Childhood asthma and GOLD‐defined chronic obstructive pulmonary disease

Background: Current understanding of chronic obstructive pulmonary disease (COPD) is that it results from an interaction of genetic and environmental factors. This study aimed to investigate the strength of association of various known risk factors for COPD. Methods: Detailed written questionnaires, full pulmonary function tests and atopy testing were completed in 749 people, aged 25–75 years, recruited from a random population sample. COPD was defined, using Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines, as a post‐bronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV₁/FVC) ratio <0.7. Results: The prevalence of COPD was higher in men (OR 1.7 (95% CI 1.1–2.7)) and increased with increasing age (OR per decade older 2.1 (95% CI 1.7–2.7)). COPD was more frequent in current and ex‐smokers and increased with increasing pack years (OR per 10 pack years 1.3 (95% CI 1.1–1.5)). On a logit scale, a diagnosis of asthma as a child conferred a similar risk as an increase in age of 22 years or 62 pack years of cigarette smoking. Conclusion: Childhood asthma emerged with the strongest association for GOLD‐defined COPD. Possible explanations for this are suggested, including limitations of the current GOLD spirometric definition of COPD, a chance observation because of the high prevalence of both disorders in this population, or alternatively childhood asthma is a risk factor for COPD.     

Mechanisms of atherothrombosis in chronic obstructive pulmonary disease

Patients affected by chronic obstructive pulmonary disease (COPD) have an increased risk of atherothrombotic acute events, independent of smoking and other cardiovascular risk factors. As a consequence, myocardial ischemia is a relevant cause of death in these patients. We reviewed studies concerning the potential mechanisms of atherothrombosis in COPD. Bronchial inflammation spreads to the systemic circulation and is known to play a key role in plaque formation and rupture. In fact, C-reactive protein blood levels increase in COPD and provide independent prognostic information. Systemic inflammation is the first cause of the hypercoagulable state commonly observed in COPD. Furthermore, hypoxia is supposed to activate platelets, thus accounting for the increased urinary excretion of platelet-derived thromboxane in COPD. The potential metabolic risk in COPD is still debated, in that recent studies do not support an association between COPD and diabetes mellitus. Finally, oxidative stress contributes to the pathogenesis of COPD and may promote oxidation of low-density-lipoproteins with foam cells formation. Retrospective observations suggest that inhaled corticosteroids may reduce atherothrombotic mortality by attenuating systemic inflammation, but this benefit needs confirmation in ongoing randomized controlled trials. Physicians approaching COPD patients should always be aware of the systemic vascular implications of this disease.     

The role of anticholinergic bronchodilators in adult asthma and chronic obstructive pulmonary disease

Our renewed interest in anticholinergic bronchodilator therapy has been sparked by the development of safe yet effective quaternary anticholinergic compounds including ipratropium bromide, oxitropium and atropine methonitrate. These agents offer gradual and sustained bronchodilatation to patients with asthma and to patients with COPD. However, their role in the maintenance treatment of these two diseases differs significantly. In asthma, the anticholinergic drugs have useful additive properties when used with adrenergic drugs or theophylline. They may be a particularly useful component of combination regimens in patients with disease of more than mild severity and in older patients. The combination of inhaled adrenergic and anticholinergic drugs is also useful in the acute setting for acute exacerbations of asthma. In chronic obstructive lung disease, the anticholinergic compounds offer greater bronchodilatation than adrenergic drugs for the majority of patients. Thus, the inhaled anticholinergic drugs may be considered as useful initial choices in the chronic maintenance therapy of COPD.     

Long-term effects of air pollution on hospital admissions and mortality for chronic obstructive pulmonary disease in Beijing,China

Objective

We aimed to clarify the association between air pollution and hospital admissions for chronic obstructive pulmonary disease (COPD) and mortality in Beijing, China.

