Current thoughts regarding treatment of chronic obstructive pulmonary disease

The clinical utility of the GOLD classification of COPD disease severity in pulmonary rehabilitation

The Global Initiative for Chronic Obstructive Lung Disease (GOLD) has introduced a four-stage classification of chronic obstructive pulmonary disease (COPD) severity. The present study investigated the discriminatory capacity of the GOLD classification for health status outcomes in patients with COPD. An additional analysis was performed to investigate the discriminatory capacity of a multidimensional staging system, i.e. the Body-Mass Index, Degree of Airflow Obstruction and Dyspnea, and Exercise Capacity Index (BODE index) for the outcome of quality of life. Retrospective analysis was performed on 253 COPD patients (30% stage II, 48% stage III, 22% stage IV), referred for outpatient pulmonary rehabilitation. Pulmonary function, exercise capacity, dyspnoea and quality of life were evaluated. Analyses of variance were used to detect differences between GOLD stages and BODE index quartiles, and scatterplots of individual responses were produced as well. The GOLD classification discriminated between stages for pulmonary function (p<0.001), exercise capacity (p<0.001), dyspnoea (p<0.001) and the activities section (p=0.001) of the St. George Respiratory Questionnaire (SGRQ). The BODE index discriminated between quartiles for the activities section (p<0.001), impacts section (p=0.04) and the total score (p=0.01) of the SGRQ. Scatterplots revealed marked inter-individual variation within each GOLD stage or BODE index quartile, and considerable overlap between stages for all health status outcomes. These findings show that the GOLD classification indeed can be used to discern groups of COPD patients, but due to large inter-individual variability it does not seem adequate as a basis for individual management plans in rehabilitation. The BODE index appeared to discriminate slightly better for quality of life, however, it still leaves a significant part of the variance unexplained.

Pulmonary Rehabilitation in Patients Undergoing Lung-Volume Reduction Surgery

Chronic obstructive pulmonary disease (COPD) is the most common form of primary pulmonary disability. Few effective treatment options exist for it, but recently, lung-volume reduction surgery (LVRS) has been shown to be effective in selected patients with emphysema. Pulmonary rehabilitation is an integral part of the preparation for and recovery from the procedure and has significant benefit in helping to improve the quality of life and conditioning of patients with COPD who undergo LVRS.

OVERALL ARTICLE OBJECTIVES

(a) To describe the role of pulmonary rehabilitation in LVRS, (b) to understand the components of a comprehensive pulmonary rehabilitation program, and (c) to describe the effects of a pulmonary rehabilitation program.

Pharmacological treatment of chronic obstructive pulmonary disease

None of the drugs currently available for chronic obstructive pulmonary disease (COPD) are able to reduce the progressive decline in lung function which is the hallmark of this disease. Smoking cessation is the only intervention that has proved effective. The current pharmacological treatment of COPD is symptomatic and is mainly based on bronchodilators, such as selective beta2-adrenergic agonists (short- and long-acting), anticholinergics, theophylline, or a combination of these drugs. Glucocorticoids are not generally recommended for patients with stable mild to moderate COPD due to their lack of efficacy, side effects, and high costs. However, glucocorticoids are recommended for severe COPD and frequent exacerbations of COPD. New pharmacological strategies for COPD need to be developed because the current treatment is inadequate.

The functional impact of an individualized, graded, outpatient pulmonary rehabilitation in end-stage chronic obstructive pulmonary disease

OBJECTIVE

To evaluate the functional impact of an individualized outpatient pulmonary rehabilitation program in end-stage chronic obstructive pulmonary disease (COPD).

METHODS

Patients with end-stage COPD were admitted into a 6-week comprehensive outpatient pulmonary rehabilitation program that was "packaged" for each patient. We compared spirometric parameters, exercise tolerance, level of breathlessness, and intensity of work before and after rehabilitation.

RESULTS

Of 45 eligible patients, only 14 consented to participate in the study. All 14 patients had forced expiratory volume in 1 second <35% of predicted, and 10 patients (72%) had a 6-minute walk test <180 m. The level of breathlessness was between 7 (moderate to severely breathless) and 10 (maximally breathless) on the Visual Analogue Scale in all patients. After the program, there was significant improvement in the FEV 1 P = 0.04), forced vital capacity P = 0.0045), 6-minute walk test P = 0.00047), and shuttle-walk test (9 of 14 patients). All patients had some improvement in level of dyspnea.

CONCLUSIONS

Individualized outpatient pulmonary rehabilitation in end-stage COPD can produce a measurable improvement in spirometry and exercise tolerance with a favorable impact on the level of physical activity.

