Real‐time,once‐daily monitoring of symptoms and FEV1 in cystic fibrosis patients – A feasibility study using a novel device

Background and Aims: We investigated feasibility and value of a real‐time electronic monitoring system adapted for early detection of cystic fibrosis (CF) pulmonary exacerbations (P Exs). Methods: This was a 6‐month prospective study. Patients recorded once daily their symptom score and spirometry using an electronic diary. The data were sent daily to the research team in real time. P Ex was considered to be present when change in symptoms and lung function values met a preset criteria. Number of P Exs during the study was compared with a parallel period of the previous and of the following years. Results: Only 19 patients (37.2%) completed recording that could be evaluated. A total of 53 P Exs were identified, 26 (49.0%) of which needed intravenous (IV) antibiotics. The number of total P Exs in the study year did not differ from the previous or the following year, but the number of courses of oral antibiotics was greater than those given during the previous year. Conclusion: Remote daily monitoring of symptoms and spirometry had a poor uptake among CF patients. For those who completed the study, this method early detected P Exs that were treated with oral antibiotics that might otherwise required IV antibiotics. Please cite this paper as: Sarfaraz S, Sund Z and Jarad N. Real‐time, once‐daily monitoring of symptoms and FEV₁ in cystic fibrosis patients – A feasibility study using a novel device. The Clinical Respiratory Journal 2010; 4: 74–82.     

A pulmonary rehabilitation program for patients with asthma and mild chronic obstructive pulmonary diseases (COPD)

The effects of a pulmonary rehabilitation program on 44 patients with chronic obstructive pulmonary disease (COPD) were compared to a control group. The treated group was admitted to the program for a period of three months. The program consisted of several parts, such as physical training, health education, and psychological and social matters. Before participation, the patients were thoroughly examined and provided with optimal medical treatment. Both groups were assessed by means of biometrical tests and questionnaires for a period of 2 years. The rehabilitation group improved significantly in endurance, psychological parameters, and consumption of medical care. Working days increased and their way of life became more active. Smoking habits and body fat percentage decreased. Bronchial hyperreactivity, need for pulmonary drugs, and coughing and sputum production did not improve in the rehabilitation group compared to the control group. Airway obstruction, expressed as forced expiratory volume in one second, and complaints of dyspnea, allergy and hyperreactivity scores on questionnaires improved only in the short term (<1 year), but did not improve significantly in the long term. This study shows that pulmonary rehabilitation can result in improvements in patients with asthma or COPD who have many complaints despite the fact that their pulmonary function is not severely disturbed.     

舒利迭和顺尔宁联合应用对CODP肺功能的影响

目的探讨沙美特罗替卡松（舒利迭）联合孟鲁斯特钠（顺尔宁）对慢性阻塞性肺疾病（COPD）患者肺功能的影响。方法40例患者随机分为舒利迭组（对照组）和舒利迭加顺尔宁组（试验组）各20例。两组入院期间均给于常规抗感染、吸氧、化痰和平喘对症治疗。对照组加用舒利迭,试验组加用舒利迭和顺尔宁,两组平喘治疗包括普通氨茶碱,按需使用喘康速气雾剂（特布他林）。出院后对照组继续使用舒利迭,试验组继续使用舒利迭和顺尔宁,共随访观察12周。两组均于治疗前查肺功能,治疗症状好转出院,12周后再次测定上述指标。结果两组治疗前肺功能无明显差异;治疗后两组肺功能较治疗前均有显著改善。试验组较对照组第一秒用力呼气容积（FEV1）、用力肺活量（FVC）、第一秒用力呼气容积／用力肺活量（FEV1／FVC）和第一秒用力呼气容积占预计值百分比（FEV1 ％ Pred）等明显改善,差异有显著性;试验组较对照组每天按需使用特布他林次数减少,差异有显著性。结论舒利迭和顺尔宁共同作用对COPD患者肺功能更有显著的改善作用。     

