Chronic Respiratory Disease recent issues

Music: More than just a melody

Bauldoff, G. — Mon, 26 Oct 2009 09:39:16 PDT

Use of pedometers to measure activity in COPD patients -- a step too far?

Walker, P. — Mon, 26 Oct 2009 09:39:16 PDT

Cost analysis of an integrated care model in the management of acute exacerbations of chronic obstructive pulmonary disease

Bakerly, N. D., Davies, C., Dyer, M., Dhillon, P. — Mon, 26 Oct 2009 09:39:16 PDT

Home treatment models for acute exacerbations of chronic obstructive pulmonary disease (AECOPD) proved to be a safe alternative to hospitalization. These models have the potential to free up resources; however, in the United Kingdom, it remains unclear to whether they provide cost savings compared with hospital treatment. Over a 12-month period from August 2003, 130 patients were selected for the integrated care group (total admissions with AECOPD = 546). These patients were compared with 95 retrospective controls in the hospital treatment group. Controls were selected from admissions during the previous 12 months (total of 662 admissions) to match the integrated care group in age, sex, and postal code. Resource use data were collected for both groups and compared using National Health Service (NHS) perspective for cost minimization analysis. In the integrated care group (130 patients), 107 (82%) patients received home support with average length of stay 3.3 (SD 3.9) days compared with 10.4 (SD 7.7) in the hospital group (95 patients). Average number of visits per patients in the integrated care group was 3.08 (SD = 0.95; 95% CI = 2.9—3.2). Cost per patient in the integrated care group was £1653 (95% CI, £1521—1802) compared with £2256 (95% CI, £2126— 2407) in the hospital group. The integrated care group resulted in cost saving of approximately £600 (P < 0.001) per patient. This integrated care model for the management of patients with AECOPD offered cost savings of £600 per patient over the conventional hospital treatment model using the new NHS tariff from an acute trust provider perspective.

Comparison of the effectiveness of music and progressive muscle relaxation for anxiety in COPD--A randomized controlled pilot study

Singh, V., Rao, V., V., P., RC, S., K., K. P. — Mon, 26 Oct 2009 09:39:16 PDT

Acute effects of music and relaxation have not been evaluated in hospitalized subjects with chronic obstructive pulmonary disease (COPD). This study aims to evaluate the acute effects of music and progressive muscle relaxation (PMR) in hospitalized COPD subjects after a recent episode of exacerbation. A Randomized controlled study was performed of pre-test post-test design after recruiting 82 COPD subjects from K.M.C hospitals. All patients were admitted for acute exacerbation and were medically stabilized. After being screened for the inclusion and exclusion criteria, 72 subjects were selected for the study. Demographic and baseline data was taken on the day subjects were screened. Music group listened to a self selected music of 60-80 beats per minute for 30 minutes. PMR group practiced relaxation through a pre-recorded audio of instructions of 16 muscle groups. Outcome variables were Spielberger’s state anxiety inventory (SSAI), Spielberger’s trait anxiety inventory (STAI), dyspnea, systolic blood pressure (SBP), diastolic blood pressure (DBP), pulse rate (PR) and respiratory rate (RR). There was statistically significant main effect across the sessions for state anxiety (F = 62.621, p = 0.000), trait anxiety (F = 19.528, p = 0.000), dyspnea (F = 122.227, p = 0.000), SBP (F = 63.885, p = 0.000), PR (F = 115.780, p = 0.000) and RR (F = 202.977, p = 0.000). There was statistically significant interaction effect between the two groups for state anxiety (F = 6.024, p = 0.003), trait anxiety (F = 8.222, p = 0.000), dyspnea (F = 10.659, p = 0.000), SBP (F = 12.889, p = 0.000), PR (F = 4.746, p = 0.008) and RR (F = 12.078, p = 0.000). There were greater changes observed after the second session in both groups however, change in DBP was not significant in either group. Music and PMR are effective in reducing anxiety and dyspnoea along with physiologic measures such as SBP, PR and RR in two sessions in COPD patients hospitalized with exacerbation. However, reductions in the music group were greater compared to the PMR group.

