CONTENTS (SO FAR)
1) BLF NSF FOR COPD
2. UPDATE - INVITATION TO HEALTH PROFESSIONALS TO PARTICIPATE IN NSF
3. BLF DISAPPOINTMENT IN LACK OF RESPIRATORY TESTS IN NEW MEDICAL CHECK UPS.
4. SERIES OF ARTICLES ON NEW TRIALS UNDERWAY FOR COPD. STATINS.
5. SERIES OF A|RTICLES DRAWN FROM Pulsetoday - The GP's website . Only a selection of articles have been printed here from Pulsetoday but you may look at the rest on line. I have NOT used any of the information contained in these articles although of course the information may be more generally available. NON-PROFESSIONALS may find some of these very interesting too.
British Lung Foundation briefing on the NSF FRAMEWORK.
With permission from the BLF. It estimated that it will be published by the end of 2008/early 2009. Of course there will be amendments. Personally I hope that it will remove the somewhat patchy care for COPD sufferers in the UK.
Update below.
National Service Framework for COPD – June 2006
NATIONAL SERVICE FRAMEWORK for Chronic Obstructive Pulmonary Disease.
• National Service Frameworks (NSFs) are Government policies that are designed to
deliver improvements in the NHS
• NSFs are long term strategies for improving specific areas of care. They set
measurable goals within set time frames
• NSFs aim to:
− set national standards and identify key things that can be done for people with a
particular condition
− put in place strategies to support the implementation of these standards, to ensure
people have access to the care they are entitled to
− establish ways to ensure progress in improving services for people within an agreed
time scale (this is usually 10 years)
− form one of a range of measures to raise quality and decrease variations in service
in the NHS
• Each NSF is developed with the assistance of health professionals, service users and
carers, health service managers, and other advocates
What the National Service Framework means for people with COPD
• The NSF will outline the minimum standards of treatment and care that people with
COPD can expect to receive in their local area
• As this is a national policy for the whole of England, it will also ensure that people
have access to the same high standards of care, regardless of where in the country
they live
• Healthcare providers will be inspected on the basis of whether they are providing the
standards outlined in the NSF
What will the National Service Framework include?
• The British Lung Foundation will work with the Department of Health to ensure the NSF
delivers improvements for people living with COPD
• We want the NSF to include:
− Prevention of COPD - One of the key interventions in the management of COPD in
primary care is the prevention of new cases. COPD is primarily caused by smoking
and, therefore, effective smoking cessation services and other stop smoking
British Lung Foundation briefing
National Service Framework for COPD – June 200
initiatives are an important element in reducing the burden this disease has on the
NHS
− Early and accurate diagnosis - Damage to the lungs from COPD is irreversible, but
there is increasing evidence that appropriate intervention can slow the rate of
damage. Early diagnosis is therefore vital for timely intervention and optimum
management of the condition
− Pulmonary rehabilitation - Pulmonary rehabilitation results in increased exercise
capacity and physical endurance, better emotional function, reduced
breathlessness, improved self-esteem and increased independence. Furthermore,
patients who have completed a course require fewer GP home visits and reduced
hospital bed admissions
− Care provided by a multi-disciplinary care team - in addition to a GP and practice
nurse, COPD patients should have access to a range of healthcare professionals
including a respiratory consultant and a physiotherapist or occupational therapist.
This team of health professionals should work together to ensure the patient
receives the optimum care available to them
− Non-invasive ventilation (NIV) - NIV is an emergency treatment that a patient may
receive if taken to hospital because of an exacerbation, it should also be available
to treat patients in their own homes where appropriate. NIV is a method of
ensuring patients get enough oxygen into their blood. It is not the same as oxygen
therapy. NIV involves wearing a mask that covers the nose and is connected to a
small machine that pushes oxygen through the mask and into the lungs
Early supported discharge from hospital - These schemes help patients leave
hospital earlier after an exacerbation by providing comprehensive at home car
from community based healthcare professionals. They are supported through th
final days of their recovery and given advice and support in preventing future
hospitalisations. Patients indicate that they would prefer to recover in the comfort
of their own home where this is possible. By providing this primary care support,
hospital beds are released earlier, reducing the burden on the secondary care
sector
− Palliative care for COPD patients - Palliative care services tend to be focused
towards cancer patients. Serious lung diseases, such as COPD, which are equally
debilitating are not thought of in this regard, although patients may suffer for up to
10 years in a state of extreme distress
For further information, please contact:
British Lung Foundation
Telephone: 020 7688 5555
Email: parliamentary@blf-uk.org
IMPORTANT UPDATES TO ABOVE FROM THE BLF.