C反应蛋白水平在COPD病人、IHD病人，吸烟者和非吸烟者中的比较研究

目的评价在COPD病人中IHD症状和吸烟对CRP升高的潜在影响，并检验糖皮质激素（ICS）药物治疗与CRP血清水平之间的联系。方法对46名COPD患者与对照组的18名吸烟者（Smoking）和20名不吸烟者（N．Smoking）进行比较。结果COPD病人的CRP血清水平[4．83±1．23mg／L]显著高于两个对照组，具有显著性差异（P〈0．05），但是CRP血清水平在两个对照组中却无统计学意义。ICS治疗后，COPD病人的CRP水平降低。结论对COPD病人使用ICS治疗能够降低CRP水平。CRP可以作为COPD患者体内组织炎症的标志物。     

Characteristics of outpatients with COPD in daily practice: The E4 Spanish project

The objective of this 1-week cross-sectional survey was to assess the clinical features of outpatients with chronic obstructive pulmonary disease (COPD). A one-page questionnaire was used to collect demographic data, smoking status, and COPD-related variables. Ten or 20 consecutive patients were selected from Primary care or specialised setting during a week. Pulmonary function (FEV1) was measured using an electronic device (Piko-1). The study sample comprised 11,973 COPD patients (83% men) with a mean (sd) age of 67 (10.7) years. Thirty-five percent of patients were current smokers and smoked a mean of 17.4 (9.9) cigarettes daily. COPD severity according to GOLD stages was mild in 20% of patients, moderate in 38%, severe in 30%, and very severe in 12%. A higher percentage of men showed severe (33%) or very severe (14%) disease compared to women (16% and 6%, respectively) (P<0.005). Forty-two percent of patients had severe functional impairment and 35% continued smoking. Moreover, 11% of patients with very severe COPD smoked more than 20 cigarettes a day. The mean frequency of visits in the previous year was every 4.6 (4.1) months, with cough as the main reason for consultation. The most commonly used drugs were long-acting beta2-agonists (78%) and inhaled steroids (77%). Inhaled steroids were used by 84% of patients with very severe, 82% with severe disease, 73% with moderate disease, and 69% with mild disease (chi2 for trend, P<0.0001). This survey carried out in a real life setting shows that 42% of the patients who completed the questionnaire had severe COPD, 35% of them continued smoking, and 69% of patients with mild COPD used inhaled steroids.     

沙美特罗／氟替卡松改善慢性阻塞性肺疾病患者肺功能的预测因素的初探

目的探讨影响吸入糖皮质醇激素（ICS）＋长效β受体激动剂（LABA）（沙美特罗/氟替卡松）改善COPD患者肺功能的预测指标。方法实验分两组,实验组COPD患者166例,对照组COPD患者73例,实验组所有COPD患者吸入50／500μg沙美特罗／氟替卡松（1吸,2次／d）,对照组吸入安慰剂,两组均治疗6个月。所有患者在治疗前后均进行诱导痰嗜酸粒细胞、IL-8、呼出气一氧化氮检测（FeNO）和肺功能的检测。应用单因素和非条件Logistic多因素回归分析方法,分析影响FEV1改善的可能因素。结果实验组患者吸入50／500μg沙美特罗替卡松（1吸,2次／d）治疗后FEV1改善值为（86±11）ml,而对照组FEV1改善值为（19±16）ml（t=6．205,P〈0．05）。我们对影响ICS＋LABA改善FEV1值的可能因素,包括诱导痰中嗜酸粒细胞、炎性介质IL-8水平、反应气道炎症水平的FENO,基础肺功能FEV1等因素进行分析,结果显示诱导痰中炎性介质IL-8水平、FENO基础水平和基础肺功能与FEV1改善无相关;而嗜酸粒细胞〉2．5％（χ^2=3．181,P〉0．05）及治疗后FeNO下降〉10bbp（χ^2=17．237,P〉0．05）与FEV1改善相关。进一步多因素Logisitc分析显示诱导痰嗜酸粒细胞〉2．5％和治疗后FeNO降低〉10ppb是影响ICS＋LABA改善FEV1的重要因素。结论诱导痰嗜酸粒细胞、治疗后FENO下降的水平可成为ICS＋LABA改善COPD患者FEV1的预测因素。     