Methods

In this retrospective study, we recruited 510 COPD patients from 1 January 2006 to 31 December 2009. The patient data were obtained from the electronic medical records of Peking University Third Hospital in Beijing. Air pollution and meteorological data were obtained from the Institute of Atmospheric Physics of the Chinese Academy of Sciences. Monthly COPD hospital admissions, mortality and air pollution data were analysed using Poisson regression in generalised additive models adjusted for mean temperature, pressure and relative humidity.

Results

There were positive correlations between sulfur dioxide (SO₂), particulate matter with an aerodynamic diameter ≤ 10 μm (PM₁₀) and COPD hospital admissions in the single-pollutant model. An increase of 10 μg/m³ in SO₂ and PM₁₀ were associated with an increase of 4.053% (95% CI: 1.470–5.179%) and 1.401% (95%CI: 0.6656–1.850%) in COPD hospital admissions. In the multiple-pollutant model [SO₂ and nitrogen dioxide (NO₂) combinations], there was only a positive correlation between SO₂ and COPD hospital admissions. An increase of 10 μg/m³ in SO₂ were associated with an increase of 1.916% (95% CI: 1.118–4.286%) in COPD hospital admissions. There was no correlation between three pollutant combinations and COPD hospital admissions. We did not find correlations between air pollution and COPD mortality in either single- or multiple-pollutant models.

Conclusions

SO₂ and PM₁₀ may be important factors for the increase in COPD hospital admissions in Beijing, China.     

外周血白介素-17检测在气道慢性炎症性疾病诊断中的临床价值

目的探讨外周血CD4+T细胞亚群Th17代表性细胞因子IL-17在哮喘、慢性阻塞性肺疾病(COPD)以及哮喘COPD重叠综合征(ACOS)等气道慢性炎症性疾病鉴别诊断中的临床价值。方法收集哮喘患者26例、COPD患者33例及ACOS患者14例的血清、临床资料及实验室检查资料,检测哮喘、COPD、ACOS患者外周血IL-17等细胞因子、炎症介质、外周血白细胞分类计数、血清免疫球蛋白亚型以及肺通气功能,并进行组间比较。健康体检者69例作为对照。结果 Th17细胞因子IL-17在哮喘及ACOS组升高较COPD组更为明显(P0.01)。调节性T细胞的主要细胞因子IL-10在哮喘患者中的水平明显低于COPD患者(P0.05)。外周血炎症细胞比例、免疫球蛋白亚型在哮喘、COPD、ACOS鉴别诊断中具有一定参考价值。但肺通气功能指标对于以上三者的鉴别价值有限。哮喘及ACOS组患IL-17与肺通气功能指标呈负相关关系。结论 IL-17作为新型Th17细胞分泌的代表性细胞因子,在鉴别上述疾病中具有重要的参考价值。Th17/Treg细胞失衡可能是难治性哮喘的潜在发病机制。     

Improved inhaler handling after repeated inhalation guidance for elderly patients with bronchial asthma and chronic obstructive pulmonary disease

Accurate evaluation of inhaler handling is essential for improved treatment of bronchial asthma (BA) and chronic obstructive pulmonary disease (COPD). Many studies have described the correlation between age, inhalation guidance, and procedure improvement. Elderly patients should receive proper inhalation guidance. This was a retrospective open cohort study conducted at a single hospital with outpatient open pharmacies that provided inhalation guidance to patients of BA and COPD. A total of 525 cases were included in the study. The median age was 71 years with no significant difference between genders (males: 71 ± 16.0 years; females: 72 ± 16.1 years; P = .24). There were 226 males (43.0%) and 299 females (57.0%; P = .03). BA was significantly more prevalent than COPD (P < .001). There was no significant difference in dry powder inhaler (DPI) and pressurized metered-dose inhaler (pMDI) visits in those <60 years of age (P = .23). pMDI was used significantly more often than DPI in those aged 60 to 90 years of age (P < .001). In both <70 and >70 years of age, the most common error with DPI use was improper inhalation speed, which reduced (improved) at the third visit. Gargling errors were most common with DPI use at the second visit and with pMDI at the first visit in both age groups, which subsequently reduced rapidly. Continuous repeated guidance steadily and significantly decreased errors with all devices (P < .001 for DPI, pMDI, and soft mist inhaler). Elderly cases (>70 years of age) should undergo continuous repeated guidance to reduce inhalation errors like inhalation speed and gargling errors.     