Using pedometers to monitor walking activity in outcome assessment for pulmonary rehabilitation

Mon, 26 Oct 2009 09:39:16 PDT

Background: The purpose of this study was to determine whether a commercially available pedometer could detect changes in home-based walking activity among chronic obstructive pulmonary disease (COPD) patients completing pulmonary rehabilitation (PR). Methods: Patients with COPD referred to outpatient PR wore a pedometer to count steps for 1 week at the beginning and 1 week at the end of PR. Patients also completed the 6-min walk test (6MWT), the Medical Research Council (MRC) dyspnea scale and the self-administered chronic respiratory disease questionnaire (CRQ) at the beginning and the end of PR. Paired t tests were used to compare pre- and post-PR changes in outcome variables. Results: 45 patients with severe COPD (forced expiratory volume in 1 second [FEV₁] 45% ± 18% of predicted) participated in a total of 17.4 ± 4.6 PR sessions. Significant improvements in 6MWT (49 ± 59 m; p < .0001), MRC dyspnea score (—0.64 ± 0.96 units; p = .003) and CRQ score (10 ± 18 units; p = .0007) were noted following PR. Patients whose pedometer-measured steps were within 20% of observed counted steps were included in the analysis. Pedometer counts increased by 33 ± 149 steps per hour worn after, as compared with before PR (p = .14). There was a significant inverse relationship between baseline pedometer counts and change in pedometer counts per hour post-PR (r = —.46; p = .001). Patients with low baseline activity levels had significant increases in pedometer activity (88 ± 30 counts per hour worn) and a greater reduction in MRC dyspnea score (—0.94 vs —0.29; p = .04) following PR, whereas those with higher baseline activity levels had a decrease in pedometer activity (—19 ± 29 counts/hour; p = .015). Conclusions: A standard pedometer worn at the waist did not detect changes in lower extremity activity following PR. This negative finding occurred despite demonstrated improvements in dyspnea, exercise tolerance and quality of life measures. Although pedometers are inexpensive and easy to use, they may not be sensitive enough to be used routinely as an outcome measure for PR.

PatientsLikeMe the case for a data-centered patient community and how ALS patients use the community to inform treatment decisions and manage pulmonary health

Frost, J., Massagli, M. — Mon, 26 Oct 2009 09:39:16 PDT

What happens when patients go online to not only discuss health and daily living but to share detailed health data? PatientsLikeMe© is an online platform where patients with life-altering conditions share structured information about symptoms, treatments, and outcomes, view individual and aggregated reports of these data, and discuss health and garner support on forums and through private messages. In this case study, we describe the components of this platform and how people with Amyotrophic lateral sclerosis have used the site to manage and improve pulmonary health. A qualitative analysis of forum content containing preset terms reveals patterns in use. As in other online communities, members of PatientsLikeMe offer one another support based on their own personal experience and advise each other on both medical issues and how to improve day-to-day life. Unique to this patient platform, members tailor questions and consults by referencing concrete data displayed for each patient member. PatientsLikeMe adds data into patient investigations on how to improve daily life and long term health outcomes.

Mechanisms of exercise limitation and pulmonary rehabilitation for patients with neuromuscular disease

Aboussouan, L. — Mon, 26 Oct 2009 09:39:16 PDT

Indications for exercise and pulmonary rehabilitation extend to neuromuscular diseases tough these conditions pose particular challenges given the associated skeletal muscle impairment and respiratory muscle dysfunction. These challenges are compounded by the variety of exercise prescriptions (aerobic, muscle strengthening, and respiratory muscle training) and the variety of neuromuscular disorders (muscular, motor neuron, motor nerve root, and neuromuscular transmission disorders). Studies support a level II evidence of effectiveness (i.e., likely to be effective) for a combination of aerobic exercise and strengthening exercises in muscular disorders, and for strengthening exercises in amyotrophic lateral sclerosis. The potential deleterious effects of work overload in the dystrophinopathies have not been confirmed in Becker muscular dystrophy. Adjunctive pharmacologic interventions (e.g., theophylline, steroids, PDE5 inhibitors, creatine), training recommendations (e.g., interval or lower intensity training) and supportive techniques (e.g., noninvasive ventilation, neuromuscular electrical stimulation, and diaphragm pacing) may result in more effective training but require more study before formal recommendations can be made. The exercise prescription should include avoidance of inspiratory muscle training in hypercapnia or low vital capacity, and should match the desired outcome (e.g., extremity training for task-specific performance, exercise training to enhance exercise performance, respiratory muscle training where respiratory muscle involvement contributes to the impairment).

Long-term oxygen therapy: aligning the clinician and patient perspective to maximize patient benefit

Restrick, L. — Thu, 30 Jul 2009 04:23:25 PDT

Self-management for breathlessness in COPD: the role of pulmonary rehabilitation

Gysels, M., Higginson, I. — Thu, 30 Jul 2009 04:23:25 PDT

Most of the effort of controlling breathlessness happens at home. Therefore, it is important to explore how patients and carers respond to breathlessness, what their self-care entails and what they experience as helpful. Data were collected from a purposive sample of 18 chronic obstructive pulmonary disease patients through participant observation during outpatient consultations and in-depth interviews at a large hospital and in the community in London. Data were analysed with the Grounded Theory approach. As information regarding the management of breathlessness was lacking and access to treatment was difficult, patients reverted to alternative strategies. Some patients developed considerable expertise and managed their symptoms competently within the limits of current care. Patients who coped successfully were involved in pulmonary rehabilitation and had adopted this as a way of life. Benefits and challenges to participation in these programmes were identified. Those patients who self-manage maintain an acceptable quality of life through self-acquired expertise relating to symptoms, medication and help-seeking. Well-being needs to be understood not as the end point, but as a precarious balance needing skilful maintenance and hard work. The findings have implications for notions such as adherence, patient involvement and responsibility in the management of chronic obstructive pulmonary disease.

Long-term oxygen therapy: review from the patients' perspective

Cullen, D., Stiffler, D — Thu, 30 Jul 2009 04:23:25 PDT

Chronic respiratory conditions are responsible for increasing numbers of patients in need of long-term oxygen therapy (LTOT). However, many patients do not use their oxygen as prescribed. Unless we can assist these patients in living with oxygen therapy, optimal clinical outcomes will not be achieved. We conducted a meta-synthesis of qualitative research studies. We included any qualitative study that focused on the psychosocial nature or experience of patients prescribed LTOT. Four research studies met the conditions of our search. We performed a rigorous methodological protocol for meta-synthesis as described by the Joanna Briggs Institute. A total of 12 findings formulated four themes. These themes included the following: adapting oxygen to life’s circumstances, living in a restricted world, self-management is fostered by oxygen, and submission and dependency. From the four thematic categories established, meta-synthesis resulted in two major results: persons prescribed oxygen rationalize its use while negotiating lifestyle interference and physical restrictions and the drive to care for one’s self is conflicted. This meta-synthesis showed that each oxygen user faces tremendous physical, psychological, and emotional challenges. They strive to adapt and maintain mastery but eventually oxygen dependency results. These challenges affect the patient’s ability to adhere to their treatment guidelines. These barriers and challenges are seldom addressed and are under-treated. Clinicians involved in LTOT need to be aware and work with the patients to facilitate their use of oxygen. Inclusion of the patients’ perspective can guide practice and assist with the development of new interventions and management strategies.

The prognostic value of C-reactive protein in long-term care patients requiring prolonged mechanical ventilation

Sierros, V, Fleming, R, Cascioli, M, Brady, T — Thu, 30 Jul 2009 04:23:25 PDT

C-reactive protein (CRP), a biomarker of inflammation, has predicted mortality in end-stage respiratory failure and in the critically ill patients. Our aim was to investigate if CRP can predict morbidity and mortality in patients requiring prolonged mechanical ventilation. A prospective study conducted in a ventilator weaning unit of a skilled nursing facility over 13 months included 98 patients older than 18 years of age requiring mechanical ventilation via tracheostomy. Serum CRP and albumin levels were tested on admission. Age, gender, body mass index (BMI), and diagnoses causing respiratory failure were recorded. The outcomes measured were as follows: hospitalization, weaned from mechanical ventilation, and death. Our population had a median age of 77 years and the median BMI, albumin, and mean CRP were 26 kg/m², 2.25 g/dL, and 5.75 mg/dL, respectively. The most common diseases leading to respiratory failure were pulmonary, neurologic, and cardiac. The patients with the empiric cutoff CRP of <2 mg/dL (n = 14) had 0% hospitalization rate at 2 weeks and 7% at 30 days, whereas the patients with CRP ≥ 2 mg/dL (n = 84) had 26% hospitalization rate at 2 weeks and 38% at 30 days. Mortality for the patients with CRP ≥ 2 mg/dL was 26% at 60 days, whereas the CRP < 2 mg/dL patients had no mortality at 60 days (P = 0.034). The patients who survived 60 days (n = 70) had significantly lower median CRP levels than the nonsurvivors (4.1 mg/dL vs 8.5 mg/dL, P = 0.009). The area under the receiver operating characteristic (ROC) curve for CRP levels predicting 2-week hospitalization was not large at 0.617 and the optimum CRP cutoff point was >2.7 mg/dL. The sensitivity and negative predictive value of the 2-week hospitalization outcome were equally high at 96%. The area under the ROC curve for 60-day survival was 0.691, and its optimum CRP cutoff point was >3.7 mg/dL with 85% sensitivity and 91% negative predictive value. CRP was not able to predict weaning success in this setting where the 60-day weaning rate was 9%. A CRP level of ≤2.7 mg/dL may be used to screen for patients who are not likely to develop acute illness requiring early 2-week rehospitalization, and a CRP level of ≤3.7 mg/dL may be used to predict 60-day survival in patients with respiratory failure requiring prolonged mechanical ventilation in the long-term care setting.

Can a chronic disease management pulmonary rehabilitation program for COPD reduce acute rural hospital utilization?

Rasekaba, T., Williams, E, Hsu-Hage, B — Thu, 30 Jul 2009 04:23:25 PDT

Chronic obstructive pulmonary disease (COPD) imposes a costly burden on healthcare. Pulmonary rehabilitation (PR) is the best practice to better manage COPD to improve patient outcomes and reduce acute hospital care utilization. To evaluate the impact of a once-weekly, eight-week multidisciplinary PR program as an integral part of the COPD chronic disease management (CDM) Program at Kyabram District Health Services. The study compared two cohorts of COPD patients: CDM-PR Cohort (4–8 weeks) and Opt-out Cohort (0–3 weeks) between February 2006 and March 2007. The CDM-PR Program involved multidisciplinary patient education and group exercise training. Nonparametric statistical tests were used to compare acute hospital care utilization 12 months before and after the introduction of CDM-PR. The number of patients involved in the CDM-PR Cohort was 29 (n = 29), and that in the Opt-out Cohort was 24 (n = 24). The CDM-PR Cohort showed significant reductions in cumulative acute hospital care utilization indicators (95% emergency department presentations, 95% inpatient admissions, 99% length of stay; effect sizes = 0.62–0.66, P < 0.001) 12 months after the introduction of the CDM Program; in contrast, changes in the cumulative indicators were statistically insignificant for the Opt-out Cohort (emergency department presentations decreased by 5%, inpatient admissions decreased by 12%, length of stay increased by 30%; effect size = 0.14–0.40, P > 0.05). Total costs associated with the hospital care utilization decreased from $130,000 to $7,500 for the CDM-PR Cohort and increased from $77,700 to $101,200 for the Opt-out Cohort. Participation in the CDM-PR for COPD patients can significantly reduce acute hospital care utilization and associated costs in a small rural health service.

Providing reviews of evidence to COPD patients: controlled prospective 12-month trial

Harris, M, Smith, B., Veale, A., Esterman, A, Frith, P., Selim, P — Thu, 30 Jul 2009 04:23:25 PDT

The aim of this study was to evaluate a novel patient-held manual designed to reduce the evidence–practice gap in chronic obstructive pulmonary disease (COPD). The intervention manual contained summaries of research evidence. It was developed using current best practice for patient information materials and designed to cause discussion of evidence between patient and doctor. A controlled before-and-after study was employed in two similar but geographically separate regions of metropolitan Adelaide, South Australia. Participants had moderate to severe COPD, with 249 included at baseline and 201 completing the study. Evidence-based COPD management was measured using an indicator with three components: rates of influenza vaccination, bone density testing, and pulmonary rehabilitation. A survey of behavioral steps leading to practice change was conducted with the trial. Analysis, by median split of socioeconomic disadvantage, showed significant difference between study arms for only one component of the indicator of evidence-based practice, enrolment in pulmonary rehabilitation and only for the most socioeconomically disadvantaged stratum. For both socioeconomic strata, more intervention participants than control participants reported remembering being given the information material, reading part or all, and finding it very or quite helpful. Other significant differences were restricted to the stratum of greatest socioeconomic disadvantage: reading all of the material, learning from it, referring back, and talking to a doctor about a topic from the material. Above 90% of all participants who received the manual reported reading from it, 42% reported discussing topics with a doctor, but only 10% reported treatment change attributable to the manual. We have found that people with COPD will read an evidence manual developed using current best practice. However, the study demonstrated improvement for only one of the three components of an indicator of evidence-based disease management for only the most socioeconomically disadvantaged stratum of participants. Future interventions should be designed to better translate reading uptake into evidence-based disease management.

Heart and Lung Disease review series

Morrell, N. — Thu, 30 Jul 2009 04:23:25 PDT

Cor pulmonale

Weitzenblum, E, Chaouat, A — Thu, 30 Jul 2009 04:23:25 PDT

The term "cor pulmonale" is still popular but there is presently no consensual definition and it seems more appropriate to define the condition by the presence of pulmonary hypertension (PH) resulting from diseases affecting the structure and/or the function of the lungs: PH results in right ventricular enlargement and may lead with time to right heart failure (RHF). Chronic obstructive pulmonary disease (COPD) is the first cause of cor pulmonale, far before idiopathic pulmonary fibrosis and obesity–hypoventilation syndrome. In chronic respiratory disease (CRD) PH is "pre-capillary," due to an increase of pulmonary vascular resistance (PVR). The first cause of increased PVR is chronic long-standing alveolar hypoxia which induces pulmonary vascular remodeling. The main characteristic of PH in CRD and particularly in COPD is its mild to moderate degree, resting pulmonary artery mean pressure (PAP) in a stable state of the disease usually ranging between 20 and 35 mmHg. However, PH may worsen during exercise, sleep, and exacerbations of the disease. These acute increases in afterload can favor the development of RHF. A minority (<5%) of COPD patients exhibit severe or "disproportionate" PH (PAP >40 mmHg), the mechanism of which is not well understood. At present long-term oxygen therapy (LTOT) is the logical treatment of PH since alveolar hypoxia is considered to be the major determinant of the elevation of PAP and PVR. LTOT stabilizes or at least attenuates and sometimes reverses the progression of PH, but PAP seldom returns to normal. Vasodilators (prostacyclin, endothelin receptor antagonists, sildenafil, nitric oxide) could be considered in patients with severe PH but controlled studies in this field are presently lacking.

Book reviews

Thu, 30 Jul 2009 04:23:25 PDT

Does community management of COPD exacerbations really prevent hospital admission?

Scullion, J — Fri, 01 May 2009 10:26:52 PDT

Hospital-at-home care for exacerbations of chronic obstructive pulmonary disease: an observational cohort study of patients managed in hospital or by nurse practitioners in the community

Ansari, K, Shamssain, M, Farrow, M, Keaney, N. — Fri, 01 May 2009 10:26:53 PDT

The Urgent Care Team (UCT) in Sunderland (pop. 293,000) is a unique nurse practitioner service operating a hospital at home 24/7/365 to deal promptly with patients suffering an exacerbation of their COPD (AECOPD). Treatment is according to patient group directions utilising nebulised bronchodilators, doxycycline and prednisolone. To compare the health status and pathophysiology during and two months after an AECOPD in 60 UCT patients (31 male) and 30 hospital-managed patients (16 male). The St. Georges Respiratory Questionnaire (SGRQ), Mahler Baseline Dyspnoea Index (BDI) and MRC dyspnoea score recorded health status. Spirometry, BMI and grip strength were also measured. All patients were reviewed 2–3 months after the AECOPD. Changes from BDI were measured using the Transitional Dyspnoea Index (TDI). Mean FEV₁% predicted was 47%. In the recovery phase the two groups were comparable for all variables. But during their AECOPD hospitalised patients had a significantly lower BDI (P < 0.05) and an oxygen saturation ranging from 84 to 93% compared with 87–96% for UCT patients. Paired t-tests indicated that on recovery SGRQ activity domain and TDI measures improved in both groups. No deaths occurred during these AECOPDs. A hospital-at-home scheme for AECOPDs can deal with patients who have severe COPD safely. The Mahler TDI appears to be a sensitive index of improvement after an AECOPD.

Health-related quality of life is associated with COPD severity: a comparison between the GOLD staging and the BODE index

Fri, 01 May 2009 10:26:53 PDT

Chronic obstructive pulmonary disease (COPD) is a highly prevalent disease. Currently, severity Global initiative for chronic Obstructive Lung Disease (GOLD) criteria are used to diagnose the severity of COPD, but a new grading system, the body mass index, bronchial obstruction, dyspnea, exercise (BODE) index, was recently proposed to provide useful prognostic information. The objective of this study is to evaluate the association between health-related quality of life (HRQOL) and COPD severity assessed by two criteria: the GOLD classification and the BODE index. Sixty-four patients with COPD were examined with lung function tests and specific and generic HRQOL questionnaires (St. George’s Respiratory Questionnaire [SGRQ], Nottingham Health Profile [NHP]). Participants were divided into four severity groups using the GOLD guidelines and the BODE index quartiles. The association between NHP and SGRQ subscales, and the BODE index was significant (P < 0.01). However, the GOLD classification shows a correlation only with SGRQ total score (P < 0.05) but not with NHP or SGRQ subscales. There was an association of the SGRQ total score between the severity groups of BODE (P = 0.0001), but there was no difference in the SGRQ total score between the severity groups of GOLD classification (P = 0.244). The present study suggests that COPD severity assessed by the BODE index can be more directly related with HRQOL.

Circulating matrix metalloproteinase-9 and osteoporosis in patients with chronic obstructive pulmonary disease

Bolton, C., Stone, M., Edwards, P., Duckers, J., Evans, W., Shale, D. — Fri, 01 May 2009 10:26:53 PDT

Matrix metalloproteinase-9 (MMP-9) has been implicated in airways injury in chronic obstructive pulmonary disease (COPD). Osteoporosis is common in patients with COPD, and MMP-9 is an indicator of activated osteoclasts. We hypothesized that circulating MMP-9 would be related to bone mineral density (BMD) in COPD. We explored the relationship between MMP-9, tissue inhibitors of metalloproteinases (TIMP)-1 and -2, and BMD status in patients with COPD. A total of 70 clinically stable patients with confirmed COPD and 39 control subjects underwent spirometry, dual-energy x-ray absorptiometry to determine BMD, and venous sampling for measurement of cytokines and MMP-9 and TIMP-1 and -2. In patients, circulating MMP-9 was increased: mean (SD) 38.5 (2.2) compared with control subjects 20.1 (2.0) ng/mL, P < 0.001, whereas TIMP-1 and -2 were not different. In the patients, MMP-9 was greater in those with osteoporosis, compared with those with osteopenia, no bone disease or control subjects, and patients with osteopenia had greater MMP-9 than control subjects. The adjusted receiver operating characteristics curve area for MMP-9 detecting osteoporosis was 0.86. Patients had elevated systemic inflammatory mediators compared with control subjects, but these were unrelated to bone status. Increased circulating MMP-9 in patients with COPD was related to the presence of osteoporosis and not to lung function. MMP-9 may be a biomarker of increased bone resorption.

Tele-eHealth review series

Nguyen, H. — Fri, 01 May 2009 10:26:53 PDT

Socio-technical and organizational challenges to wider e-Health implementation

Vitacca, M, Mazzu, M, Scalvini, S — Fri, 01 May 2009 10:26:53 PDT

Recent advances in information communication technology allow contact with patients at home through e-Health services (telemedicine, in particular). We provide insights on the state of the art of e-Health and telemedicine for possible wider future clinical use. Telemedicine opportunities are summarized as i) home telenursing, ii) electronic transfer to specialists and hospitals, iii) teleconsulting between general practitioners and specialists and iv) call centres activities and online health. At present, a priority action of the EU is the Initiative on TM for chronic disease management as home health monitoring and the future Vision for Europe 2020 is based on development of Integrated Telemedicine Services. There are pros and cons in e-Health and telemedicine. Benefits can be classified as benefits for i) citizens, patients and caregivers and ii) health care provider organizations. Institutions and individuals that play key roles in the future of e-Health are doctors, patients and hospitals, while the whole system should be improved at three crucial levels: 1) organizational, 2) regulatory and 3) technological. Quality, access and efficiency are the general key issues for the success of e-Health and telemedicine implementation. The real technology is the human resource available into the organizations. For e-Health and telemedicine to grow, it will be necessary to investigate their long-term efficacy, cost effectiveness, possible improvement in quality of life and impact on public health burden.

Eradication of early Pseudomonas infection in cystic fibrosis

Lee, T. — Fri, 01 May 2009 10:26:53 PDT

Chronic infection with the environmental bacterium Pseudomonas aeruginosa is associated with greater morbidity and mortality for people with cystic fibrosis. Strict infection control measures including segregation appear to reduce but not eliminate the risk of initial acquisition of the organism. There is now good evidence from randomized controlled trials that early eradication regimens consisting of anti-pseudomonal antibiotics are effective in clearing P. aeruginosa and delaying the development of chronic infection in the majority of subjects. These regimens are safe and cost-effective. Ensuring that such regimens are widely adopted is therefore of considerable importance to improving outcomes for people with cystic fibrosis. The most effective antibiotic regimen, and the effects of new nebulizer technologies and methods to improve concordance remain to be determined.

A systematic review of recent asthma symptom surveys in Iranian children

Entezari, A, Mehrabi, Y, Varesvazirian, M, Pourpak, Z, Moin, M — Fri, 01 May 2009 10:26:53 PDT

Asthma is the most prevalent chronic disease in children. To quantify the national prevalence of asthma symptoms in Iranian children, we conducted a systematic review and meta-analysis. After internet and hand searching for population-based prevalence estimates published from 1998 to 2003 from 142 articles, dissertations and reports of research projects, 19 of them were selected. All the selected studies on children had been performed by the International Study of Asthma and Allergies in Childhood (ISAAC) protocol. We analyzed the data using NCSS software. In the included 19 studies, 61,067 children in different age groups had been examined by the ISAAC protocol. The lowest prevalence of asthma symptoms was 2.7% in Kerman and the highest was 35.4% in Tehran (capital of Iran). Overall prevalence of asthma symptoms at a national level was estimated as 13.14% (95% CI: 9.97–16.30%). Based on this study, the prevalence of asthma symptoms in Iran is higher than that estimated in the international reports. This information can be used to help prioritize asthma prevention and control within the range of Iranian public health concerns.

Book reviews

Fri, 01 May 2009 10:26:53 PDT

Exhaled nitric oxide: time to employ or make redundant?

Shaw, D — Wed, 28 Jan 2009 09:07:00 PST

Three-year follow-up after a two-year comprehensive pulmonary rehabilitation program

Steinsbekk, A, Lomundal, B. — Wed, 28 Jan 2009 09:07:00 PST

The main objective of this study is to investigate the long-term effects, 3 years after the end of a 2-year pulmonary rehabilitation program with three weekly 1-h exercise sessions and 32 h of education in patients with chronic obstructive pulmonary disease. The method consists of open prospective observational study with 30 patients. Outcome measures were quality of life (QoL) (St George’s Respiratory Questionnaire, SGRQ), physical exercise performance (6-min walking test, 6MWT), self-management abilities, lung function, hospitalization, and self-reported exercise. FEV₁ at baseline was 40.1% of predicted. The participants had statistical and clinical significant decrease in SGRQ (improved QoL) and increase in 6MWT during the program. They maintained the level of health they achieved during the program in the next 3 years, with a stable SGRQ score (–0.5 points, 95% CI –3.8 to 2.6 P = 1.000) and 6MWT (+10 m 95% CI 28 to –4, P = 0.273). Eighty percent of the participants had exercised at least 30 min three times a week from the end of the program to year 5. In conclusion, the participants had maintained their achieved level of health, improved their lung function slightly, and continued to exercise regularly 3 years after the end of the program.

Palliative care services for those with chronic lung disease

Partridge, M., Khatri, A, Sutton, L, Welham, S, Ahmedzai, S. — Wed, 28 Jan 2009 09:07:00 PST

Excellent palliative care is available for patients with advanced lung cancer. Whether the same services are available for those with nonmalignant respiratory disease is less clear. A questionnaire was sent to 210 named respiratory physicians, each representing a major hospital in England, Wales, and Northern Ireland. A total of 107 replies were received; the response rate was 51.0%. Respondents cared for patients with chronic obstructive pulmonary disease, asbestosis, and diffuse parenchymal lung disease but only a third had responsibility for cystic fibrosis. Physicians were supported by a mean of 3.4 respiratory nurse specialists per department and 73.8% had a specialist lung cancer nurse. In only 16 cases (20.3%) did that nurse extend care to those with nonmalignant disease. Only a minority reported easy access to hospice in-patient care or day care. About 21.5% of the respondents had formal policies in place for care of patients with chronic respiratory disease nearing the end of life, but 87.9% of respondents had no formal process for initiating end of life discussions with those with terminal respiratory illness. Patients with advanced nonmalignant respiratory disease have less universal access to specialist palliative care services than do those with malignant lung disease, and in the majority of hospitals there is no formalized approach to end of life care issues with patients with chronic lung disease.

Exhaled nitric oxide in the diagnosis and management of asthma: clinical implications

Rodway, G., Choi, J, Hoffman, L., Sethi, J. — Wed, 28 Jan 2009 09:07:00 PST

Exhaled nitric oxide (eNO) used as an aid to the diagnosis and management of lung disease is receiving attention from pulmonary researchers and clinicians alike because it offers a noninvasive means to directly monitor airway inflammation. Research evidence suggests that eNO levels significantly increase in individuals with asthma before diagnosis, decrease with inhaled corticosteroid administration, and correlate with the number of eosinophils in induced sputum. These observations have been used to support an association between eNO levels and airway inflammation. This review presents an update on current opportunities regarding use of eNO in patient care, and more specifically on its potential usage for asthma diagnosis and monitoring. The review will also discuss factors that may complicate use of eNO as a diagnostic tool, including changes in disease severity, symptom response, and technical measurement issues. Regardless of the rapid, convenient, and noninvasive nature of this test, additional well-designed, long-term longitudinal studies are necessary to fully evaluate the clinical utility of eNO in asthma management.

Health-related quality of life measurement in cystic fibrosis: advances and limitations

Abbott, J — Wed, 28 Jan 2009 09:07:00 PST

Health-related quality of life (HRQoL) measurement in cystic fibrosis (CF) allows the inclusion of the patient’s perspective in research and clinical practice. HRQoL scales have been used for many purposes and this review focuses on how HRQoL measurement has been implemented in CF research and care. Specifically, the review considers 1) the instruments used to measure HRQoL, 2) the factors that influence how people report HRQoL, 3) the monitoring of HRQoL in clinical practice, 4) HRQoL as an outcome measure in interventions and clinical trials and 5) whether HRQoL can predict survival. The challenge for the future is to use the available information to develop and evaluate psychological interventions that would be expected to improve HRQoL in children and adults with CF.

Breathing retraining for individuals with chronic obstructive pulmonary disease - a role for clinicians

Hillegass, E. — Wed, 28 Jan 2009 09:07:01 PST

Breathing retraining for individuals with chronic obstructive pulmonary disease - no role for clinicians

Holland, A. — Wed, 28 Jan 2009 09:07:01 PST

A fatal case of airway obstruction by an organic one-way valve

Bresci, F, Di Paolo, M, Martelli, M, De Simone, L, Giunta, F, Ambrosino, N — Wed, 28 Jan 2009 09:07:01 PST

We report a fatal case of airway obstruction. A tracheostomized, spontaneously breathing 39-year-old man developed dyspnea, cardiac, and respiratory arrest after tracheal cannula replacement. Inspection of the cannula showed a blood clot obstructing the tube. Autopsy showed pink foam in the trachea, pulmonary hyperinflation, and congested lung parenchyma. Histological examination showed acute pulmonary emphysema without any sign of blood inhalation. The probable pathophysiological mechanism is a clot creating a one-way valve allowing inspiration but not expiration, resulting in dyspnea and pulmonary hyperinflation.

Saber-sheath trachea in a patient with bronchiolitis obliterans syndrome after lung transplantation

Hayes, D, Ballard, H. — Wed, 28 Jan 2009 09:07:01 PST

Chronic rejection remains a major source of morbidity and mortality following lung transplantation. The clinical characteristics of chronic rejection involves bronchiolitis obliterans syndrome (BOS), which leads to progressive airway obstruction. Changes in intrathoracic tracheal dimensions and shape are commonly present in the setting of airway obstruction, leading to the narrowing of the intrathoracic trachea in the coronal plane with anteroposterior lengthening characteristic of the saber-sheath trachea deformity. We present a 64-year-old man who underwent left lung transplantation for idiopathic pulmonary fibrosis who later developed saber-sheath trachea as a result of chronic airway obstruction due to BOS.

Book reviews

Wed, 28 Jan 2009 09:07:01 PST

Thanks to Reviewers

Wed, 28 Jan 2009 09:07:01 PST