Identifying viral infections in vaccinated Chronic Obstructive Pulmonary Disease (COPD) patients using clinical features and inflammatory markers

Background  Known inflammatory markers have limited sensitivity and specificity to differentiate viral respiratory tract infections from other causes of acute exacerbation of COPD (AECOPD). To overcome this, we developed a multi‐factorial prediction model combining viral symptoms with inflammatory markers. Methods  Interleukin‐6 (IL‐6), serum amyloid A (SAA) and viral symptoms were measured in stable COPD and at AECOPD onset and compared with the viral detection rates on multiplex PCR. The predictive accuracy of each measure was assessed using logistic regression and receiver operating characteristics curve (ROC) analysis. Results  There was a total of 33 viruses detected at the onset of 148 AECOPD, the majority 26 (79%) were picornavirus. Viral symptoms with the highest predictive values were rhinorrhoea [Odds ratio (OR) 4·52; 95% CI 1·99–10·29; P < 0·001] and sore throat (OR 2·64; 95% CI 1·14–6·08; P = 0·022), combined the AUC ROC curve was 0·67. At AECOPD onset patients experienced a 1·6‐fold increase in IL‐6 (P = 0·008) and 4·5‐fold increase in SAA (P < 0·001). The addition of IL‐6 to the above model significantly improved diagnostic accuracy compared with symptoms alone (AUC ROC 0·80 (P = 0·012). Conclusion  The addition of inflammatory markers increases the specificity of a clinical case definition for viral infection, particularly picornavirus infection.     

EBUS对慢性阻塞性肺疾病气道重构的研究

目的 探讨气道内超声(EBUS)在慢性阻塞性肺疾病(COPD)患者气道重构中的应用价值.方法 26例COPD患者,22例健康对照,选择右中叶为目标气道.经电子支气管镜工作通道插入超声探头,并在其引导下到达目标支气管.结果 COPD患者右中叶管壁厚度、管壁面积以及黏膜层、黏膜下层厚度与对照组比较有显著差异;而两组软骨层的厚度无显著差异.结论 COPD患者右中叶存在气道壁增厚,管壁面积增大.气道重构主要发生在黏膜层及黏膜下层.EBUS可以成为研究COPD患者气道重构的新方法.     

Prognostic value of different scoring models in patients with multiple organ dysfunction syndrome associated with acute COPD exacerbation

Background and objective

Chronic obstructive pulmonary disease (COPD) represents an increasing healthcare concern as a leading cause of morbidity and mortality worldwide. Our objective was to predict the outcome of COPD patients associated with multiple organ dysfunction syndrome (MODS) by scoring models.

Methods

A retrospective study was performed on severe COPD patients within 24 hours of the onset of MODS. The Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Multiple Organ Dysfunction Score (MODS), Simplified Acute Physiology Score II (SAPS II), and Sepsis-related Organ Failure Assessment (SOFA) scores were calculated for patients.

Results

A total of 153 elderly patients were recruited. Compared to 30-day survivors, the number of failing organs and all of the scoring models were significantly higher in 30-day non-survivors. The SOFA showed the highest sensitivity and area under the curve (AUC) for predicting the prognosis of patients with MODS induced by acute exacerbation of COPD. The results of logistic regression indicated that factors that were correlated with the prognosis of COPD included the exacerbation history, SOFA score, number of failing organs, and duration of ICU stay. The value of exacerbation frequency for predicting the outcome of COPD was excellent (AUC: 0.892), with a sensitivity of 0.851 and a specificity of 0.797.