Prevalence of gastroesophageal reflux disease in patients with asthma and chronic obstructive pulmonary disease

Background and Aim: It is speculated that the prevalence of gastroesophageal reflux disease (GERD) might increase with asthma or chronic obstructive pulmonary disease (COPD). The aim of the present study was to evaluate the prevalence of GERD in patients with asthma and COPD in an area representative of developing countries. Methods: A validated GERD questionnaire was conducted face‐to‐face with 308 consecutive asthma (240 women) and 133 COPD (35 women) patients in the tertiary referral pulmonary outpatient clinic, and 694 controls from the research area. Detailed histories of patients and pulmonary function tests were also recorded. Results: The prevalence of GERD (heartburn/regurgitation once a week or more) was 25.4%, 17.0%, 19.4% and occasional symptoms (less than weekly) were 21.2%, 16.3% and 27.0% of patients with asthma, COPD and controls, respectively. The prevalence was higher in the asthma group compared with the controls and the COPD group. No significant difference was found between the COPD group and the controls. Heartburn started following pulmonary disease in 24.1% of the asthma group, and 26.4% of the COPD group. The majority of additional symptoms were significantly higher in asthmatics compared with the controls. No difference was found in the consumption of pulmonary medications in asthmatic patients in groups with different symptom frequency. Heartburn was increased 13.8% by the consumption of inhaler medications. Conclusions: These results implicate that the prevalence of GERD in asthma and COPD are lower than in published reports in a tertiary referral center. These differences might be related to the characteristics of developing countries, increased consumption of powerful medications in GERD and pulmonary diseases, or methodological flaws in earlier studies.     

Cough in chronic obstructive pulmonary disease

Patients with chronic obstructive pulmonary disease (COPD) most commonly complain of cough, production of phlegm and breathlessness. The cough reflex sensitivity is heightened compared with that in healthy volunteers and is similar to that in subjects with asthma. The degree of airflow obstruction does not predict cough reflex sensitivity or objective cough counts, implying an independent process. Objective cough rates seem to be relatively low in COPD, despite frequent reporting of the symptom by patients. The relative contribution of cough to disability in COPD seems to be small, if assessed by subjective reporting. Effective treatments for cough in COPD have not yet been identified. Improved outcome measures of cough, a better understanding of the mechanisms underlying cough, and the importance of cough to patients is required to progress in this field.     

Factors influencing short-term re-admission and one-year mortality in patients with chronic obstructive pulmonary disease

BACKGROUND AND OBJECTIVES: Fourteen day re-admission rates are deemed to be an important indicator of the quality of medical care for COPD in Taiwan. This study identified the characteristics of patients with COPD who required short-term re-admission and analysed the risk factors for 1-year mortality. METHODS: Consecutive patients with COPD who were re-admitted to hospital within 14 days of discharge and a random computer generated selection of patients with COPD not re-admitted within 14 days of discharge were recruited to the study and their medical data collected from hospital records. Recruitment occurred over an 18-month period. RESULTS: Fifty patients were recruited to each group. Multivariate analysis revealed statistically significant differences in oral steroid use (P = 0.013) and FEV1 (P = 0.04) between the re-admission group and non-re-admission group. Of the many variables assessed, risk of death within 1 year of discharge was significantly associated with re-admission within 14 days alone (P = 0.02; odds ratio = 15.01). CONCLUSION: COPD patients using long-term oral corticosteroids and with a low FEV1 are at risk of re-admission with 14 days of hospital discharge, and medical care of these patients warrants much greater attention.     

Predictors of long-term survival in elderly patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease

Background and objective: There is a paucity of survival data regarding the prognosis of elderly patients following acute exacerbations of COPD (AECOPD). We undertook a study to examine long‐term mortality rates and to identify clinical and laboratory predictors of these outcomes. Methods: A retrospective cohort study was conducted of 786 consecutive elderly (>65 years) patients admitted to general medicine acute‐care wards for AECOPD. Factors determining short‐ and long‐term mortality were analysed. Results: The mean (±SD) age of the study population was 75.8 ± 7.3 years (range 65–100 years). The in‐hospital mortality rate for the entire cohort was 7.25%. The risk of mortality at 1, 3 and 5 years was 28%, 47% and 54%, respectively. In univariate analysis age (hazard ratio 1.52; 95% confidence interval: 1.23–1.91), FEV₁ (1.45; 1.73–2.35), active cancer (1.23; 1.64–2.32), current smoking (1.74; 1.35–2.11), ischaemic heart disease (1.58; 1.28–2.02), congestive heart failure (1.55; 1.23–2.26) and maintenance use of oral glucocorticosteroids (1.58; 1.11–2.79) were significantly associated with mortality. In multivariate analysis, only current smoking (1.89; 1.18–1.93), ischaemic heart disease (1.41; 1.07–1.68), PaCO₂ on admission (1.49; 1.03–1.60), hospital readmission (2.23; 1.40–2.18) and FEV₁ (1.41; 1.12–1.54) were independent predictors of mortality. Conclusions: This study provides new insights into the predictive factors associated with long‐term prognosis in elderly patients admitted for acute exacerbations of COPD, which differ from those previously identified for younger patients.     

Empowering family physicians to impart proper inhaler teaching to patients with chronic obstructive pulmonary disease and asthma

BACKGROUND:

Patients with chronic obstructive pulmonary disease (COPD) and asthma depend on inhalers for management, but critical errors committed during inhaler use can limit drug effectiveness. Outpatient education in inhaler technique remains inconsistent due to limited resources and inadequate provider knowledge.

OBJECTIVE:

To determine whether a simple, two-session inhaler education program can improve physician attitudes toward inhaler teaching in primary care practice.

METHODS:

An inhaler education program with small-group hands-on device training was instituted for family physicians (FP) in British Columbia and Alberta. Sessions were spaced one to three months apart. All critical errors were corrected in the first session. Questionnaires surveying current inhaler teaching practices and attitudes toward inhaler teaching were distributed to physicians before and after the program.

RESULTS:

Forty-one (60%) of a total 68 participating FPs completed both before and after program questionnaires. Before the program, only 20 (49%) reported providing some form of inhaler teaching in their practices, and only four (10%) felt fully competent to teach patients inhaler technique. After the program, 40 (98%) rated their inhaler teaching as good to excellent. Thirty-four (83%) reported providing inhaler teaching in their practices, either by themselves or by an allied health care professional they had personally trained. All stated they could teach inhaler technique within 5 min. Observation of FPs during the second session by certified respiratory educators found that none made critical errors and all had excellent technique.

CONCLUSION:

A physician inhaler education program can improve attitudes toward inhaler teaching and facilitate implementation in clinical practices.     

Cardiac response to exercise in mild-to-moderate chronic obstructive pulmonary disease

Objective Chronic obstructive pulmonary disease （COPD） increases the risk of cardiovascular problem.The symptom of dyspnea on exertion may be associated with pulmonary dysfunction or heart failure, or both. The study objective was to determine whether cardiac dysfunction adds to the mechanism of dyspnea caused mainly by impaired lung function in patients with mild-tomoderate COPD. Methods Patients with COPD and healthy controls performed incremental and constant work rate exercise testing. Venous blood samples were collected in 19 COPD patients and 10 controls before and during constant work exercise for analysis of Nterminal-pro-BNP （NT-pro-BNP）. Results Peak oxygen uptake and constant work exercise time （CWET） were significantly lower in COPD group than in control group （15.81±3.65 vs 19.19±6.16 ml/min kg, P=0.035 and 7.78±6.53 min vs 14.77±7.33 rain, P=0.015, respectively）. Anaerobic threshold, oxygen pulse and heart rate reserve were not statistically significant between COPD group and control group. The NT-pro-BNP levels both at rest and during constant work exercise were higher in COPD group compared to control group, but without statistical significance. The correlations between CWET and NT-proBNP at rest or during exercise in patients with COPD were not statistically significant. Conclusions Heart failure does not contribute to exercise intolerance in mild-to-moderate COPD.（J Geriatr Cardioi 2009; 6：147-150）.     

Advances in chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is characterised by progressive airflow limitation in the presence of identifiable risk factors. Inflammation is the central pathological feature in the pathogenesis of COPD. In addition to its pulmonary effects, COPD is associated with significant extrapulmonary manifestations, including ischaemic heart disease, osteoporosis, stroke and diabetes. Anxiety and depression are also common. Spirometry remains the gold standard diagnostic tool. Pharmacologic and non‐pharmacologic therapy can improve symptoms, quality of life and exercise capacity and, through their effects on reducing exacerbations, have the potential to modify disease progression. Bronchodilators are the mainstay of pharmacotherapy, with guidelines recommending a stepwise escalating approach. Smoking cessation is paramount in managing COPD, with promotion of physical activity and pulmonary rehabilitation being other key factors in management. Comorbidities should be actively sought and managed in their own right. Given the chronicity and progressive nature of COPD, ongoing monitoring and support with timely discussion of advanced‐care planning and end‐of‐life issues are recommended.     

肺康复治疗对稳定期COPD患者肺功能及血气分析的影响

目的探讨肺康复治疗对稳定期慢性阻塞性肺疾病（COPD）患者肺功能及血气分析的影响。方法将80例稳定期COPD患者随机分为肺康复组（n=40）与对照组（n=40）,肺康复组给予体能锻炼、呼吸肌锻炼、氧疗、心理与行为干预等肺康复治疗措施,治疗6～8周,治疗前后测定肺功能及血气分析,比较两组患者肺功能及血气分析的变化。结果观察组治疗后肺功能、血气分析较治疗前及对照组治疗后均显著改善（P〈0．01）。结论肺康复治疗可提高稳定期COPD患者肺功能及血气分析,从而提高患者的生存质量。     

Using Telehealth technology to deliver pulmonary rehabilitation in chronic obstructive pulmonary disease patients

BACKGROUND:

Pulmonary rehabilitation (PR) is an effective therapeutic strategy to improve health outcomes in patients with chronic obstructive pulmonary disease (COPD); however, there is insufficient PR capacity to service all COPD patients, thus necessitating creative solutions to increase the availability of PR.

OBJECTIVE:

To examine the efficacy of PR delivered via Telehealth (Telehealth-PR) compared with PR delivered in person through a standard outpatient hospital-based program (Standard-PR).

METHODS:

One hundred forty-seven COPD patients participated in an eight-week rural PR program delivered via Telehealth-PR. Data were compared with a parallel group of 262 COPD patients who attended Standard-PR. Education sessions were administered two days per week via Telehealth, and patients exercised at their satellite centre under direct supervision. Standard-PR patients viewed the same education sessions in person and exercised at the main PR site. The primary outcome measure was change in quality of life as evaluated by the St George’s Respiratory Questionnaire (SGRQ). A noninferiority analysis was performed using both intention-to-treat and per-protocol approaches.

RESULTS:

Both Telehealth-PR and Standard-PR resulted in clinically and statistically significant improvements in SGRQ scores (4.5±0.8% versus 4.1±0.6%; P<0.05 versus baseline for both groups), and the improvement in SGRQ was not different between the two programs. Similarly, exercise capacity, as assessed by 12 min walk test, improved equally in both Telehealth-PR and Standard-PR programs (81±10 m versus 82±10 m; P<0.05 versus baseline for both groups).

CONCLUSION:

Telehealth-PR was an effective tool for increasing COPD PR services, and demonstrated improvements in quality of life and exercise capacity comparable with Standard-PR.