The benefits of exercise training for quality of life in HIV/AIDS in the post-HAART era

The use of highly active antiretroviral therapy (HAART) has served to significantly reduce the mortality of HIV-infected persons. However, this treatment is associated with a host of adverse effects: fatigue, nausea, pain, anxiety and depression. Rather than utilise traditional pharmacological treatments for these effects, many HIV/AIDS patients are utilising adjunct therapies to maintain their quality of life while they undergo treatment. Exercise has consistently been listed as one of the most popular self-care therapies and a small number of studies have been conducted to examine the impact of exercise on the most common self-reported symptoms of HIV and AIDS and the adverse effects of treatment. Although the results are generally positive, there are clear limitations to this work. The existing studies have utilised small samples and experienced high rates of attrition. In addition, the majority of the studies were conducted prior to the widespread use of HAART, which limits the ability to generalise these data. As a result, data from other chronic disease and healthy samples are used to suggest that exercise has the potential to be a beneficial treatment across the range of symptoms and adverse effects experienced by HIV-infected individuals. However, additional research is required with this population to demonstrate these effects.

Factors Associated With Outcomes of Acute Exacerbations of Chronic Obstructive Pulmonary Disease

The purpose of this article is to provide a general review of the current literature on the factors associated with the outcomes of hospitalizations, survival and health-related quality of life in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), highlighting the limitations and the complexities in interpretation of the results of current studies. There is no consensus definition for AECOPD; onsets may be difficult to define and the determination of duration elusive. The prevalence of acute exacerbations of COPD (AECOPD) in the community appears to be underestimated as exacerbations are underreported by patients and their doctors. Hospitalization for COPD is due mainly to severe AECOPDs which drive the cost of care. There are few longitudinal epidemiological studies on factors associated with hospitalizations for AECOPD. The results of current studies do not allow clear differentiation between associations that are predictors of event, the consequences of the event, or indicators of severity. Strategies to reduce severe exacerbations of COPD include pharmacological treatment, vaccinations, pulmonary rehabilitation, and home care programs. The optimal strategy for the reduction of hospitalization in COPD remains unclear. Long-term interventional studies are needed to provide clearer information for the prevention of exacerbations and hospitalizations in COPD.

Systematic assessment of clinical practice guidelines for the management of chronic obstructive pulmonary disease

OBJECTIVE

To systematically evaluate the quality of the development of guidelines for the management of chronic obstructive pulmonary disease (COPD).

METHODOLOGY

MEDLINE and Excerpta Medica search for published guidelines, followed by independent evaluation by two reviewers, according to previously reported guideline development quality criteria, on a three-point scale.

RESULTS

Five national COPD guidelines and two international COPD guidelines were retrieved. Reviewers demonstrated good inter-observer agreement in assessing the 10 combined guideline development criteria for the seven guidelines [kappa = 0.66]. Guidelines were only partly multi-disciplinary with little or no consumer input, were up to 48 pages in length, and often lacked practical summaries or management flow charts which could have facilitated retrieval of key management recommendations. Almost all the papers were based upon a consensus approach, rather than evidence based, and methods of resolution of differences of opinion were not stated. Patient outcomes, ethical and medico-legal implications were not addressed and six of the guidelines were sponsored directly or indirectly by a single drug company.

CONCLUSIONS

In spite of COPD guidelines being reported by major national bodies for over a decade now, most fail to meet important criteria for high-quality guideline development, and evaluation of clinical impact remains undetermined.

Specific psychiatric morbidity among patients with chronic obstructive pulmonary disease in a Nigerian general hospital

OBJECTIVE

The goal of this study was to explore specific psychiatric morbidity among chronic obstructive pulmonary disease (COPD) patients in Nigeria.

METHOD

The mental status of 30 COPD patients was compared with those of 30 uncomplicated hypertensive patients and 30 apparently healthy controls using the 30-item General Health Questionnaire (GHQ-30) and Present State Examination (PSE). The sociodemographic characteristics of the three groups were also compared.

RESULTS

The COPD population was significantly least educated and predominantly subsistent farmers. Thirty percent of the COPD population, 13.3% of the hypertensive patients and 3.3% of apparently healthy controls had psychiatric morbidity (P<.05). The COPD population, with psychiatric diagnoses consisted of 16.7% depressive episode, 10% generalized anxiety disorder and 3.3% delirium. This pattern is similar to data from industrialized countries. No sociodemographic factors were significantly associated with psychiatric morbidity.

CONCLUSION

Improving the psychiatric knowledge of the primary physician will result in better management of the COPD patient.

Predictors of perioperative morbidity and mortality in lung volume reduction surgery

BACKGROUND

Selection criteria for lung volume reduction surgery are still being refined. We sought to determine whether preoperative features could be used to predict early morbidity or mortality.

