MMP-9 AND TNF-α GENE POLYMORPHISMS IN KOREAN PATIENTS WITH CHRONIC OBSTRUCTIVE PULMONARY DISEASE
Sung Chul Lim, Jin Yung Ju, and Yu II Kim Departments of Internal Medicine, Chonnam National University Medical School, Gwangju, South Korea
Background: Cigarette smoking has been known to be one of the important contributing factors for developing COPD. However, only 10 to 20% of heavy cigarette smokers can be affected with COPD, and they can have airway obstruction and respiratory symptoms. These facts imply that genetic factors might have an important role in the genetic susceptibility to COPD. Matrix metalloproteinase (MMP) 9 and tumor necrosis factor alpha (TNF-α) appear to play an important role in the development of COPD. To study whether such protease and cytokine contribute to genetic susceptibility to Korean COPD, we have performed a study on MMP-9 and TNF-α gene polymorphism in Korean COPD. Materials and Methods: Twenty-eight patients with COPD and 16 smoker control subjects were included in this study. Genomic DNA was used as a template for amplification by PCR to determine the MMP-9 and TNF-α polymorphism. The products were investigated by auto-sequencing analysis. Results: The frequencies of CT genotype in MMP-9 (C-1562T) gene promoter region were 46% (13/28) in the COPD patients and 6% (1/16) in the smoker control subjects. There were statistically significant differences between the two groups (p = 0.007). And the frequencies of GA genotype in TNF-α -308 gene promoter region were 14% (4/16) in the COPD patients and 31% (5/16) in the smoker control subjects. There were statistically no significant differences between the two groups (p = 0.250). Conclusions: The genetic polymorphism in promoters of MMP-9 (C-1562T) gene might be associated with the susceptibility to smoking-related COPD in Korean population. But a role for the TNF-α -308 gene promoter polymorphism in COPD development was not demonstrated in this study.
THE EFFECTS OF TIOTROPIUM AND INHALED CORTICOSTEROID/LONG ACTING BETA-AGONIST IN PATIENTS WITH TUBERCULOUS DESTROYED LUNG
Moon Jun Na, Mee Hye Kwon, Ji Woong Son, and Eu Gene Choi Konyang University Hospital, Gasuwon-dong 685, Seo-gu, Daejeon, Korea
Background: Pulmonary tuberculosis often complicated by extensive destruction of lung parenchyme and airflow obstruction similar to chronic obstructive pulmonary diseases. The objective is to evaluate the effects of tiotropium and ICS/LABA in TDL patients with severe obstructive airway disease. Methods: We selected 19 TDL patients with history of treatment of pulmonary tuberculosis who were treated with tiotropium and ICS/LABA over at least 2 months. They had severe obstructive airway disease whose predicted value of forced expiratory volume for 1 second (FEV1%), predicted value of forced vital capacity (FVC%), and FEV1/FVC ratio were 41.76 ± 15.21%, 70.99 ± 17.06%, and 46.34 ± 12.83%, respectively. We measured and compared the pulmonary function before and after treatment. Results: After short-term treatment (3.6 ± 1.34 month, n = 14) with tiotropium and ICS/LABA, the FEV1 and FEV1% were increased by 0.18 ± 0.23 L and 8.71 ± 9.69%, FVC and FVC% were increased by 0.10 ± 0.40 L and 6.64 ± 10.09%, and FEV1/FVC ratio was improved by 5.18 ± 10.88%. And, after long-term treatment (12.0 ± 1.9 month, n = 7) with tiotropium and ICS/LABA, the improvement of FEV1, FEV1%, FVC, FVC%, and FEV1/FVC were 0.08 ± 0.29 L, 5.44 ± 9.48%, 0.04 ± 0.48 L, 4.03 ± 12.78%, and 2.68 ± 8.51%, respectively. Discussion: The treatment with tiotropium and ICS/LABA was effective in improvement of airway obstruction in TDL patients with severe obstructive airway disease.
