bronchiectasis before and after resolution of an exacerbation. Sputum induction and a QoL questionnaire were undertaken on the first day, day 14, and 4 weeks after completion of intravenous antibiotics (day 42). Eighteen patients (12 female) were recruited, median (IQ range) age of 54 (47–60) years. There was a trend towards an improvement in lung function from visit 1 to visit 2, but this was not statistically significant. C-reactive protein (CRP) [mean (SEM)] reduced between visit 1 and visit 2 [55.4 (21.5) vs 9.4 (3.1) mg/L, P = 0.03] but did not increase significantly on visit 3 [44.4 (32.9) mg/L, P = 0.27]. The median (interquartile range) sputum cell count (x10⁶ cells/g of sputum) decreased from visit 1 to visit 2 [21.6 (11.8–37.6)–13.3 (6.7–22.9) x 10⁶ cells/g, respectively, P = 0.008] and increased from visit 2 to visit 3 [26.3 (14.1–33.6) x 10⁶ cells/g, P = 0.03]. All soluble markers of inflammation significantly reduced from visit 1 to visit 2 but increased on visit 3 with the exception of TNF-. Regarding QoL, three of the four domains (dyspnoea, emotional, mastery) significantly improved from visit 1 to visit 2 but did not change between visit 2 and visit 3. The improvements in QoL scores could not be explained by the improvements in lung function or inflammatory markers.

Anabolic steroids in COPD: a review and preliminary results of a randomized trial

2008-08-06

Patients with severe chronic obstructive pulmonary disease (COPD) commonly develop weight loss, muscle wasting, and consequently poor survival. Nutritional supplementation and anabolic steroids increase lean body mass, improve muscle strength, and survival in patients enrolled in comprehensive rehabilitation programs. Whether anabolic steroids are effective outside an intensive rehabilitation program is not known. We conducted a prospective, double-blind, placebo-controlled, 16-week trial to study the benefits of anabolic steroids in patients with severe COPD who did not participate in a structured rehabilitation program. Biweekly intramuscular injections of either the drug (nandrolone decanoate) or placebo were administered. Sixteen patients with severe COPD were randomized to either placebo or nandrolone decanoate. The placebo group weighed 55.32 ± 11.33 kg at baseline and 54.15 ± 10.80 kg at 16 weeks; the treatment group weighed 68.80 ± 6.58 at baseline and 67.92 ± 6.73 at 16 weeks. Lean body mass remained unchanged, 71 ± 6 vs. 71 ± 7 kg in placebo group and 67 ± 7 vs. 67 ± 7 in treatment group, at baseline and 16 weeks respectively. The distance walked on 6 min was unchanged at baseline, 8 weeks, and 16 weeks in placebo (291.17 ± 134.83, 282.42 ± 115.39, 286.00 ± 82.63 m) and treatment groups (336.13 ± 127.59, 364.83 ± 146.99, 327.00 ± 173.73 m). No improvement occurred in forced expiratory volume in one second, forced vital capacity, maximal inspiratory pressure, maximal expiratory pressure, VO₂ max or 6-min walk distance or health related quality of life. Administration of anabolic steroids (nandrolone decanoate) outside a dedicated rehabilitation program did not lead to either weight gain, improvement in physiological function, or better quality of life in patients with severe COPD.

Chronic obstructive pulmonary disease: a forgotten killer: Carol Midgley Published by Oxford University Press, 2008.ISBN: 9780 1992 3732 6 (Paperback)Price: {pound}18.99

Scullion, J. — 2008-08-06

Book reviews

2008-08-06