Effects of oral terbutaline in chronic airflow limitation

Comparison of Oral and Depot Intra‐muscular Steroids in Assessing Steroid‐Responsiveness in COPD

Non-compliance or euphoria may limit the usefulness of prednisolone tablets in assessing steroid-responsiveness in chronic obstructive pulmonary disease (COPD). Depot intra-muscular methyl-prednisolone (imMP), producing a plateau steroid effect over two weeks, may be more reliable. Following two weeks of placebo, twenty-seven COPD patients (mean FEV 1 43% predicted) participated in a two-week randomised, double-blind, placebo-controlled, parallel-design trial taking either 120 mg imMP with placebo tablets or placebo injection with prednisolone 30 mg daily. After each period, post-bronchodilator FEV 1, forced vital capacity (FVC), inspiratory capacity (IC) and six-minute walking distance (6MWD) were assessed and patients completed both quality-of-life scores (St. George's 30 and Short Form 36) and mood scores (Hospital Anxiety and Depression scores and Altman's Self-rating Mania Scale). There were no significant changes in 6MWD, quality of life or mood scores after either type of steroids and no change in lung function after imMP. By contrast, there were small mean improvements in lung function on oral prednisolone (mean FEV 1, FVC and IC increased by 100, 320 and 150 ml, respectively). Only the improvement in FVC was significantly greater after prednisolone compared with imMP. Single depot intra-muscular injections of steroids have no advantage over oral daily prednisolone in testing steroid-responsiveness in COPD patients.

Reliability, repeatability and sensitivity to change of externally and self-paced walking tests in COPD patients

In COPD, several walking tests have been proposed to measure exercise tolerance but their relative merits are uncertain. We studied 57 moderate-to-severe, stable COPD patients (mean FEV1 35 +/- 12% predicted). Within a 2-month period, we compared reliability (inter-subject variability) and repeatability (intra-subject variability) of the most widely used 6-min walks (6MWD), with self-paced 2-min walks (2MWD) and externally paced, incremental shuttles (Shuttle). On 9 separate days either of the three 6MWD, 2MWD or Shuttles were performed (nine walks of each type). Then, each walk was performed before and after bronchodilators (BD) to assess sensitivity to change (mean change/standard deviation of change (sensitivity index--SI)). For all exercise tests, reliability was >90% (2MWD 95%, 6MWD 92% and Shuttle 91%). Repeatability was excellent (overall <10% intra-subject variation; for 2MWD 5%, 6MWD 8% and Shuttle 9%). On average, the first walking distance was significantly shorter, but there were no significant differences between second and third walks. Dyspnoea scores were much less reproducible. BD produced highly significant improvements in Shuttle (pre-BD 27 SD=11 --> post-BD 30 SD=11), 6MWD (424 m SD=115 --> 462 m SD=106) and 2MWD (153 m SD=35 --> 162 m SD=34), (P < 0.0001). SI was similar for all walks (6MWD 0.84, 2MWD 0.75 and Shuttle 0.76). In moderate-to-severe COPD, 2MWDs are as informative as 6MWDs without their disadvantages. Self-paced walks are as useful as externally paced Shuttles.

Audit of a complete home nebulizer service provided by a respiratory nurse specialist

A retrospective audit was performed of a home nebulizer service managed entirely by a Respiratory Nurse Specialist (RNS). We examined (i) the role and workload of the RNS, (ii) the outcome of referrals to the service and (iii) the subsequent compliance with treatment of patients prescribed home nebulized bronchodilators. The case notes and RNS records of all patients referred for consideration of home nebulized bronchodilators over a 9-month period were reviewed. The nebulizer service encompassed patient assessment, trials of nebulized therapy, nebulizer tissue and patient registration and an exchange and servicing system. The non clerical aspects of the service took 9 h per week, 24% of total RNS time. A further 15 h weekly of clerical time was also required. Of 76 referrals, 57 (75%) patients had chronic airflow obstruction (CAO). In CAO patients, 41 had a trial of nebulized therapy and in 27 (66%) such therapy was considered beneficial. In the other 16 CAO patients the RNS deemed a trial inappropriate or impractical and 12 such patients were prescribed nebulized therapy. Overall, therefore 39/57 (68%) of CAO referrals were prescribed home nebulized therapy. At 3-6 months, seven (18%) patients were using their nebulizer infrequently or not at all, 25 (64%) one to four times daily, and seven (18%) four times daily. We conclude that a RNS can manage a complete nebulizer service, but at a considerable cost in professional time. Clerical assistance is essential if appropriate use is to be made of the skills of an RNS.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of inhaled terbutaline on FEV1, FVC, dyspnoea and walking distance in patients with chronic obstructive lung disease

This double-blind, placebo-controlled, crossover study was performed to evaluate the effect of terbutaline administered by a turbuhaler on spirometry, walking distance and dyspnoea during exercise in patients with chronic obstructive lung disease (COLD) and to evaluate relationships between changes in spirometry and working indices. The patients had a maximum reversibility in FEV1 of 15% predicted, and to ensure the option of studying correlations between changes in spirometry and working indices in patients with COLD a wide range of reversibility in FVC was ensured. Eighteen patients (M, 12; F, 6; mean age 68.5 years) were included in the trial. Mean baseline FEV1 was 0.921 and FVC 2.081. Six minutes unpaced walking distance on flat ground (WD) and Brog dyspnoea index scale (BS) were used as working indices. Baseline mean WD was 467.9 m, and median BS 3.2. No significant difference was found in the effect of terbutaline compared to placebo on the spirometry findings or WD. However, BS during exercise improved significantly on the terbutaline day. No significant correlation was found between changes in working indices and change in spirometry. Thus, the use of exercise testing and dyspnoea-scoring may reveal patients who benefit from acute bronchodilation without significant improvement in lung function.

Effect of controlled-release salbutamol in predominantly non-reversible chronic airflow obstruction

We conducted a multicentre, randomized, double-blind, placebo-controlled, parallel group study to determine the efficacy of controlled release salbutamol (SCR) tablets in clinically stable patients with predominantly non-reversible chronic airflow obstruction (CAO). Patients received either 8 mg SCR or matching placebo tablets twice daily for 6 weeks. Fifty-eight patients (30 on SCR and 28 on placebo) completed the study. Outcome measurements included FEV1, FVC, 6-min walking distance, and patient assessment of efficacy recorded at the clinic visits and twice daily PEFR measurements plus daytime symptom score recorded in diary cards. The absolute change between baseline and 6-week measurements with SCR was compared to that with placebo. Favourable trends were observed with SCR for all variables tested except FVC. The only significant difference between SCR and placebo was in FEV1 where there was a small net change of 95 ml in favour of SCR. We conclude, therefore, that the effects of lung function of long-term bronchodilator therapy with SCR in patients with stable non-reversible CAO are slight, and are likely to be of limited clinical benefit.

The St George's Respiratory Questionnaire

The St George's Respiratory Questionnaire is a standardized self-completed questionnaire for measuring impaired health and perceived well-being ('quality of life') in airways disease. It has been designed to allow comparative measurements of health between patient populations and quantify changes in health following therapy. The background and rationale for its development are discussed together with an analysis of its performance.