Respiratory Medicine: COPD Update最新文献

Although the benefits of pulmonary rehabilitation (PR) have been demonstrated in patients with COPD, most studies suggest that short-term programs are insufficient to maintain the benefits beyond a post-discharge period of 6 months to 1 year. We were interested to evaluate the effects of an innovative maintenance intervention compared with a usual after-care. Forty moderate to severe COPD patients, who had just completed their first inpatient PR, were consecutively included in either a maintenance group (MG) or a standard after-care group. The maintenance program was coordinated within a health-care network including self-help associations, and offered weekly activities. We measured the 6-min walk distance (6MWD), the quality of life using the St George Respiratory Questionnaire (SGRQ), the dyspnea, the maximal workload and the health-care utilization. Data were collected at respiratory clinic admission and discharge, and at 6- and 12-month visits after the PR. After 12 months, we found statistically and clinically significant differences in favor of the MG in 6MWD (74 m; p⩽0.01) and in the three domains of SGRQ: symptom (19%; p⩽0.01), activity (27%; p⩽0.01) and impact (32%; p⩽0.01). The results showed no difference between groups in dyspnea and maximal workload. We also found that the number of days spent in hospital for respiratory disorders was significantly lower in the MG after 12 months (p⩽0.03). The multidisciplinary management of COPD patients in the post-rehabilitation period within a health-care network including self-help associations seems to be an effective strategy for maintaining, and even improving, the benefits of a first initial structured program.

Background

Chronic obstructive pulmonary disease (COPD) is a common disease with a steadily increasing prevalence and mortality. However, recent epidemiological estimates differ depending on the population studied and methods used.

Aim

To investigate the prevalence, severity and burden of COPD in a primary care setting.

Methods

From 4730 patients registered in a single primary care practice, all 2250 patients aged 40 years or more were invited to participate. Participants completed a questionnaire on smoking, respiratory symptoms, education and social status. A physical examination was followed by pre- and post-bronchodilator (BD) spirometry.

Results

Of the eligible patients, 1960 (87%) participated. Ninety-two percent of spirometric tests met the ATS criteria. Airflow limitation was demonstrated in 299 (15%) of the participants pre-BD and in 211 (11%) post-BD. COPD was diagnosed in 183 patients (9.3%). Of these patients, the degree of post-BD airflow limitation was mild in 30.6%, moderate in 51.4%, severe in 15.3% and very severe in 2.7%. Only 18.6% of these patients had previously been diagnosed with COPD; almost all of these had severe or very severe airflow limitation. As a result of the study, a diagnosis of asthma was made in 122 patients.

Conclusions

The prevalence and underdiagnosis of COPD in adult patients in this primary care setting made case finding worthwhile. Large numbers of newly detected patients were symptomatic and needed treatment. Limiting investigations to smokers would have reduced the number of COPD diagnoses by 26%.

Reproduced with permission from the BMJ Publishing Group.

Rationale

Physical activity is reduced in patients with chronic obstructive pulmonary disease (COPD). COPD has a systemic component that includes significant extrapulmonary effects that may contribute to its severity in individual patients.

Objectives

To investigate the association of extrapulmonary effects of the disease and its comorbidities with reduced physical activity in patients with COPD.

Methods

In a cross-sectional study, 170 outpatients with COPD (GOLD [Global Initiative for Chronic Obstructive Lung Disease] stages I-IV; BODE [body mass index, airway obstruction, dyspnea, and exercise capacity] score 0-10) underwent a series of tests. Physical activity was assessed over 5 to 6 consecutive days by using a multisensor accelerometer armband that records steps per day and the physical activity level (total daily energy expenditure divided by whole-night sleeping energy expenditure). Cardiovascular status was assessed by echocardiography, vascular Doppler sonography, and levels of N-terminal pro-B-type natriuretic peptide. Mental status, metabolic/muscular status, systemic inflammation, and anemia were assessed by Beck Depression Inventory, bioelectrical impedance analysis, handgrip strength, high-sensitivity C-reactive protein/fibrinogen, and hemoglobin, respectively.

Measurements and main results

In a multivariate linear regression analysis using either steps per day or physical activity level as a dependent variable, the extrapulmonary parameters that were associated with reduced physical activity in patients with COPD independently of GOLD stages or BODE score were N-terminal pro-B-type natriuretic peptide levels, echocardiographically measured left ventricular diastolic function, and systemic inflammation.

Conclusions

Higher values of systemic inflammation and left cardiac dysfunction are associated with reduced physical activity in patients with COPD.

Reproduced with permission from the American Thoracic Society.

Aims

To assess whether exhaled nitric oxide (FENO) measurements improve management and clinician confidence in patients presenting with non-specific respiratory symptoms.

Methods

This observational study was based in a large primary care practice (15,500 patients, 14 GPs). Patients had non-specific respiratory symptoms for at least 6 weeks. FENO and spirometry measurements were performed at initial assessment. An algorithm was employed to assist interpretation of FENO and spirometry results. GPs evaluated the diagnostic contribution of FENO and spirometry at 3-month follow-up.

Results

In 48/51 (94%) of cases, FENO was considered significant in formulating a diagnosis. Spirometry was deemed helpful in 27/51 (54%).

Conclusion

FENO measurements improved diagnostic confidence when assessing non-specific respiratory symptoms. This may be because, in contrast to spirometry, both low and high FENO values have clinical significance. Trial registration: Australian Clinical Trials Registry ACTRN012605000354684.

Reproduced with the permission of the General Practice Airways Group (awaiting permission).

This review provides an overview of the randomised controlled trials covering the topic of chronic non-invasive positive pressure ventilation (NIPPV) in severe stable COPD patients. Studies investigating patients receiving bilevel NIPPV via nasal, oronasal or total face mask interfaces for at least 1 week or more, were described.

Eight RCTs were included, from which six trials used NIPPV for up to 3 months (short-term) and two trials also obtained long-term effects (3 months to ⩾2 years).

Outcome parameters were: arterial blood gases, pulmonary function, respiratory mechanics, respiratory muscle strength, dyspnoea, exercise tolerance, health-related quality of life, neuropsychologic function, sleep quality, hospital admissions and survival.

We found that NIPPV in addition to standard care can have beneficial effects on certain outcome measures, however results are conflicting. Therefore, evidence is insufficient to recommend NIPPV routinely in stable but severe COPD patients. Nevertheless, it seems that hypercapnic patients, who receive enough time to adjust to the ventilator and so obtain improved ventilation, could benefit from NIPPV.