METHODS

We reviewed preoperative characteristics of the first 89 patients who underwent lung volume reduction surgery at the Alfred Hospital. Data included arterial blood gases, prednisolone use, pulmonary function tests, 6-minute walk test, and anesthetic time. Length of stay and reintubation for respiratory failure were used as markers of morbidity.

RESULTS

Findings included PaCO2 of 43 +/- 0.7 mm Hg, PaO2 70 +/- 1.1 mm Hg, percent predicted values for forced expiratory volume in 1 second 29.6% +/- 0.8%, TLCO% predicted 35.2 +/- 1.4%, and 6-minute walk test of 315 +/- 10.6 m (mean +/- SEM). Mean length of stay was 19 +/- 2 days, with 17 (19%) patients reintubated for respiratory failure. Mortality rate was 5.6% at 1 year post surgery, with no deaths in patients less than 65 years old. Multivariate analysis revealed that length of stay, reintubation and mortality were predicted by age and surgical time (p < 0.05), with no correlation with any other variables tested. Age greater than 70 years was associated with a significant risk of mortality (OR 9.0; p = 0.04).

CONCLUSIONS

Age greater than 70 years and anesthetic time greater than 210 minutes predict both perioperative morbidity and mortality.

The combination of ipratropium and albuterol optimizes pulmonary function reversibility testing in patients with COPD

STUDY OBJECTIVES

To determine whether the combination of ipratropium bromide and albuterol results in greater and more consistent pulmonary function test (PFT) response rates than ipratropium bromide or albuterol alone in patients with COPD.

DESIGN

Retrospective review of two recently completed 3-month, randomized, double-blind, parallel, multicenter, phase III trials.

SETTING

Outpatient.

PATIENTS

A total of 1,067 stable patients with COPD.

INTERVENTIONS

Ipratropium bromide (36 microg qid), albuterol base (180 microg qid), or an equivalent combination of ipratropium bromide and albuterol sulfate (42 microg and 240 microg qid, respectively).

MEASUREMENTS AND RESULTS

PFT response rates were analyzed using 12% and 15% increases in FEV1 compared with baseline values and were measured in the various treatment groups on days 1, 29, 57, and 85 in these trials. Regardless of whether a 12% or a 15% increase in FEV1 was used to define a positive response, an equivalent combination of ipratropium bromide and albuterol sulfate was superior to the individual agents (p < 0.05; all comparisons within 30 min). In addition, a 15% or more increase in FEV1 was seen in > 80% of patients who received the combination of ipratropium and albuterol sulfate during the initial PFT and continued to be observed 3 months after initial testing.

CONCLUSIONS

Use of a combination of ipratropium bromide and albuterol sulfate is superior to the individual agents in identifying PFT reversibility in patients with COPD.

Lung volume reduction surgery at a community hospital: program development and outcomes

STUDY OBJECTIVES

Description of the development and results of a program in lung volume reduction surgery (LVRS) at a community hospital.

DESIGN

Prospective data collection.

SETTING

A 320-bed community hospital.

PATIENTS

Fifty-five patients consecutively discharged from the hospital following LVRS. The mean preoperative FEV1 averaged 28% (+/-8%) of predicted values, while the preoperative PaCO2 averaged 49 mm Hg (+/-11.5 mm Hg). Forty-eight patients completed a preoperative conditioning regimen and underwent the procedure on an elective basis. Seven patients underwent the procedure during a hospital admission for a COPD exacerbation. Eight patients required mechanical ventilation preoperatively, including three who had required long-term mechanical ventilatory support.

RESULTS

Three patients (5%) died in the hospital following surgery. One patient developed chronic ventilator dependence. All three of the patients who required long-term mechanical ventilation preoperatively were weaned from the ventilator and returned home. Follow-up pulmonary function testing is available for 42 patients 3 months after surgery, and for 20 patients 6 months after the operation. At 3 months, the mean FEV1 improved 0.19 L (p=0.0002), the mean improvement for FVC was 0.37 L (p=0.0001), and the mean drop in residual volume was 0.97 L (p=0.0001). Similar changes are seen at 6 months. Highly significant improvements were also seen in quality of life measurements and exercise performance. The benefits of surgical treatment of emphysema seemed similar in both elective and urgent groups.

CONCLUSIONS

LVRS can be done safely and effectively at a community hospital, with significant improvement in pulmonary function and quality of life.

Evaluation and preoperative management of lung volume reduction surgery candidates

The efficacy of lung volume reduction surgery has been demonstrated by improvements in functional status, dyspnea, pulmonary function, alveolar gas exchange, and exercise tolerance. However, surgery has a significant morbidity, mortality, and cost. Surgical outcome is dependent on the clinical, anatomical, and physiological features of the patients and their emphysema. Therefore, the patient evaluation process and the preoperative optimization of medical therapy are crucial for success. Through understanding mechanisms for improvement have added insight to the selection process, patient selection needs further clarification.