MANAGING COPD: THE PLYMOUTH MODEL
Margaret Barnett Plymouth PCT, Chest clinic level 6, Derriford Hospital, Plymouth, Devon. PL6 8DH
The Plymouth COPD service was set up in 2000 to provide support to patients with moderate to severe COPD living within the Plymouth area. Monies from the winter pressures budget primarily funded this initiative, and over time further funds have been obtained from the commissioning directorate to develop the service further. The service structure includes an Inreach service to secondary care, which facilitates an early discharge scheme, an outreach service within primary care which aims to optimize and manage patients in the community preventing hospital admissions whereby over a 1000 hospital bed days per year have been saved, as well as a home and community-based pulmonary rehabilitation program. Audit has demonstrated that implementation of this service has proved safe and effective with many benefits. The response from general practitioners has been very positive. From a patient perspective, 84% felt that the specialist nurses had a good understanding of their condition and 80% were very satisfied with the service provided. In terms of controlling and stabilizing their symptoms, 47% stated that their condition had improved, whereas 44% felt that it was much the same. Many patients indicated that the provision of expert care has improved their self-confidence and their quality of life.
THE EVALUATION OF A HOME-BASED COPD PULMONARY REHABILITATION PROGRAM
Sherrie Choy and Margaret Barnett Plymouth PCT, Chest Clinic, Level 6, Derriford Hospital, Plymouth Devon. PL6 8DH
Many patients with advance COPD suffer from a reduced functional capacity, mainly due to breathlessness on exertion. Various studies have demonstrated the benefits of pulmonary rehabilitation, and the NICE guidelines (2004) suggest that all patients with an MRC dyspnoea score of 3 should have the option of attending a pulmonary rehabilitation program. However, many patients with this disability are unable to travel to a community or hospital-based venue for one reason or another. To address this need, an 8-week home-based exercise program has been set up in Plymouth and facilitated by the COPD team physiotherapist. Audit data have been collected pre and post the program using various quality markers including the 6-minute walking test, the Borg scale, measurement of oxygen saturations, and spirometry, as well as completion of quality of life (CRQ) and depression (HADS) questionnaires. Results demonstrate that many patients increased their exercise capacity by over 50%, which correlated with the quality-of-life scores in particular showing over 50% of patients reported an improvement related to fatigue. The program has been well received by patients and the data encouraging enabling COPD patients to receive optimal care and to achieve an enhanced quality of life.
SURVEY OF COPD MANAGEMENT AMONG THE PRIMARY CARE PHYSICIAN IN KOREA
Myung Jae Park, Young Kyoon Kim, Kyung Ho Kang, Kwan Ho Lee, Jin Hwa Lee, Sung-Chul Lim, Ki-Suck Jung, Dong Ho Shin, and Jee-Hong Yoo Kyung Hee University, Yeungnam University, Chonnam Univeristy, 1 Hoegi-dong, Dongdaemun-gu, Seoul, 130-702, Korea
Background: Chronic obstructive pulmonary disease (COPD) is increasing and becoming an important cause of morbidity and mortality worldwide. The aim of this survey is to investigate pattern of COPD management among primary care physicians (PCPs) and to consider it to the development of Korean COPD guideline. Methods: Web-based questionnaire consisted of 25 questions for the pattern of COPD management. Two hundred seventeen PCPs participated in the survey. Results: Many PCPs (61.8%) possessed the spirometer but application rate was relatively low (35.8%), and more than half of the COPD patients (57%) were not diagnosed based on spirometry. When it comes to the medication, oral medication was preferred than inhaled medication for both stable and acutely exacerbate state of COPD. It was noted that PCPs were aware of the GOLD guideline in 56.7% but only 7.3% tended to fully implement the guidelines. Conclusion: The result of the survey shows that, despite the high awareness rate of the COPD guidelines, deficits exist among PCPs with respect to diagnosis and treatment of COPD. It is required to apply the results of this survey to the development of COPD guideline in order to decrease the discrepancy between guideline and daily practice of PCPs.
ALTERED ALVEO-VASCULAR CHANGES IN A CHRONIC TOBACCO SMOKE INHALATION MOUSE MODEL
Nirmal Parajuli, Michael Seimetz,1 Markus Roth,1 Beate Fuchs,1 Ralph Theo Schermuly,1 Hossein Ardeschir Ghofrani,1 Christian Schudt,2 Christian Hesslinger,2 Werner Seeger,1 Friedrich Grimminger,1 and Norbert Weissmann,1 1Department of Internal Medicine, University of Giessen Lung Center, Giessen, Germany, 2Nycomed GmbH, Konstanz, Germany
Introduction: COPD is a progressive disease having nonfully reversible airflow limitation associated with chronic obstructive bronchitis and emphysema. Genetic factors, environmental pollution, and tobacco smoke inhalation are the major factors for induction of this disease. The aim of this study was to establish and to identify the pathogenesis of lung emphysema development in chronic tobacco-smoke inhalation COPD mouse model. Material and Methods: Wild-type mice (C57/Bl6J) were exposed to cigarette smoke for 6 hours/day, 5 days per week up to 8 months. Exposure of smoke was maintained at a particle concentration of 140 mg/m3. In parallel, wild-type control mice were exposed to room air. After exposure, mice were anesthetized for histological fixations of the lung to analyze alveolar air space, septal wall thickness, and mean linear intercept. Lung function and vasoreactivity were also measured with isolated perfused ventilated mouse lung experiment. Weight changes of all animals were examined weekly. Results: Tobacco smoke exposure resulted in an increase in mean linear intercept, alveolar airspace and a decrease in septal wall thickness of all lobes in lung (p < 0.05) within 8 months, but the diseases progression started even earlier to upper extremities (p < 0.05). Increased lung compliance and tidal volume were observed in smoke-exposed mice (p < 0.05). Increased vasoconstrictive response and decreased vasodilator response were observed in smoke-exposed mice (p < 0.05). Body weight was also decreased simultaneously in smoke-exposed mice (p < 0.05). Conclusion: Emphysema is induced by chronic tobacco smoke inhalation in C57/Bl6J mice with a higher susceptibility to the proximal regions of the lung. Lung function capacity is reduced and vascular response is altered. This model now allows studying mechanisms of emphysema in mice by investigation of transgenic animals.
THE EFFECT OF CRP AND PROCALCITONIN LEVELS ON THE ESTIMATION OF INFECTION IN THE PATIENTS WITH COPD WHO ARE ADMITTED TO ICU WITH A DIAGNOSIS OF RESPIRATORY FAILURE
Ferah Ece, Levent Kilickan, Jale Aytac, Halim Issever, and Osman Bayindir Istanbul Bilim University Medical School, Avrupa Florence Nightingale Hastanesi Mehmetcik caddesi, No: 1Mecidiyekoy-Istanbul, Turkey
Background: Acute respiratory failure is one of the most frequent reasons for ICU admittance of patients with acute exacerbation of COPD. Those patients almost always receive antimicrobial treatment in the ICU. Unnecessary antibiotic usage causes increase in antibiotic resistance, cost of hospitalization, and side effects. In this study we aimed to investigate whether the levels of CRP and procalcitonin affect the decision of antimicrobial therapy in those patients. Methods: Twenty-four patients who were consecutively admitted to the ICU with a diagnosis of acute respiratory failure after COPD exacerbation were examined. CRP, procalcitonin, CPIS, and CURB-65 scores were assessed for each patient at the time of admittance to the ICU. Microbial culture of tracheal secretions, urine, and blood samples were done routinely as well. According to the results of antibiogram tests, patients received antimicrobial treatment. However, if there was a suspicion of the infective disease such as fever (> 40°C, < 35°C), 30000 < WBC < 4000, etc., empiric antibiotic treatment was given to the patients. Results: Patients with culture positivity showed significantly higher levels of CRP and procalcitonin than culture (–) patients. CPIS and CURB-65 scores were comparable with the CRP and procalcitonin levels. After antimicrobial treatment, CRP and procalcitonin levels were decreased in both empiric treatment and antimicrobial culture-positive group; however, it was statistically significant only in the latter. Conclusion: The initiation of antimicrobial therapy may be manipulated by the levels of CRP and procalcitonin.
HYPEROXIC EFFECTS ON INSPIRATORY MUSCLE FATIGUE IN CYCLING HEALTHY HUMANS
Marina Segizbaeva Pavlov Institute of Physiology 199034, Russia, St. Petersburg, nab. Makarova 6, Laboratory of Respiratory Physiology
During high-intensive exercise to exhaustion and/or respiratory load the inspiratory muscles of healthy trained human can fatigue. The aim of the present study was to determine the rate of the inspiratory muscle fatigue development in healthy man during incremental cycling under low- and high-resistive loaded breathing in air and oxygen. VT, VE, TI, TT, PACO2, PmI, and parasternal-integrated EMG activities were recorded each minute during incremental cycling test under resistive load 12 (low) and 40 (high) cm H2O/l s-1 in air and oxygen in 10 healthy men. The degree of inspiratory muscle fatigue was evaluated by the dynamics of inspiratory mouth pressure, “tension-time” index TTm, as well as the fall of the ratio of high-frequency to low-frequency power (H/L) of the parasternal EMG. Oxygen breathing during low-resistive load decelerates the development of inspiratory muscle fatigue compared to air, although the maximal work performance was higher in oxygen than in air (210 ± 11 Wt and 181 ± 12 Wt, respectively). However, the inspiratory muscle fatigue develops at an equal rate during cycling with high-resistive load in air and oxygen and maximal work performance was the same too (135 ± 9 and 139 ± 11 Wt in air and oxygen, respectively). Oxygen breathing has a positive effect on inspiratory muscles function only during low-resistive load, whereas hyperoxia does not improve the energy supply of the inspiratory muscles as well as increase the maximal work performance of human during high-resistive load. It is supposed that in forced respiration with high-resistive load, the arterial supply of the inspiratory muscles is impaired due to occlusion of intramuscular vessels during intense muscular contractions and a significant shortening of the relaxation time of respiratory muscles in the expiratory phase.
AN AUDIT OF THE COMMUNITY PULMONARY REHABILITATION SERVICE IN WAKEFIELD DISTRICT PRIMARY CARE TRUST
Tara Bader, Anna Phillips, Rachel Birmingham, Mohammed Hotak, Gethin Lane, Lizzie Lloyd, and Elizabeth Hutchinson School of Medicine, University of Leeds, Worsley Building, University of Leeds, Leeds, LS2 9JT.
An audit of the community pulmonary rehabilitation service was carried out for Wakefield District Primary Care Trust (WDPCT). Chronic Obstructive Pulmonary Disease (COPD) is a major public health issue and remains the fifth leading cause of death in the United Kingdom. Pulmonary rehabilitation is a multidisciplinary program consisting of exercise and education sessions that aim to reduce symptoms, decrease disability, and improve quality of life for people with COPD. This audit aimed to assess WDPCT/s pulmonary rehabilitation service. The audit was based on National Institute for Health and Clinical Excellence (NICE) guidelines and evaluated the location, content, and duration of the service. A postal questionnaire was designed and sent to service users of pulmonary rehabilitation. Service user feedback on the program was then used to determine whether or not WDPCT is meeting the recommendations set by NICE. Overall, the findings show that WDPCT is meeting the required standards. However, the following aspects could potentially be improved: attendance at the education sessions, increasing the benefit received by patients, and the introduction of a follow-up program. This audit is the first of its kind and, therefore, new standards had to be set. The audit cycle will be repeated by WDPCT using the recommended standards and methods to ensure future monitoring of the community pulmonary rehabilitation service. (This presentation would give information on how to provide effective community pulmonary rehabilitation to interested service providers.)
A STAIR-CLIMBING TEST IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD) ASSESSMENT
Estelle Villiot-Danger, Gregory Reychler, Bertrand Selleron, Jean Christophe Villiot-Danger, and Hassan Razzouk Centre de Pneumo-Allergologie Les Acacias, 46 Route de Grenoble, BP29 5107 Briançon cedex, France
Introduction: Exercise tolerance is a cornerstone of COPD assessment. Six-minute walking test (6MWT) is the gold standard for its evaluation but it does not simulate walking up a slope. Objectives: To compare a stair-climbing test (SCT) to the 6MWT and to observe specifically their sensitivity to dyspnoea. Material and method: A self-paced 2-minutes SCT and the 6MWT were performed in 14 stable COPD patients (mean age = 65.9; SD = 13.8 years; FVC = 79.6 10.6% pred.val.; FEV1 = 52 17.2% pred.val.; 10/4 GOLD II/III, BMI = 24.5 3.8 kg· m–2) without encouragement, on a separate day. SaO2, heart rate (HR), walking distance or height, and dyspnoea (modified Borg scale) were measured before and after the tests. The physiological cost index (PCI) was calculated. Results: Delta SaO2 and HR are similar after both tests. Dyspnoea and PCI were significantly higher with SCT (6 2 vs 3 1.5, p < 0.001 and 0.29 0.12 vs 2.44 1.50, p < 0.001, respectively). There was a significant correlation between PCI and FEV1 only with 6MWT (r = 0.59, p < 0.05). Conclusion: These preliminary data suggest that SCT could be an alternative to assess exercise tolerance in COPD patients. SCT seems more sensitive than 6MWT regarding dyspnoea.
SPIROMETRIC SCREENING ON WORLD COPD DAY
Tanja Grzetic-Romcevic, Boris Devcic, and Silvana Sonc Department of pneumology, Clinical department for respiratory diseases and allergy, University, Clinical center, Ljubljana, Slovenia, Hospital Sezana, Cankarjeva 4, 621, Slovenia
Objectives: To determine the importance of spirometric screening for early detection of chronic obstructive pulmonary disease (COPD). Methods: Spirometric screening has been performed annually on World COPD day in Sezana from 2003. Sezana is a semiurban region of Slovenia, with 12.002 inhabitants. A total of 646 persons were enrolled (342 women and 304 men). The participators completed a questionnaire and had spirometry performed. Subjects with postbronchodilator FEV1/FVC < 0.70 were defined as having COPD, according to GOLD guidelines. Results: A total of 14.4% subjects with impaired lung function were found. Of these, obstructive pattern of ventilatory impairment had 72% and 28% a restrictive pattern. We identified 63 individuals with COPD and 4 with bronchial asthma. Subjects with COPD were > 70 years old in 46%. The majority of individuals with COPD were men (77.7%).A total of 90% of patients with COPD were smokers and in 10% were nonsmokers. Patients with COPD had mild disease in 46%, moderate in 38%, and severe in 16%. The majority of the patients had mild disease. A total of 94% of those with COPD (59/63) have not been recognized prior. Conclusions: These results suggest that with spirometry screening patients with COPD could be detected in the earlier stages of the disease.
AMBULATORY OXYGEN ASSESSMENT: ENDURANCE SHUTTLE WALK VERSUS THE 6-MINUTE WALK TEST
S. Revill, Noor, G. Butcher, and M.J. Ward Sherwood Forest Hospitals NHS Trust, Ashfield Community Hospital, Kirkby-in-Ashfield, Notts, NG17 7AE
Assessment of exertional desaturation and correction with ambulatory oxygen involves monitoring the response to a standard walking test. Previous studies have shown a variable response with the 6-minute walk test (6MWT), while there have been few studies on the response of the endurance shuttle walking test (ESWT). The aim of this study was to evaluate the responsiveness of the ESWT and the 6MWT to the acute effects of ambulatory oxygen in patients with COPD. Methods: A total of 23 patients performed, in random order, the ESWT and the 6MWT on air and while breathing oxygen at 2 l/min. Oxygen saturation and Borg scores were recorded. On a third day, 11 patients repeated the ESWT with oxygen in order to measure repeatability. Results: The change in distance walked when breathing oxygen was significantly greater on the ESWT than the change on the 6MWT (66 (91) vs 6 (28) m, respectively; p < 0.05). When repeated, the mean difference (95% CI) between distances walked with oxygen on the ESWT was 0.91 (–47, 49) m. Conclusion: The ESWT is more responsive than the 6MWT for detecting improvements in walking capacity while breathing ambulatory oxygen.
INCREASED CD8+ T LYMPHOCYTES IN SMALL AIRWAYS AND ALVEOLAR WALL IN CENTRILOBULAR EMPHYSEMA
Won-Dong Kim,1 Kang-Hyeon Choe,2 Woo-Sung Kim,1 Younsuck Koh,1 Sang-Do Lee,1 Chae-Man Lim,1 Tae-Sun Shim,1, Yeon-Mok Oh,1, Sang-Bum Hong,1, Dong-Soon Kim,1, and Kyu-Rae Kim3 1Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine; 3Department of Pathology, University of Ulsan College of Medicine, Seoul; and 2Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
Subjects with COPD have an increased number of CD8+ T lymphocytes in the peripheral airways and lung parenchyma. Centrilobular emphysema (CLE) has greater abnormalities in small airway wall than panlobular emphysema (PLE). Small airway wall thickness is associated with the degree of emphysema in CLE. We hypothesized that CLE would have a higher number of CD8+ T lymphocytes in small airways and alveolar wall than PLE. Immunohistochemical staining was performed to identify CD8+ T lymphocytes in small airways and alveolar wall of surgically resected lungs from 8 normal, 8 PLE, and 14 CLE subjects. A higher number of CD8+ T lymphocytes per mm2 of small airway wall (p < 0.05, respectively) and per mm of alveolar wall (p < 0.01, respectively) were found in CLE than in normal or PLE. The number of CD8+ T lymphocytes in small airway walls was correlated with those in alveolar wall in CLE (rho = 0.763, p = 0.002). The results suggest that CD8+ T lymphocytes might simultaneously play a role in the pathogenesis of small airway wall thickening and centrilobular emphysematous lung destruction. It is suspected that small airway disease and centrilobular emphysema could be the dual manifestations of a single disease process.
CORRELATIONS OF PLASMA C-REACTIVE PROTEIN WITH OUTCOME MEASURES IN ALPHA-1-ANTITRYPSIN DEFICIENCY
Paul A. Dawkins, Darren L. Bayley, and Robert A. Stockley University Hospital Birmingham, Edgbaston, Birmingham. B15 2TH
C-reactive protein (CRP) is an acute phase protein and a measure of systemic inflammatory response. High-sensitivity CRP assays were performed on plasma samples from patients with PiZ phenotype on the UK alpha-1-antitrypsin (A1AT) registry. Correlations were made between plasma CRP and lung function, exacerbation rates, health status scores, CT scan emphysema scores, body mass index (BMI), and chronic bronchitis (CB). CRP was also studied in relation to mortality and speed of FEV1 decline over 3 years. Results: CRP correlated with FEV 1% predicted (r = 0.193, p = 0.007, n = 192) and there was a direct relationship of CRP with GOLD severity groups. However, there was no significant correlation with gas transfer (DLCO/VA). CRP correlated with St. George's Respiratory Questionnaire (SGRQ) total score (r = 0.207, p = 0.003, n = 197), activity score (r = 0.198, p = 0.005, n = 197), and impact score (r = 0.202, p = 0.004, n = 197) but not symptoms score. CRP also correlated with SF36 physical component score (r = 0.222, p = 0.002, n = 199) but not mental component score. There was a correlation of CRP with CT scan lower zone expiratory Voxel Index scores (r = 0.216, p = 0.029, n = 107) and upper zone expiratory scores (r = 0.165, p = 0.050, n = 101), but not inspiratory scores. CRP also correlated with BMI (r = 0.228, p = 0.001, n = 208). Average CRP in patients with CB (n = 90) was 10.6 mg/l; average CRP in patients without CB (n = 122) was 9.3 mg/l; p = 0.035. There was no correlation with exacerbation rates over 3 years (r = 0.092, p = 0.424, n = 77). Mortality was similar in 198 survivors compared with 16 nonsurvivors, and there was no difference between the 50% of patients with fastest decline of FEV1 over 3 years compared with the 50% of patients with slowest decline of FEV1 over 3 years. In conclusion, CRP measurements correlate with a variety of outcome measures in A1AT deficiency, including FEV1, health status, CT scan emphysema scores, BMI, and CB but not with mortality or speed of FEV1 decline.
PATIENT INSIGHTS ON THE IMPACT OF MORNING SYMPTOMS OF COPD
Martyn R. Partridge and Niklas Karlsson Faculty of Medicine, Imperial College London, NHLI Division at Charing Cross Hospital, St Dunstans Road, London W6 8RP, UK
Many diseases are associated with symptoms that are worse at one particular time of the day. In respiratory medicine asthma is well-known to be associated with worsening during sleep and in the early morning. In COPD there are a number of pathophysiological reasons why the disease may be worse in the early morning: these include the effects of recumbency, ciliary slowing, diminished sighing, reduced frequency of coughing, low lung function, and relative nocturnal hypoventilation. Whether these changes result in increased symptoms in the early morning is not clear from the published literature. We, therefore, retrospectively reviewed in-depth interviews with 78 patients from four European countries. The transcripts were themed and while these were qualitative studies it was clear that at least 50% of patients with COPD spontaneously reported that symptoms of cough, wheezing, and breathlessness were worse in the morning. Many patients spontaneously mentioned that morning symptoms significantly limited their activities of daily living and necessitated use of reliever medication. If symptoms are worse, first thing in the morning we need is new tools to assess the burden of this on patients and, therapies may need to be specifically studied and directed for use at this time of day.
CLINICAL ASSESSMENTS OF COPD IN PRIMARY CARE: THE ROLE OF SUBJECTIVE AND OBJECTIVE ASSESSMENTS
Chris Loveridge, Hazel Madoc-Sutton, Monica Fletcher, and Jane Upton Education for Health, The Athenaeum, 10 Church Street, Warwick, CV34 4AB
Introduction: The UK primary care nurses are increasingly responsible for the follow-up care of patients with chronic obstructive pulmonary disorder (COPD). Here we assess the extent to which they perform both objective and subjective assessments in accordance with current guidelines. Methods: A total of 500 randomly selected UK general practices were sent questionnaires. Lead COPD nurses recorded the frequency they performed key follow-up tasks on a 4-point Likert-type scale (always to never). Results: A total of 74% of nurses responded (n = 368). Of the 95% who gave follow-up care, the following always or often performed objective measurements: 98% checked inhaler technique, 95% checked symptom control, 93% checked exacerbation frequency, 86% recorded spirometry, and 85% recorded body mass index (BMI). Fewer performed subjective assessments: 51% always or often assessed patients' psychosocial problems and 48% always or often used a validated score to measure quality of life. Conclusion: Respondents performed objective assessments more frequently than subjective assessments. This may be due to the General Medical Services Contract (2003), which while raising the profile of COPD, focuses care on objective assessments. Practice nurses should strive to conduct broad assessments in which the psychosocial impact of COPD and its impact on quality of life are also assessed.
CLINICAL PATHWAY FOR ACUTE EXACERBATIONS OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE (AECOPD): DEVELOPMENT AND 5-YEAR EXPERIENCE
Koichi Nishimura,1 M. Santo, Y. Hoko,1 T. Kondo,1 A. Takahagi,1 K. Tamura,1 S. Ito,1, T. Yoshimura,1, N. Yamashita,1 T. Hanawa,1 Y. Matsubara,1 M. Okamoto,2 and T. Oga3 1Respiratory Division, Kyoto-Katsura Hospital, Kyoto, Japan; 2The First Department of Internal Medicine, Kansai Medical University, and 3Department of Respiratory Care and Sleep Control Medicine, Respiratory Division, Kyoto-Katsura Hospital, 17 Yamadahirao, Nishikyo-ku, Kyoto, 615-8256, Japan
Background: A clinical pathway is a part of total quality management concept. The paucity of the pathway in AECOPD may be related to the difficulty in acute severe illness and a concern about treatment failure. Methods: The clinical pathway was formalized by a multidisciplinary group in November 2002. The pathway provided general rules for frequency of patient assessment and laboratory evaluation, pharmacotherapy including bronchodilator, oral corticosteroid and antibiotics, oxygen administration, NPPV (PaCO2 > 45–50 mm Hg), usage of rehabilitation program, education of inhalation technique (pharmacist intervention), nutritional support, social work intervention, and discharge planning. Exclusion criteria included pneumothorax-related exacerbations and mechanical ventilation with intubations. Results: The pathway has been applied to 241 hospitalizations by 154 patients. Seven patients died during the hospitalization (3%). Treatment with the pathway was interrupted and defined as a dropout in 27 hospitalizations (11%). Eight cases required intubations and mechanical ventilator use. Treatment with the pathway was completed in 214 out of 241 hospitalizations (89%). NPPV was administrated in 97 treatment arms. Hospital length of stay was over 30 days in 30 admissions, mainly due to the complications. Conclusions: AECOPD can be treatable via a clinical pathway. The pathway could fill in the gaps between guidelines and clinical practice.
TOTAL CALORIC INTAKE IN COPD PATIENTS CORRELATES WITH TOTAL LUNG CAPACITY AND DIFFUSING CAPACITY
Ho I Yoon, Young Ae Kang, Jae Ho Lee, and Choon-Taek Lee Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine. 300 Gumi-dong, Bundang-gu, Seongnam-si, Gyeongi-do, 463-707, Korea
Typical emphysematous changes were demonstrated in starved animals. In addition, the previous report about emphysema-like changes in the lungs of patients with anorexia nervosa suggests that the possibility of malnutrition affects severity of emphysema in COPD patients. Our research aimed to find correlation between total caloric intake and lung function parameters in stable COPD patients. A total of 51 COPD patients were enrolled in this study. Total caloric intake was evaluated through a 3-day-record by a dietician. Total caloric intake correlated with FVC (r = 0.305, p = 0.035) and FEV1 (r = 0.377, p = 0.008) but not with % predicted FVC (r = 0.022, p = 0.883) and % predicted FEV1 (r = 0.221, p = 0.131). It correlated with % predicted diffusing capacity of carbon monoxide (DLCO) (r = 0.367, p = 0.018), % predicted DLCO/VA (r = 0.381, p = 0.014), and inversely correlated with % predicted total lung capacity (TLC) (r = −0.344, p = 0.037). In conclusion, total lung capacity and diffusing capacity of carbon monoxide (DLCO) correlate with total caloric intake in COPD patients. Whether total caloric intake affects severity of emphysema needs to be further elucidated. Supported by a grant of the Korean Health 21 R&D Project, Ministry of Health & Welfare, Republic of Korea (A040153).
TUBERCULOSIS, SMOKING, AND COPD: THE GUANGZHOU BIOBANK COHORT STUDY
KH Lam,1 P Adab,1 RE Jordan,1 MR Miller,2 CQ Jiang,3 KK Cheng,1 and TH Lam4 1Department of Public Health and Epidemiology, University of Birmingham, Birmingham, UK; 2Department of Medicine, University Hospital Birmingham NHS Trust, Selly Oak Hospital, Birmingham, UK; 3Guangzhou Number 12 People's Hospital, Guangzhou, China; and 4Department of Community Medicine and School of Public Health, The University of Hong Kong, