Chronic Respiratory Disease recent issues

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

The lung in diabetes - yet another target organ?

Kuitert, L. — 2008-06-06

Different short-term and longitudinal results on perceived health status for asthma and COPD patients after pulmonary rehabilitation. Patients living alone have the largest improvements in perceived quality of life

Haave, E, Hyland, M. — 2008-06-06

A combined sample (n = 132) of asthma (70%, n = 92) and chronic obstructive pulmonary disease (COPD) (30%, n = 40) patients was assessed for short-term and longitudinal changes in perceived health status (HS), quality of life (QoL), and trait anxiety after a 4-week inpatient pulmonary rehabilitation program (PRP). The total sample improved on HS (P = 0.009 effect size (ES) = 0.12) and QoL (P = 0.011, ES = 0.16) immediately after rehabilitation but improvements diminished at 6 months follow-up. Trait anxiety scores changed very little. The COPD group improved on HS immediately after the rehabilitation program (P = 0.005, ES = 0.16) but scores had deteriorated at follow-up. The asthma group had only a small and non-significant HS improvement immediately after the program but got better during the follow-up period and improved significantly on HS (P = 0.040, ES = 0.21) from before rehabilitation to follow-up 6 months after the program. Within both diagnosis groups, patients who were living alone had the largest improvements in QoL scores. PRP may have different longitudinal effects for patients with asthma and COPD. After-care procedures are probably important in rehabilitation of patients with COPD.

Rehabilitation in COPD: the long-term effect of a supervised 7-week program succeeded by a self-monitored walking program

2008-06-06

Pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) improves exercise tolerance and health status, however, these effects have been shown to decline after termination of the rehabilitation program. This study has examined the long-term effect of a 7-week supervised rehabilitation program combined with daily self-monitored training at home on exercise tolerance and health status. Two hundred and nine consecutive COPD patients who had completed a 7-week pulmonary rehabilitation program were assessed with endurance shuttle walk test (ESWT) and the St George's Respiratory Questionnaire (SGRQ) at baseline, 0, 3, and 12 months after the program. Sixty-eight (32.5%) patients did not attend the 1-year follow-up. Among the 141 patients who competed the 1-year evaluation, the initial improvement after the 7-week program in the ESWT time was 180 s or 101% (p = 0.001) and in SGRQ 3.4 units (p = 0.001). These effects were maintained at the 1-year evaluation (ESWT 59% above baseline; p < 0.001 and improved SGRQ 3.0 units compared with baseline; p = 0.011). The 31 patients who attended the 6-month, but not the 12-month evaluation, improved ESWT time by 96 s (p = 0.02) without any change in SGRQ +2.0 (p = 0.40). A relative simple and inexpensive 7-week supervised rehabilitation program combined with daily self-monitored training at home was able to maintain significant improvement in exercise tolerance and health status throughout 1 year. Death and hospital admissions due to acute exacerbations were the main reasons for non-attendance in the follow-up period.

Domiciliary humidification improves lung mucociliary clearance in patients with bronchiectasis

Hasani, A, Chapman, T., McCool, D, Smith, R., Dilworth, J., Agnew, J. — 2008-06-06

Inspired air humidification has been reported to show some benefit in bronchiectatic patients. We have investigated the possibility that one effect might be to enhance mucociliary clearance. Such enhancement might, if it occurs, help to lessen the risks of recurrent infective episodes. Using a radioaerosol technique, we measured lung mucociliary clearance before and after 7 days of domiciliary humidification. Patients inhaled high flow saturated air at 37 °C via a patient-operated humidification nasal inhalation system for 3 h per day. We assessed tracheobronchial mucociliary clearance from the retention of ^99mTc-labelled polystyrene tracer particles monitored for 6 h, with a follow-up 24-h reading. Ten out of 14 initially recruited patients (age 37–75 years; seven females) completed the study (two withdrew after their initial screening and two prior to the initial clearance test). Seven patients studied were non-smokers; three were ex-smokers (1–9 pack-years). Initial tracer radioaerosol distribution was closely similar between pre- and post-treatment. Following humidification, lung mucociliary clearance significantly improved, the area under the tracheobronchial retention curve decreased from 319 ± 50 to 271 ± 46%h (p < 0.07). Warm air humidification treatment improved lung mucociliary clearance in our bronchiectatic patients. Given this finding plus increasing laboratory and clinical interest in humidification mechanisms and effects, we believe further clinical trials of humidification therapy are desirable, coupled with analysis of humidification effects on mucus properties and transport.

A comparison of invasive versus noninvasive full-time mechanical ventilation in Duchenne muscular dystrophy

Soudon, P, Steens, M, Toussaint, M — 2008-06-06

The aim of this study was to compare morbidity and causes of death in a series of 42 Duchenne patients receiving full-time mechanical ventilation either by tracheostomy (TR, n = 16 or by noninvasive methods (noninvasive ventilation [NIV], n = 26). At inclusion for a 5-year observation period (2002–2006), TR and NIV patients were 32.7 and 27 years old, respectively. A program of follow-up with similar ventilation devices, techniques of respiratory physiotherapy, and drugs was applied to all the patients [TR + NIV]. Ages and respiratory characteristics at death and causes of death were comparable between groups. Morbidity was worse in TR compared with NIV patients; mucus hypersecretion and tracheal injuries were more frequent, whereas loss of weight and need for gastric feeding appeared less frequent in the TR group. Because noninvasive techniques avoid the severe complications associated with TR with comparable mortality, the authors support the use of noninvasive interfaces as default choice when assisted ventilation is required for daytime use.

Late respiratory effects of sulfur mustard: how is the early symptoms severity involved?

Ghanei, M, Adibi, I, Farhat, F, Aslani, J — 2008-06-06

The association between severity of exposure to sulfur mustard (SM) and late respiratory complications is not clear. The aim of this study was to determine the presence of late pulmonary complications in patients with mild, moderate, and severe initial symptoms of sulfur mustard exposure. This was a retrospective cohort study on patients with mild, moderate, and severe initial symptoms of sulfur mustard exposure (during 1983–1988) in Baqyatallah University of medical sciences (2004–2005). The ‘mild’ group (n = 115) had no early symptom at the time of exposure. The ‘moderate’ group (n = 273) had early symptoms after exposure and were not hospitalized for that reason. The ‘severe’ group (n = 215) had early symptoms and had been hospitalized accordingly. Pulmonary function tests and high-resolution computed tomography of the chest were performed. The chi-square test was used for data analysis. The severe and moderate groups had a similar frequency of obstructive pattern (21%), whereas only one patient in the mild group showed this pattern. Air trapping did not significantly differ between groups. In the mild group, 74.8% (n = 86) showed significant air trapping, whereas it was 62.3% (n = 170) in moderate and 67.0% (n = 144) in severe groups (P = 0.057). Moderate and severe exposure to sulfur mustard causes an equal risk of late pulmonary complications, while mild exposure has lesser risk. Bronchiolitis obliterans is the main underlying respiratory consequence of sulfur mustard exposures and may relate to host factors rather than to severity of early symptoms.

Pulmonary complications in diabetes mellitus

2008-06-06

Clear decrements in lung function have been reported in patients with diabetes over the past two decades, and many reports have suggested plausible pathophysiological mechanisms. However, there are no reports of functional limitations of activities of daily living ascribable to pulmonary disease in patients with diabetes. This review attempts to summarize the available information from the present literature, to describe the nature of the lung dysfunction in diabetes and the emerging clinical implications of such dysfunction.

Oxygen conserving devices and methodologies

Tiep, B, Carter, R — 2008-06-06

Collective experience with pulmonary rehabilitation and disease management has shown that patients with lung diseases including COPD and restrictive lung diseases live a longer and more productive quality of life if they can remain active. Patients who require oxygen supplementation but can otherwise be active should have the most portable and non-encumbering systems possible. Oxygen conserving devices have made a high level of portability possible. Small gas, liquid and even some concentrators have replaced the 20 pound E cylinder with 4 and 5 pound systems. In a parallel physiological development, exercise plus oxygen increases the physiological benefits of exercise and thereby enhances the patient's ability to function in life. This paper examines available options and their mechanical and physiological foundations.

Assessing the airways

Enright, P, McCormack, M — 2008-06-06

Spirometry is the best test to detect airway obstruction, categorize the severity of obstructive lung diseases, and objectively measure changes in severity because of disease progression or treatment. However, peak flow may be helpful to rule out moderate to severe airway obstruction and for home monitoring in some patients with asthma.

The physiological basis of respiratory disease: Hamid, Shannon, Martin: Published by BC Decker: ISBN: 1550092367 Price: �58.99 (Hardcover)

Steiner, M. — 2008-06-06

Which is the best exercise test to assess therapeutic intervention in COPD?

Jenkins, S. — 2008-02-26

Quality of life in patients with chronic obstructive pulmonary disease: the predictive validity of the BODE index

2008-02-26

Background: Chronic obstructive pulmonary disease (COPD) is currently the fourth cause of mortality and morbility in the developed world. Patients with COPD experience a progressive deterioration of health-related quality of life (HRQOL). A new model of severity classification, the body mass index, bronchial obstruction, dyspnoea, exercise (BODE) index, has recently been proposed.

Objective: To evaluate the relationship between HRQOL and the BODE index, and the predictive ability of BODE on HRQOL measurements.

Methods: Two HRQOL questionnaires were administered, namely the Nottingham Health Profile (NHP) and St George's Respiratory Questionnaire (SGRQ), in a sample of 67 patients with severe COPD.

Results: Pearsons correlation coefficient analysis shows a positive correlation between the BODE index and the total scores of the specific (P < 0.001), and general HRQOL (P < 0.001); the analysis shows a significant correlation between the BODE index and the subscales of symptoms, activity and impact of SGRQ (P < 0.001) and the subscales energy and physical mobility of the NHP (P < 0.001). The regression analysis shows that the BODE index is a significant predictor of HRQOL, explaining 46,1% of the total score of the SGRQ (P < 0.001) and 14.8% of the total score of the NHP (P < 0.001).

Conclusions: The BODE index is good at predicting the worsening of HRQOL in patients with severe COPD. Chronic Respiratory Disease 2008; 5: 7—11

Quality of life measurements and bronchodilator responsiveness in prescribing nebulizer therapy in COPD

Brophy, C., Kastelik, J., Gardiner, E., Greenstone, M. — 2008-02-26

Nebulized bronchodilators are widely regarded as the optimal treatment for maintenance therapy in patients with severe chronic obstructive pulmonary disease (COPD). The aim of the study was to assess whether detailed physiological, functional and quality of life-related measurements can assist in determining the requirement for nebulized bronchodilator therapy in patients with moderate to severe COPD. This was an unblinded, randomized, crossover study that compared intermediate (120mcg ipratropium bromide and 600mcg of salbutamol using metered dose inhaler (MDI) and spacer) and high dose (nebulized 500 mcg ipratropium bromide and 2.5 mg salbutamol) bronchodilator therapy, on physiological, functional and quality of life-related measurements in patients with COPD. A total of 25 patients (12 female), mean (SD) age 68 (7) years, FEV₁ 45 (10) % predicted completed the study. There was no statistically significant difference between the treatments in the pre- and post-bronchodilator lung function values, six-minute walk distance, breathlessness score or quality of life questionnaires. Fifteen patients preferred bronchodilator therapy with nebulizer and 10 with MDI and spacer. In 20 patients at least one positive response in quality of life score, lung function or six-minute walk, was observed on the preferred treatment.

Only a proportion of patients with moderate or severe COPD prefer nebulized bronchodilator therapy. This study found that none of the parameters singly or in combination were consistently predictive of patients' preference for nebulized bronchodilator therapy. Therefore, we suggest that clinicians institute a trial of stepping up to an intermediate dose of bronchodilators prior to introducing nebulized therapy. Chronic Respiratory Disease 2008; 5: 13—18

Invasive pulmonary aspergillosis in patients with COPD: a report of five cases and systematic review of the literature

Samarakoon, P., Soubani, A. — 2008-02-26

Background: There are increasing reports describing invasive pulmonary aspergillosis (IPA) in patients with chronic obstructive pulmonary disease (COPD) without the classic risk factors for this severe infection. The available literature on this association is based on case reports or small case series. The aim of this review is to systematically review these cases and describe the clinical features, diagnostic studies and outcome.

Methods: We identified all the cases of IPA and COPD reported in the literature and had enough clinical information. We also included five cases of IPA in patients with COPD identified by the authors. These cases were systematically reviewed for clinical features, diagnostic studies and outcome.

Results: There were 60 cases of IPA in patients with COPD identified from the literature. The total number of cases reviewed was 65. The mean age was 65.1 years, the mean FEV1 was 39% of predicted (n = 17, range 19—56%). Forty-nine patients were documented to be on systemic corticosteroids. The mean dose was 24mg/day (range 15—65 mg/day). Five patients were only on inhaled corticosteroids and in 11 patients there was no documentation of corticosteroid therapy. The clinical and radiological findings were nonspecific. Thirteen patients had documented evidence of disseminated IPA. Sputum examination was positive for Aspergillus in 76% and bronchoscopy with bronchoalveolar lavage that was positive in 70%. The diagnosis of IPA was definite in 43 patients and probable in 22 patients. Forty-six patients were treated with anti-fungal therapy. Fifty-nine patients (91%) died with IPA.

Conclusion: Invasive pulmonary aspergillosis is an emerging serious infection in patients with COPD. The majority of these patients have advanced COPD and/or on corticosteroid therapy. The clinical and radiological presentation is nonspecific. High index of suspicion is necessary for the timely treatment of these patients. Chronic Respiratory Disease 2008; 5: 19—27

Risk factors for increased need for intravenous antibiotics for pulmonary exacerbations in adult patients with cystic fibrosis

Jarad, N. A., Giles, K. — 2008-02-26

Background: Pulmonary exacerbations (P Exs) are important in cystic fibrosis (CF). They are very common, and are associated with poor quality of life. P Exs are regarded as an important end point in clinical trials. Risk factors associated with increase in P Exs have not been examined at a large scale. This study investigates factors associated with P Exs in a large cohort of adolescent and adult patients.

Patients and methods: This is a cross-sectional study on data collected in the South and West Regions in England in 2002. Patients aged 16 years and over were included. Data on age, gender, FEV₁, body mass index (BMI), infection with Pseudomonas aeruginosa (Pa) and on CF-related diabetes were included in the analysis. P Ex was defined as an episode treated with IV antibiotics. Forward stepwise multiple regression analysis was performed with the number of P Exs being the independent variable. The rest of the variables were considered to be the dependent variables.

Results: Data from 341 patients (194 female), mean age (SD), 24.9 (8.9) years were available. In 2002, a total of 599 P Exs were reported, median 1.00 range 0—16 P Exs. Using stepwise multiple regression analysis factors associated with increased number of P Exs were: infection with Pa (t-value —5.0, P < 0.0001), FEV₁, (t-value —4.9, P < 0.0001) and diabetes mellitus, (t-value —2.1, P = 0.04). Age, gender and BMI did not influence the annual number of exacerbations.

Conclusions: In this study, risk factors for P Exs were found to be as follows: growth of Pa in the sputum, reduced FEV1 and CF-related diabetes mellitus. Chronic Respiratory Disease 2008; 5: 29—33

Metabolic and inflammatory profile in obese patients with chronic obstructive pulmonary disease

2008-02-26

Background: Overweight and obesity have been associated with better survival in patients with chronic obstructive pulmonary disease (COPD). On the other hand, excess body weight is associated with abnormal metabolic and inflammatory profiles that define the metabolic syndrome and predispose to cardiovascular diseases. This study was undertaken to evaluate the impact of overweight and obesity on the prevalence of the metabolic syndrome and on the metabolic and inflammatory profiles in patients with COPD.

Methods: Twenty-eight male patients with COPD were divided into an overweight/obese group [ n = 16, body mass index (BMI) = 33.5 ± 4.2 kg/m²] and normal weight group (n = 12, BMI = 21.1 ± 2.6kg/m²). Anthropometry, pulmonary function and body composition were assessed. The metabolic syndrome was diagnosed according to waist circumference, circulating levels of triglyceride and high-density lipoprotein cholesterol levels, fasting glycemia and blood pressure. C-reactive protein, tumor necrosis factor- (TNF-), interleukin-6 (IL-6), leptin and adiponectin plasma levels were measured.

Results: Airflow obstruction was less severe in overweight/obese compared with normal weight patients (forced expiratory volume₁: 51 ± 19% versus 31 ± 12% predicted, respectively, P < 0.01). The metabolic syndrome was diagnosed in 50% of overweight/obese patients and in none of the normal weight patients. TNF-, IL-6 and leptin were significantly higher in overweight/obese patients whereas the adiponectin levels were reduced in the presence of excess weight.

Conclusions: The metabolic syndrome was frequent in overweight/obese patients with COPD. Obesity in COPD was associated with a spectrum of metabolic and inflammatory abnormalities. Chronic Respiratory Disease 2008; 5: 35—41

Review Series: Chronic cough: Epidemiology

Morice, A. — 2008-02-26

Chronic cough is perhaps the commonest symptom of medical importance with some 12% of the general population having the symptom on a daily or weekly basis. Chronic cough causes a large degree of morbidity, with both the physical e.g. incontinence, and the psychological e.g. social isolation, domains.

The causes of chronic cough are numerous, but fall into two broad categories; that causing an asthma-like syndrome characterized by eosinophilic infiltration of the airways, and oesophageal disease, particularly weakly acid reflux. Failure to make, particularly this latter, diagnosis leads to enormous consequences in terms of loss of employment, healthcare utilisation and a psychosocial morbidity. Chronic Respiratory Disease 2008; 5: 43—47

Review Series: The Politics of TB: TB control services need tailoring for new arrivals, not vice versa

Wang, Y., Taegtmeyer, M., Squire, S.B., Theobald, S.J. — 2008-02-26

High rates of TB amongst new arrivals to the UK require flexible, innovative responses that go beyond traditional biomedical models and take into account the needs of these heterogeneous groups. This article explores the merging of public health and human rights based approaches to TB control in response to the challenge of increasing rates of TB amongst new arrivals in the UK. Chronic Respiratory Disease 2008; 5: 49—51

Book Review: Disorders of the Respiratory Tract -- Common Challenges in Primary Care, Mathew L Mintz Published by Huimana Press, New Jersey, 2006, $79.50. ISBN: 1-58829-556-7 (hardcover)

Levy, M. — 2008-02-26

COPD exacerbations: who is safe to be managed at home

Hernandez, C., Roca, J. — 2007-11-20

Too little, too late the patients' perspective on education for COPD

Jones, Dr. R. — 2007-11-20

Effect of PaO2 and social circumstances on outcomes in out-patient treatment of COPD exacerbations

Khalid, S., Elliott, A.C., Pilling, A., Wolstenholme, R.J. — 2007-11-20

The current British Thoracic Society guidelines on COPD recommend that patients with COPD exacerbations should be admitted to hospital if they either have partial pressure of arterial oxygen of <7.0 kilopascals (kPa) or if they are living alone. This study was carried out to see if either of these factors have any effect on the outcome in patients presenting with COPD exacerbation in the setting of well established COPD services. This study was to see if patients with PaO₂ < 7.0 kPa or those living alone were readmitted more frequently or had higher mortality than other patients discharged through the same scheme. A retrospective analysis was carried out on 1078 patients with acute exacerbation of COPD who were discharged home through Wigan "hospital at home" scheme in the period between November 1999 and February 2004 prior to the introduction of the new guidelines. This study found that there was no statistically significant difference in the rates of readmissions in patients with low PaO₂ or those living in adverse social circumstances compared to other groups of patients. The number of patients dying in this period was too small to analyse with adequate power. This study indicates that such patients can be safely managed at home in the context of well established COPD services. Chronic Respiratory Disease 2007; 4: 191—194

Evaluation of the information needs of patients with chronic obstructive pulmonary disease following pulmonary rehabilitation: a focus group study

Rodgers, S., Dyas, J., Molyneux, A.W.P., Ward, M.J., Revill, S.M. — 2007-11-20

Aims: This study aimed to understand patient information needs and how best to meet them in order to improve rehabilitation provision and aid disease self-management by exploring experiences of people who had recently completed a pulmonary rehabilitation programme in a community hospital setting.

Methods: Qualitative research using focus groups was undertaken with 23 patients who had completed pulmonary rehabilitation within the previous four months. The focus groups were tape-recorded and contemporaneous notes made. The tapes were transcribed verbatim and template analysis was used to develop themes.

