Respiratory Medicine: COPD Update最新文献

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 be addressed with the suggestion that individual counseling 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 counseling and ongoing peer group support to aid disease self-management.

Reproduced with permission from Sage Publications Ltd.

The prevalence of ischemic heart disease is approximately twofold higher in chronic obstructive pulmonary disease (COPD) cohorts compared to the general population. Likewise, cardiac patients with COPD have a reduced short- and long-term survival. This co-morbidity of COPD with atherosclerotic vessel disease is associated with common risk factors, such as smoking. However, atherosclerosis, in addition, shares many of the inflammatory mechanisms with those found in COPD. Atherosclerotsic lesions, as well as the COPD lung, are sites of local inflammation. Furthermore, a systemic inflammatory response, measured as increased CRP, has been reported in both patient populations. There are a number of inflammatory mediators produced in both the vessel wall and in the lungs, which potentially induce common pathological processes. For example, leukotriene B₄, which induces chemotaxis of neutrophils, monocytes, T-lymphocytes and smooth muscle cells, has been suggested as a therapeutic target in both diseases. Furthermore, activation of smooth muscle cells may lead to a narrowing of the lumen in both airways and vessels. Finally, proteolytic activities of matrix metalloproteinases may be involved both in emphysema formation and in atherosclerotic plaque rupture, leading to myocardial infarction and stroke. Taken together, the associated co-morbidity of COPD with atherosclerosis and their potential common pathophysiological mechanisms support a notion of these, and other inflammatory diseases, as manifestations of chronic inflammation.

The current study aimed to assess the impact on patient health status during an acute exacerbation of chronic obstructive pulmonary disease (AECOPD). A total of 421 COPD patients were enrolled in a multicentre, single-arm study with a 6-month observational follow-up period. Patients received two inhalations of Symbicort 200 Turbuhaler(R) twice a day. Patients were assessed before the run-in period, at baseline and at 1, 3 and 6 months. Patients were instructed to report a change in respiratory symptoms lasting >24 h. This defined an AECOPD. In addition to the initial call, the St George's Respiratory Questionnaire (SGRQ), COPD Control Questionnaire (CCQ), Medical Research Council (MRC) dyspnoea scale and activities of daily living (ADL) were completed at 5–7 and 12–14 days. A group of 176 patients reported at least one AECOPD. Exacerbations were associated with statistically significant mean changes (worsening) in the SGRQ activity and impact domains at onset (mean+/−sd 12.1+/−18.1 and 14.0+/−15.2), during the first (9.8+/−19.0 and 9.4+/−16.6) and second weeks (3.1+/−15.5 and 3.3+/−14.7). Clinically significant deterioration in SGRQ impact scores was shown in 71% of patients following early identification, with 55 and 37% during the first and second weeks of an AECOPD, respectively. Acute exacerbation severely impacts on health status. The current study provides valuable information on the change in health status during an acute exacerbation of chronic obstructive pulmonary disease that can be utilised for future trials that evaluate therapeutic intervention.

Reproduced with permission from European Respiratory Society Journals Ltd.

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 PaO(2) <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 PaO(2) 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.

Reproduced with permission from Sage Publications Ltd.

Objective

To determine whether clinicians’ prognoses in patients with severe acute exacerbations of obstructive lung disease admitted to intensive care match observed outcomes in terms of survival.

Design

Prospective cohort study.

Setting

92 intensive care units and three respiratory high dependency units in the United Kingdom.

Participants

832 patients aged 45 years and older with breathlessness, respiratory failure, or change in mental status because of an exacerbation of COPD, asthma, or a combination of the two.

Main outcome measures

Outcome predicted by clinicians. Observed survival at 180 days.

Results

517 patients (62%) survived to 180 days. Clinicians’ prognoses were pessimistic, with a mean predicted survival of 49% at 180 days. For the fifth of patients with the poorest prognosis according to the clinician, the predicted survival rate was 10% and the actual rate was 40%. Information from a database covering 74% of intensive care units in the UK suggested no material difference between units that participated and those that did not. Patients recruited were similar to those not recruited in the same units.

Conclusions

Because decisions on whether to admit patients with COPD or asthma to intensive care for intubation depend on clinicians’ prognoses, some patients who might otherwise survive are probably being denied admission because of unwarranted prognostic pessimism.

Reproduced with permission from BMJ Publishing Group Ltd.

Rationale

Chronic obstructive pulmonary disease (COPD) is a progressive, smoking-related, inflammatory lung disease in which tumor necrosis factor-alpha is overexpressed and has been suggested to play a pathogenic role.

Objectives

To determine if infliximab, an anti-TNF-alpha antibody, results in clinical benefit and has an acceptable safety profile in patients with moderate to severe COPD. METHODS: In a multicenter, randomized, double-blind, placebo-controlled, parallel-group, dose-finding study, subjects with moderate to severe COPD received infliximab (3 mg/kg [n=78] or 5 mg/kg [n=79]) or placebo (n=77) at Weeks 0, 2, 6, 12, 18, and 24. Efficacy, health status, and safety were assessed through Week 44.

Measurements and main results

Infliximab was generally well tolerated, but showed no treatment benefit as measured by the primary endpoint, Chronic Respiratory Questionnaire total score. Similarly, there was no change in secondary measures, including prebronchodilator FEV(1), 6-min walk distance, SF-36 physical score, transition dyspnea index, or moderate-to-severe COPD exacerbations. Post hoc analysis revealed that subjects who were younger or cachectic showed improvement in the 6-min walk distance. Malignancies were diagnosed during the study in 9 of 157 infliximab-treated subjects versus 1 of 77 placebo-treated subjects. No opportunistic infections were observed, and there were no differences in the occurrence of antibiotic-requiring infections, although the incidence of pneumonia was higher in infliximab-treated subjects. No infection-related mortality was observed. Higher proportions of infliximab-treated subjects discontinued the study agent due to adverse events (20-27%) than did placebo-treated subjects (9%).

Conclusions

Subjects with moderate to severe COPD did not benefit from treatment with infliximab. Although not statistically significant, more cases of cancer and pneumonia were observed in the infliximab-treated subjects. The impact of infliximab on malignancy risk in patients with COPD needs to be further elucidated.

Reproduced with permission from the American Thoracic Society