Conclusions

The SOFA score, determined at the onset of MODS in elderly patients with COPD, was a reliable predictor of the prognosis. The exacerbation frequency, number of failing organs, and the SOFA score were risk factors of a poor prognosis, and the exacerbation frequency could also effectively predict the outcome of COPD.     

Detecting oxygen desaturation in patients with COPD: incremental versus endurance shuttle walking

BACKGROUND: There has been no direct comparison between an incremental and endurance walking test to detect the relative oxygen desaturation in patients with chronic obstructive pulmonary disease (COPD). This is of some importance as current guidelines have suggested that ambulatory oxygen should only be prescribed after a standard assessment and desaturation documented. No clear advice about the nature of the required exercise task is given. This study therefore compared the relative desaturation between the incremental shuttle walking test (ISWT) and the constant speed walking test (ESWT) and response to ambulatory oxygen. METHODS: Forty-one patients (29 male), mean (SD), age 71.18 (7.48) yrs, FEV(1) 0.85 (0.29) l with stable COPD were recruited after completion of a 7-week pulmonary rehabilitation programme. Patients completed a baseline (without carrying a cylinder) ISWT and ESWT and then, in random order in double blind fashion, completed the walk tests with a cylinder of air or a cylinder of oxygen. Measurements included distance walked, oxygen saturation, heart rate, perceived breathlessness and exertion (Borg scale). RESULTS: All patients desaturated (<4% below 90%). There was no significant difference in desaturation between the ISWT and the ESWT. There was a significant improvement in performance with supplementary oxygen compared to cylinder air (p<0.05) for both tests. However, compared to the baseline walk, supplementary oxygen did not enhance the distance walked for either test. There was a significant decrease in walking performance on both the ISWT and the ESWT when carrying an air cylinder compared with the control walk. When comparing the percentage difference between oxygen and air for responders (i.e. those that achieve a 10% or more increase), the ESWT showed a greater percentage change 42.1% compared to 26.1% for the ISWT. CONCLUSIONS: This study identifies that incremental and endurance walking provokes significant desaturation and that there is a short-term benefit of oxygen versus air in enhancing exercise performance. There was no significant difference in the level of desaturation between tests. Therefore the ISWT is a suitable exercise test that can be used to evaluate desaturation and is practically more realistic.     

慢性阻塞性肺疾病患者膈肌功能与CAT评分相关研究

目的探讨慢性阻塞性肺疾病(简称慢阻肺)患者平板数字化X线摄影检测膈肌功能与慢阻肺评估量表得分之间关系,为患者肺功能评估提供参考。方法 2013年3月31日至2014年5月31日共56例慢阻肺患者,行平板数字化X线摄影系统检查和CAT评分,统计结果采用均数±标准差,数据组间分析采用pearson相关分析。结果患者平板数字化X线摄影系统膈肌移动度、膈肌弧度与CAT评分之间为负相关,结果有统计学意义。结论平板数字化X线摄影系统与慢阻肺评估量表具有一致性,结合双方优势有利于更好进行肺功能评估。     

Effect of pharmaceutical care on medication adherence and hospital admission in patients with chronic obstructive pulmonary disease (COPD): a randomized controlled study

Background

Poor adherence leads to a high rate of exacerbation and poor health-related quality of life (HRQoL) in patients with chronic obstructive pulmonary disease (COPD). However, few strategies are acceptable and effective in improving medication adherence. We investigated whether pharmaceutical care by clinical pharmacists could reinforce medication adherence to reduce exacerbation and improve HRQoL.