Findings: The key information needs were for a full understanding of the disease to be generated for patients, their families and the wider public much earlier in the disease process and preferably at the point of diagnosis. Patients perceived that they needed to come to terms with the condition. In order to improve disease self-management feelings of anxiety and frustration should to be addressed with the suggestion that individual counselling might be made available through the rehabilitation programme. The need for continued support was highlighted with an emphasis on peer group support activities.

Conclusions: The findings have implications for primary care in terms of unmet needs in the early stages of the condition and pulmonary rehabilitation programmes in terms of providing individual counselling and ongoing peer group support to aid disease self-management. Chronic Respiratory Disease 2007; 4: 195—203

Review Series: Lung function made easy: Assessing gas exchange

Hughes, J.M.B. — 2007-11-20

In clinical practice there are two sorts of measurements, a) arterial oxygen and carbon dioxide partial pressure (PaO₂, PaCO₂) or arterial oxygen saturation (SaO₂), and b) the transfer capacity for carbon monoxide (TLCO). The former measures the output or performance of the lung as a gas exchanger, and the latter estimates the available surface area or potential for gas exchange. As gas exchange deteriorates (PaO₂ falls and PaCO₂ rises), the body compensates by increasing ventilation and lowering PaCO₂. Therefore, a high PaCO₂ represents chronic respiratory or "compensation" failure, either chemo-insensitivity ("won't breathe") or neuromuscular weakness/increased work of breathing ("cannot breathe"). Chronic respiratory failure may progress to acute failure in which PaCO₂ falls and PaCO₂ rises progressively, assisted ventilation is usually required. The TLCO is a laboratory test which measures the integrity of the blood-gas barrier, it is particularly useful in the assessment of emphysema, interstitial disease and pulmonary vascular disease. Chronic Respiratory Disease 2007; 4: 205—214

Review Series: Chronic cough: Common causes and current guidelines

McGarvey, L.P.A., Polley, L., MacMahon, J. — 2007-11-20

Chronic cough is a common and disabling symptom. Recent guidelines have attempted to provide direction in the clinical management of cough in both primary and secondary care. They have also provided a critical review of the available literature and identified gaps in current knowledge. Despite this they have been criticized for a reliance on a low quality evidence base. In this review, we summarize the current consensus on the clinical management of chronic cough and attempt to rationalize this based on recent evidence. We have also provided an overview of the likely pathophysiological mechanisms responsible for cough and highlighted areas, where knowledge deficits exist and suggest directions for future research. Such progress will be critical in the search for new and effective treatments for cough. Chronic Respiratory Disease 2007; 4: 215—223

Review Series: Occupational and environmental lung disease: Introduction

Fishwick, Dr. D. — 2007-11-20

Review Series: Occupational and environmental lung disease: The non-occupational environment and the lung: opportunities for intervention

Kurmi, O.P., Ayres, J.G. — 2007-11-20

Many environmental factors, both indoors and outdoors, can cause or worsen respiratory disease. Although in many cases individuals have little influence over environmental exposures (e.g., weather conditions), there are many (such as environmental tobacco smoke (ETS) and outdoor air pollution) where interventions can improve health. While for environmental exposures such as air pollution, remediation largely devolves to the government, for exposures such as ETS advice to individuals in these settings will confer benefit. Climate change has begun to feature more and more in the context of health but how this may affect pulmonary disease remains debatable. It is possible that heat associated changes in allergen exposures may be more than counterbalanced by potential reductions in cold related exacerbations of diseases such as COPD. An improved assessment of environmental exposures is key in how we approach the effects of the environment on lung disease which would allow better understanding of gene-environment interactions and how remediation might influence population health for the better. Chronic Respiratory Disease 2007; 4: 227—236

Tracheostomy for advanced neuromuscular disease. Pro

Pratt, P. — 2007-11-20

Tracheostomy for advanced neuromuscular disease. Con

Bach, J.R. — 2007-11-20

Book Review: Sleep Disorders in Women: A Guide to Practical Management Edited by Hrayr P Attarian Published by The Humana Press, $99.50. ISBN: 1 588 29 592 3 (hardback)

Hardinge, M. — 2007-11-20