Calling Health and Social Care Professionals, Managers and Commissioners
The British Lung Foundation would like to invite Health and Social Care Professionals, commissioners and managers to join a virtual forum which aims to:
* Explore what is needed from the forthcoming National Service Framework for COPD in England and discuss how the BLF can support you in its implementation
* Share information and good practice in COPD care
The forum will be an excellent opportunity for you to network with other professionals across England, and to discuss how you can work with the BLF to ensure that COPD services meet the needs of people living in the communities that you serve.
Click here to join free of charge or contact the COPD project team for more information on 020 7688 5589
Respiratory disease missing from government’s early screening plans, says British Lung Foundation - 01/04/08
The British Lung Foundation was today left disappointed by the Governments failure to include respiratory disease, when announcing early screening for patients in England.
The Government outlined plans to offer health checks to everyone aged 40 to 74 for conditions such as heart disease, stroke, diabetes and kidney disease.
Ministers believe the assessments will save lives and cut the number of people affected by these conditions.
Dame Helena Shovelton, Chief Executive of the British Lung Foundation said, “Respiratory disease is the UK’s second biggest killer and places a huge financial burden on the NHS yet it is ‘the bit missing’ from the government’s early screening plans announced today. A simple lung test in primary care can detect lung problems such as asthma, Chronic Obstructive Pulmonary Disease and other chronic respiratory problems and could bring huge benefits in early detection, particularly in deprived areas of the UK. If the government is committed to reducing health inequalities then it is essential they introduce a respiratory screening programme as soon as possible as it will help to save millions of lives.”
For more information please contact Casey Purkiss or Katherine Huntly or call the Press Office on 020 7688 5564
POSSIBLE HOPE FOR A CURE FOR COPD/EMPHYSEMA PATIENTS
Now I don't wish to raise our hopes too much but Professor Robert Stockley, at University Hospital Birmingham, is currently running a research trial with a new drug that may make damaged lungs regrow ( started early May 2006 I believe). Initially this trial will involve half the 260 alpha-1 antitrypsin patients, recruited in England and Holland (the other half will be given a dummy drug or placebo). There are around 25,000 people in the UK suffering from this genetic condition. There is no point in you ringing the British Lung Foundation or the University of Birmingham because the trial is now FULL and the team is no longer looking for candidates.
The results of this trial will be known towards the end of 2007. Professor Stockley is reported to have said in 'The Daily Mail'. "We're in completely new territory with this drug - it's the first that actually reverses damage to the lungs, and is the closest anyone has been to a cure." Yes well I have heard about all this before but I hope for all our sakes that the trial is successful. So if you need a reason to keep on going - this possibility is as good as anything else I can think of. I repeat though that the trial is full and there is no point in bothering your GP, PALS, BLF or any other NHS or private body about this. We must be patient and wait for the results.Naturally I will report back on this as soon as I hear anything more - if I'm able to that is!!!
There are also a number of drugs in the pipeline specifically designed to halt lung function decline.
Royal Brompton Hospital to trial promising emphysema treatment
NEWS RELEASE
16 July 2007
A hollow loop of stainless steel, smaller than a rubber on the end of a pencil, could be the next breakthrough in the treatment of a debilitating lung disease.
Emphysema is a progressive disease which is typically caused by long-term cigarette smoking. In Britain, nearly 30,000 people die each year from chronic obstructive pulmonary disease (COPD), which includes emphysema.
Patients suffering from the disease are unable to exhale sufficiently due to a loss of the lungs’ natural elasticity. This causes their lungs to over-inflate, causing a severe shortness of breath.
Current treatment for emphysema is limited to inhaled oxygen, medications to relax the muscles of constricted airways (bronchodilators), anti-inflammatory drugs and pulmonary rehabilitation (exercise and support programmes). Highly invasive procedures such as surgery to remove diseased tissue or lung transplantation are also performed.