Methods

A randomized controlled study was carried out at The First Affiliated Hospital of Guangzhou Medical University from February 2012 to January 2014. Non-adherence patients were randomly assigned to receive pharmaceutical care or to usual care. The pharmaceutical care consisted of individualized education and a series of telephone counseling for 6 months provided by clinical pharmacists. Medication adherence was measured by pill counts plus direct interview at 1- and 6-month pharmaceutical care and one-year follow-up. Severe exacerbations were defined as events that led to hospitalization for acute COPD attack. An interview was conducted to investigate hospital admissions and evaluate severe exacerbations at one-year follow-up. HRQoL was measured by St George’s Respiratory Questionnaire at 6 months.

Results

At 6-month pharmaceutical care and one-year follow-up, the pharmaceutical care group exhibited higher medication adherence than the usual care group (73.4±11.1 vs. 55.7±11.9, P=0.016 and 54.4±12.5 vs. 66.5±8.6, P=0.039, respectively). There are 60 acute exacerbations resulted in a hospital admission in the usual group while 37 ones in the pharmaceutical care group during one-year follow-up (P=0.01). Hospital admissions due to acute exacerbation in the pharmaceutical care group were 56.3% less than the usual care group (P=0.01). There was a significant difference in the symptoms and impact subscales respectively at 6-month pharmaceutical care between two groups (P=0.032, P=0.018).

Conclusions

Individualized pharmaceutical care improved medication adherence, reduced hospitalization and elevated HRQoL in patients with COPD.     

History of pneumonia is a strong risk factor for chronic obstructive pulmonary disease (COPD) exacerbation in South Korea: the Epidemiologic review and Prospective Observation of COPD and Health in Korea (EPOCH) study

Background

In South Korea, chronic obstructive pulmonary disease (COPD) is one of the ten leading causes of death. COPD exacerbations are significantly associated with mortality in COPD patients. This study was conducted to investigate the epidemiology of COPD in South Korea, specifically the clinical characteristics of South Korean COPD patients, the COPD exacerbation rate and the risk factors associated with COPD exacerbations.

Methods

This study covers a 2-year interval. One year was data collected retrospectively and the second year was prospectively obtained data.

Results

A total of 1,114 subjects were enrolled in the study. These subjects were observed for a period of 1 year from the enrollment, and a total of 920 subjects completed the study. A total of 1,357 COPD exacerbations occurred in 711 subjects (63.8%) out of the total of 1,114 subjects during the study period of 2 years. Multivariate logistic regression results showed that if patients had had a pneumonia before the retrospective year of analysis, they had a 18 times greater chance of having an exacerbation during the prospective year when other variables were controlled. Also, the subjects who had a history of two or more exacerbations during the retrospective year were approximately 6 times more likely to experience the COPD exacerbation compared to those who did not.

Conclusions

This study examined the demographic and clinical characteristics of South Korean COPD patients and found that a history of pneumonia and two or more occurrences of exacerbation within 1 year was significantly associated with a higher rate of COPD exacerbation.     

Diagnosis and early detection of COPD using spirometry

The standard respiratory function test for case detection of chronic obstructive pulmonary disease (COPD) is spirometry. The criterion for diagnosis defined in guidelines is based on the FEV₁/FVC ratio forced expiratory ratio (FER) and its severity is based on forced expiratory volume in one second (FEV₁) from measurements obtained during maximal forced expiratory manoeuvres. Spirometry is a safe and practical procedure, and when conducted by a trained operator using a spirometer that provides quality feedback, the majority of patients can be coached to provide acceptable and repeatable results. This allows potentially wide application of testing to improve recognition and diagnosis of COPD, such as for case finding in primary care. However, COPD remains substantially under diagnosed in primary care and a major reason for this is underuse of spirometry. The presence of symptoms is not a reliable indicator of disease and diagnosis is often delayed until more severe airflow obstruction is present. Early diagnosis is worthwhile, as it allows risk factors for COPD such as smoking to be addressed promptly and treatment optimised. Paradoxically, investigation of the patho-physiology in COPD has shown that extensive small airway disease exists before it is detectable with conventional spirometric indices, and methods to detect airway disease earlier using the flow-volume curve are discussed.