A new device that has the potential to reduce shortness of breath in emphysema patients, known as the Exhale drug-eluting stent, is being trialled at the Royal Brompton Hospital in London. Respiratory consultant, Dr Pallav Shah, explains: “Under a general anaesthetic, patients have a flexible tube (bronchoscope) passed down their windpipe and manoeuvred into areas of the lung with the most amount of emphysema. We then use a special ultrasound probe to find areas free of blood vessels. Once located, a hole is made into the lung beyond and a special stent is inserted. We usually insert around six stents in total.”
Shah continues: “One of the main problems in emphysema is that air becomes trapped in the lungs and cannot efficiently escape. The artificial airway passages we create using stents allows air from these trapped areas to escape and therefore returning the lungs to a more normal size. This gives patients a better exercise tolerance and a reduction in breathlessness.”
Shah says that while the procedure is technically challenging, the rewards are great and most patients are able to leave the hospital after 24 hours. To date over 80 patients have been treated worldwide and have demonstrated significant improvements in key pulmonary function tests and in their quality of life.
The Royal Brompton Hospital is the first in the United Kingdom to trial the device and is currently seeking London residents with chronic emphysema to participate. Patients who are able to easily travel to the hospital would also be considered.
“We are looking for patients over the age of 35 with emphysema who have stopped smoking for at least two months. All the patients have to undergo pulmonary rehabilitation and there are a number of detailed tests that are performed. Entry into the study is strictly controlled and only patients who meet the criteria are allowed to proceed. In the study two thirds of patients will have the procedure and one third of patients will undergo a placebo procedure (as the control group). The patients will be assessed by a second team with no knowledge of what procedure the patients had. They have a number of breathing tests, scans and exercise tests to measure the degree of improvement,” says Shah.
PLEASE NOTE THAT THE STENTS ARE SUITABLE ONLY FOR THOSE PATIENTS WHO HAVE HETEROGENEOUS COPD/EMPHYSEMA - that means that the emphysema is not all over the lungs but confined.
FOR THOSE PATIENTS WHO HAVE HOMOGENEOUS (all over) EMPHYSEMA TRIALS ARE BEING CONDUCTED AT THE ROYAL BROMPTON FOR AIRWAY BY PASS STENTS. THESE HELP PATIENTS TO EXHALE MORE. AS OF NOW TRIALS ARE ABOUT TO START ON EXTRA-PLEURAL AIRWAYS - sorry little information about this except that it involves entering the lung from the chest from the outside and not through bronchoscopy and you have to have a limited capacity to exhale.
Published ahead of print on August 2, 2007, doi:10.1164/rccm.200705-656OC
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American Journal of Respiratory and Critical Care Medicine Vol 176. pp. 742-747, (2007)
© 2007 American Thoracic Society
doi: 10.1164/rccm.200705-656OC
Original Article |
Statin Use Reduces Decline in Lung Function
VA Normative Aging Study
Stacey E. Alexeeff1, Augusto A. Litonjua2, David Sparrow2,3, Pantel S. Vokonas3 and Joel Schwartz1,2
1 Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts; 2 Channing Laboratory, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; and 3 VA Normative Aging Study, VA Boston Healthcare System and Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
Correspondence and requests for reprints should be addressed to Stacey E. Alexeeff, B.Sc., Exposure, Epidemiology, and Risk Program, Harvard School of Public Health, Landmark Center West, 415, 401 Park Drive, Boston, MA 02215. E-mail: sackerma@hsph.harvard.edu
Rationale: Decreased lung function has been linked to increased inflammation and oxidative stress. Statins have demonstrated antiinflammatory and antioxidant properties.
Objectives: We investigated the effect of statin use on decline in lung function in the elderly, and whether smoking modified this effect.
Methods: Our study population included 2,136 measurements on 803 elderly men from the Normative Aging Study whose lung function (FVC and FEV1) was measured two to four times between 1995 and 2005. Subjects indicated statin use and smoking history at each visit. We used mixed linear models to estimate the effects of each covariate, adjusting for subject and possible confounders.
Measurements and Main Results: For those not using statins, the estimated decline in FEV1 was 23.9 ml/year (95% confidence interval [CI], –27.8 to –20.1 ml/yr), whereas those taking statins had an estimated 10.9-ml/year decline in FEV1 (95% CI, –16.9 to –5.0 ml/yr). We also examined the effect of statins with smoking by dividing the cohort into four groups: never-smokers, longtime quitters (quit 10 yr ago), recent quitters (quit < 10 yr ago), and current smokers. We found a significant three-way interaction between time since first visit, statin use, and smoking status (P < 0.001). Within each smoking category, the effect of statins was always estimated to be beneficial, but the size of the improvement in the decline rate varied among smoking groups. We found similar results for FVC decline.
Conclusions: Our results indicate that statin use attenuates decline in lung function in the elderly, with the size of the beneficial effect modified by smoking status.
Key Words: statins • lung function • FVC • FEV1 • smoking
My consultant has no opinion on the above.
I received this from Frant Barrett of “Efforts” – a US site for emphysema.
NEW YORK (Reuters Health) - Treatment with a stent coated with the drug
paclitaxel to reduce hyperinflation of the lungs appears to be a feasible
treatment for patients with severe emphysema, according to the results of a small
study. This treatment can improve lung function and reduce shortness of breath,
according to the results of small study.
"These results indicate that airway bypass is a potentially viable
therapeutic option for patients with marked severe pulmonary destruction, whose only
current option may be to wait for a lung transplant," lead author Dr. Paulo F.
G. Cardoso, from Santa Casa de Porto Alegre-Pavilhao Pereira Filho Hospital
in Brazil, said in a statement.
The stents are placed through the airway walls to release the air trapped in
diseased segments of the lung, allowing it to be expelled normally, Cardoso
and colleagues' explained in their report, published in The Journal of
Thoracic and Cardiovascular Surgery.
Stents are tiny wire mesh tubes used to prop open diseased heart arteries.
This type of stent which releases a drug to keep the artery open -- is also
used in heart patients to keep the vessels open after they are cleared of the
clog-forming plaque that can cause heart attacks.
In the current feasibility study, Cardoso's team assessed the safety and
efficacy of airway bypass in 35 patients with severe emphysema. The "Exhale"
paclitaxel-coated stent used by the researchers was developed by Broncus
Technologies, Inc., which funded the study. Continued...
About eight stents were implanted in each patient. At 6-month follow-up, the
average lung volume had fallen by 400 milliliters from 5.34 liter when the
study began. Stent placement was also associated with a significant
improvement in shortness of breath.
The authors noted that patients with the most severe hyperinflation prior to
treatment gained the greatest benefit from airway bypass. In this group, the
average volume had dropped by 870 milliliters by the 6-month evaluation from
a starting volume of 5.92 liters.
"The data from the study are very exciting, as they help build the case that
airway bypass might reduce hyperinflation and have long-term benefit," Dr.
Cary Cole, CEO of Broncus, said in a statement. "We hope to continue this
success with the current, pivotal EASE Trial, our largest clinical study to date."
SOURCE: The Journal of Thoracic and Cardiovascular Surgery, October, 2007.
http://uk.reuters.com/article/healthNews/idUKTON30405820071023?pageNumber=2
......For more on the larger Phase III EASE trial now underway at many
locations, see http://www.easetrialus.com/
and http://clinicaltrials.gov/ct/show/NCT00391612?order=1
Again From: "Frank Barrett" of Efforts
Subject: Encouraging early results on Airway Bypass Stents Date: 23 October 2007 15:49 NEW YORK (Reuters Health) - Treatment with a stent coated with the drug paclitaxel to reduce hyperinflation of the lungs appears to be a feasible treatment for patients with severe emphysema, according to the results of a small study. This treatment can improve lung function and reduce shortness of breath, according to the results of small study. "These results indicate that airway bypass is a potentially viable therapeutic option for patients with marked severe pulmonary destruction, whose only current option may be to wait for a lung transplant," lead author Dr. Paulo F. G. Cardoso, from Santa Casa de Porto Alegre-Pavilhao Pereira Filho Hospital in Brazil, said in a statement. The stents are placed through the airway walls to release the air trapped in diseased segments of the lung, allowing it to be expelled normally, Cardoso and colleagues' explained in their report, published in The Journal of Thoracic and Cardiovascular Surgery. Stents are tiny wire mesh tubes used to prop open diseased heart arteries. This type of stent which releases a drug to keep the artery open -- is also used in heart patients to keep the vessels open after they are cleared of the clog-forming plaque that can cause heart attacks. In the current feasibility study, Cardoso's team assessed the safety and efficacy of airway bypass in 35 patients with severe emphysema. The "Exhale" paclitaxel-coated stent used by the researchers was developed by Broncus Technologies, Inc., which funded the study. Continued... About eight stents were implanted in each patient. At 6-month follow-up, the average lung volume had fallen by 400 milliliters from 5.34 liter when the study began. Stent placement was also associated with a significant improvement in shortness of breath. The authors noted that patients with the most severe hyperinflation prior to treatment gained the greatest benefit from airway bypass. In this group, the average volume had dropped by 870 milliliters by the 6-month evaluation from a starting volume of 5.92 liters. "The data from the study are very exciting, as they help build the case that airway bypass might reduce hyperinflation and have long-term benefit," Dr. Cary Cole, CEO of Broncus, said in a statement. "We hope to continue this success with the current, pivotal EASE Trial, our largest clinical study to date." SOURCE: The Journal of Thoracic and Cardiovascular Surgery, October, 2007. http://uk.reuters.com/article/healthNews/idUKTON30405820071023?pageNumber=2 ......
From Pulse
COPD screening backed
23 Feb 07
By Eleanor Goodman
GP screening of smokers picks up one-fifth with undiagnosed COPD
Screening smokers for COPD identifies up to a fifth who have undiagnosed disease, a new primary care study reveals.
The research appears to strengthen the case for GP screening using spirometry, with proposals to be submitted for inclusion in the quality and outcomes framework.
Of 818 current or former smokers over the age of 40 screened for COPD, 19 per cent were found to have the disease. A substantial proportion of patients had moderate or severe disease, as measured by the GOLD severity criteria.
Researchers classified COPD as mild in 57 per cent of cases, moderate in 37 per cent and severe in 6 per cent. The study, published in February's Primary Care Respiratory Journal, examined spirometry screening results taken in practices in the UK and US.
Study leader Dr Robert Halbert, assistant professor of community health sciences at University College Los Angeles in the US, said: 'Earlier diagnosis through targeted case-finding will allow early, aggressive smoking cessation efforts. It may lead to a reduction in the burden of COPD symptoms.'
Dr Steve Holmes, chair of the General Practice Airways Group and a GP in Somerset, said the group would be submitting proposals for COPD screening to the QOF review.
'The research is very important and highlights clearly that we have a number of undiagnosed cases with COPD we're not managing early on. That fits in with a lot of the epidemiological research showing we have only picked up about a third of people. It builds on NICE guidance that screening people is a good idea.
'But he said GPs would need new resources if they were to take on screening. 'GP practices definitely have the skills and abilities to do this; the problem may be with resources and time, as this process isn't funded.'
Dr Mark Levy, editor of the Primary Care Respiratory Journal and a GP in Middlesex, said: 'It's a good piece of research, but are we really underdiagnosing people or are the criteria incorrect? According to the paper it's being undiagnosed, but that's based on the GOLD criteria.'
The GOLD guidelines used a fixed FEV1/FVC value of 0.70 to define airway obstruction, but a discussion paper in the same issue of the journal suggested the lower limit of normal would be a better classification.
Need to know - COPD
27 Mar 08
Respiratory specialist Professor Wisia Wedzicha answers Dr Steve Brown’s questions on home oxygen, screening and reversibility testing
1. What is the current thinking on screening for COPD in general practice? If we did it, at what age should we start?
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COPD is currently underdiagnosed or diagnosed late, so many patients with mild COPD are missed. A key objective is to diagnose it earlier so we can encourage patients to stop smoking – one of the few interventions that can reduce disease progression. NICE’s 2004 COPD guidelines suggested a diagnosis should be considered in patients over 35 who have any risk factor for COPD, and cigarette smoking is the most important factor1. But we now know that there are other risk factors apart from smoking, including exposure to biomass fuels during cooking, occupational factors such as fumes and coalmining, low birth weight and recurrent infections and reduced lung function in childhood.
2. Should GPs be able to make the diagnosis of COPD just on spirometry findings? How useful is a chest X-ray?
For the diagnosis of COPD, spirometry is the best way to demonstrate the presence of airflow obstruction. Airflow obstruction is defined as a reduced FEV1:FVC – less than 0.7 after administration of a bronchodilator.
NICE guidelines define COPD as when the FEV1 falls to below 80% predicted, although the WHO GOLD guidelines define mild COPD as an FEV1:FVC ratio less than 0.7 but an FEV1 that is at or above 80%, allowing COPD at an early stage of airflow obstruction to be diagnosed2. So spirometry is also useful to monitor the severity of the condition. Peak expiratory flow rate may underestimate airflow obstruction in COPD and is not useful for diagnosis.
The common symptoms associated with COPD are breathlessness, cough, sputum production and wheeze, but symptoms may appear late in the course of the disease, when lung damage has already occurred.
A chest X-ray is useful to exclude any other pathologies and may show the presence of emphysema, but this will require confirmation with specialist tests such as CT scanning. We also now recognise that comorbidity – such as cardiovascular disease and diabetes – are important components of COPD and must be evaluated at diagnosis.
3. Do GPs everywhere have to refer for a consultant opinion to decide which COPD patients should have home oxygen? How well has the home oxygen service bedded in?
Home oxygen therapy usually refers to the provision of long-term oxygen therapy (LTOT) at 15 hours per day for patients with evidence of arterial hypoxaemia – that is PaO2 less than 7.3kPa or between 7.3kPa and 8kPa in the presence of nocturnal hypoxia, pulmonary hypertension or secondary polycythaemia3. So all patients who are potential candidates for LTOT must have a clear diagnosis with arterial blood gas measurements performed.
Oximetry is useful as screening for hypoxaemia, but not accurate enough for LTOT prescription and does not measure arterial carbon dioxide. At present, arterial blood gases can be only performed in respiratory specialist centres or lung function units. It is also important that patients have been optimally treated and any complications of hypoxaemia recognised and managed. So it is to be recommended that at the start of LTOT, all potential patients are reviewed in a respiratory specialist clinic, usually run by a consultant.
Some of these patients will also need ambulatory oxygen and this will require further assessment of disability and usage usually by a respiratory nurse or physiotherapist. The evidence for short-burst oxygen therapy (SBOT) is weak, so any patient with progressive breathlessness not responding to therapy should be referred for a consultant opinion prior to prescription of SBOT.
The new Home Oxygen Service for England and Wales was introduced in February 2006 and some early difficulties were experienced, especially as it was difficult to ascertain exactly who required oxygen provision for SBOT and some patients had bought ambulatory oxygen or had it provided by charities. But the service is running much more smoothly now, helped by increased awareness of the importance of appropriate home oxygen therapy.
4. I have heard that inhaled steroids are not that useful if there is no evidence of reversibility. What’s your view?
We now know that bronchodilator reversibility testing in COPD is too variable to be useful diagnostically and the same reversibility test performed on another occasion gives a different result. We also now know from the ISOLDE study of long-term inhaled steroids in COPD that reversibility did not predict the long-term response to the inhaled steroids4. In addition, a short course of oral steroids also did not predict the response to long-term steroid therapy.
5. When treating acute exacerbations, what dose of oral steroids is best and should the dose reduction be tapered?
COPD exacerbations vary in severity and oral steroids will be indicated when they significantly affect the patient’s daily activities. Exacerbations will be more severe in patients with more advanced COPD and these are the patients most likely to need oral steroids. The evidence suggests that the main action of steroids is in the first few days of an exacerbation, and therefore, to minimise side-effects, I use prednisolone 30mg daily for seven to 10 days, without then tapering the dose. Milder exacerbations may just require an increase in inhaled steroid dose.
6. Is there any good evidence that flu or pneumococcal vaccine prevents admissions?
There is good evidence from studies in elderly populations and some from COPD patients that flu vaccination is effective and that it also prevents hospital admission and reduces mortality. But flu vaccination will obviously not protect against other viral triggers of COPD exacerbations such as rhinovirus and respiratory syncytial virus that are also more common in winter.
But the evidence for the effectiveness of pneumococcal vaccine is less well documented, though again data from studies in the elderly suggest that hospital admission may be reduced. Few studies have been performed in COPD patients, but there is some evidence that patients with more severe COPD obtain benefit from pneumococcal vaccination.
7. What is the role of respiratory rehabilitation, and what’s your view on community versus hospital provision?
The goal of respiratory – or pulmonary – rehabilitation is to optimise the patient’s physical and social functioning. This is achieved through a multidisciplinary programme, consisting of courses of exercise training and education.
The exercise programme needs to be given at least twice a week for a minimum of six weeks, and then patients need to maintain their daily activity. There is strong evidence that pulmonary rehabilitation programmes improve activity, quality of life and reduce the length of hospital stays.
Pulmonary rehabilitation programmes can be done in the community and are usually led by physiotherapists or nurses, but the team needs to be multidisciplinary. Patients with severe disease will need supervised programmes with gradual increases in activity, whereas patients with milder disease can follow their exercise programme after initial instruction, either from a healthcare professional or fitness trainer familiar with the needs of patients with respiratory disability.
8. How reliable an indicator of bacterial infection is sputum colour?
It’s broadly correct that patients with purulent sputum – either when stable or at exacerbation – are more likely to have bacterial infection, commonly Haemophilus influenzae or Streptococcus pneumoniae. So if an exacerbation is accompanied by clear sputum, antibiotics are not necessary but they are recommended for exacerbations with increase in sputum production and/or purulent sputum.
9. How rare is alpha-1 antitrypsin deficiency and what tips can help GPs recognise it?
Alpha-1 antitrypsin deficiency is an uncommon cause of COPD – accounting for only about 2% of cases – but it’s important to be aware of the condition as early intervention with smoking cessation can reduce disease progression. COPD in patients with alpha-1 antitrypsin deficiency has a more aggressive natural history and patients may show a fast decline in lung function. Some non-smokers with alpha-1 antitrypsin deficiency may also develop COPD, so seeing COPD in a non-smoker is a clue to the presence of the condition. Alpha-1 antitrypsin deficiency is genetic and other members of the family may be affected and need to be screened. It also causes early onset of COPD and tends to be associated with basal emphysema.
10. What proportion of COPD patients will need to remain on a low maintenance dose of steroids?
After an exacerbation, most patients recover their lung function to their usual stable state within 14 days. However, some patients can develop more prolonged symptoms and even another or recurrent exacerbation. In this situation, treat first with another course of oral steroids with or without antibiotics as indicated. It is also important to optimise the patient’s usual therapy, which if the patient has more severe disease will consist of combination therapy of long-acting bronchodilators (anti-cholinergics and ß-agonists) and higher dose inhaled steroids. Any other underlying condition such as bronchiectasis needs to be recognised. Most patients will recover at this stage but a very small proportion may be unable to manage without the steroid therapy and will need some low-dose maintenance therapy.
11. Is it worth advising patients with COPD to stop smoking once there is established disease?
Yes. As discussed above, smoking cessation is one of the few interventions that reduces disease progression in COPD. In addition to the effects on reducing FEV1 decline, there is evidence that some therapies such as inhaled steroids may not be so effective in patients who are cigarette smokers.
Smoking is also the most important risk factor for lung cancer, and COPD itself is a risk for lung cancer – so this is another important reason why patients should be encouraged to stop smoking. Smoking is also associated with cardiovascular co-morbidity, which is common in COPD.
We now know that smokers with COPD are more likely to have airway bacteria in the stable state (colonisation) and this may also enhance disease progression.
It is also important that patients prescribe home oxygen therapy do not smoke for safety reasons.
Thus there are a number of important reasons that we must strive to stop patients smoking at all stages of COPD.
Professor Wisia Wedzicha is professor of respiratory medicine at the Royal Free and University College Medical School, London
Competing interests: Professor Wedzicha has received funding for research and honoraria for lectures and/or advisory boards from GlaxoSmithKline, Astra Zeneca and Boehringer Ingelheim
What I Will Do Now
-
Dr Brown reflects on the answers to his questions
• I will do more lung function tests on smokers to help with smoking cessation, and explain early if their lung function tests are suboptimal
• I will prescribe up to 10 days of oral steroids for acute exacerbations
• I will not attach too much significance to reversibility testing results
• I will refer more patients for pulmonary rehabilitation
• I will encourage COPD patients to have the flu vaccine and be less concerned if they refuse the pneumococcal vaccine
• I will make short burst oxygen therapy less of a priority
Dr Steve Brown is a GP in Beaconsfield, Buckinghamshirel
Readers' comments
- Ava Aveeno | 25 Mar 08
Alpha-1 Antitrypsin Deficiency is not COPD! The disease is actually a liver deficiency but many GPs will not correctly diagnose the genetic disease. The right name for the genetic condition is Alpha-1 Antitrypsin liver Deficiency. Without knowing the correct name GPs can never treat the genetic condition appropriately for the patients. Alpha-1 antitrypsin (AAT) is a protein (also called “alpha-1 proteinase inhibitor”) produced by the liver to protect the human body from damage caused by the enzyme neutrophil elastase. This enzyme is released by white blood cells during times of inflammation and infection and is necessary in digesting damaged cells and bacteria. When AAT is not available to neutralize this enzyme, healthy body tissues can be damaged such as lungs, liver and skin.
Because AAT is made in the liver there can be a strain on the liver. Sometimes individuals develop liver disease either shortly after birth or occasionally later in life. AAT Deficiency, also referred to as Alpha-1, is an inherited disorder, which results in low or no levels of AAT in the blood.
While the enzyme neutrophil elastase performs valuable and healthy functions like digesting damaged cells and bacteria, removing pollutants and fighting infections, the activities of these substances must be controlled or they can attack normal tissues. Most people have 7 to 10 times more AAT than the person with the alpha-1 deficiency.
ALPHA-1 ANTITRYPSIN LIVER DEFICIENCY IS NOT COPD!!!
- Editor's comment
Dr Steve Brown, the GP who set the questions for this Need To Know on COPD, asked Professor Wedzicha about alpha-1 antitrypsin deficiency not because he thought A1AD and COPD are the same disease - but because the symptoms are similar, shortness of breath and wheezing. As many as 3% of individuals with COPD symptoms may have undiagnosed A1AD - making it vital that GPs bear the diagnosis in mind, especially in a younger non-smoker with COPD sympt
End-of-life care issues in COPD
27 Mar 08
In the final article on our special repot on COPD, Dr David Seamark, Dr Clare Seamark and Dr David Halpin give an overview of palliative care issues GPs face when treating COPD patients.
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There is a 24-39% five-year survival rate for those with severe COPD, and more than 25,000 people a year in the UK die of COPD – 5% of all deaths.
The mortality and associated symptom burden is similar to that of those with lung cancer, but the need for holistic palliative care has only recently been recognised.
A palliative care register has also been added to the QOF and may lead to a more co-ordinated approach.
Identifying patients
Prognostic uncertainty often prevents end-of-life issues being discussed. Features related to a poor prognosis in COPD include FEV1 of less than 30% predicted, frequent exacerbations, long-term oxygen therapy and cor pulmonale. It has been suggested that if the clinician expects a patient to die within the next 12 months, this is a strong indication to adopt a palliative care approach. It is a question GPs could ask themselves at annual reviews.
Advance care planning
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GPs are in a key position to both deliver and co-ordinate care for the patient dying from COPD. Patients with severe COPD need to be given honest and clear information, summarised in the box lef. They are often receptive to this dual agenda: ‘Hope for and expect the best and prepare for the worst’.
Advance care planning is seen by some as a way of preparing for the worst and has been implemented successfully in the US.
Although UK GPs acknowledge a need to discuss end-of-life issues with severely ill COPD patients, it is not reflected in their behaviour. This probably relates to unease at being too prescriptive in planning ahead, and the fact that patients can adopt new perspectives – such as the decision to receive ventilatory support during an exacerbation – as their disease progresses.
A helpful development is a move from a prescriptive advance directive to an approach involving the patient’s values.
Symptom control
Patients with COPD at the end of life have physical and psychological needs at least as severe as patients with lung cancer. Breathlessness, anorexia and constipation feature in severe COPD along with significant problems with fatigue, pain, anxiety and depression and poor sleep.
The evidence base for symptom control in end-stage COPD is poor, and management relies on a mix of best practice and experience.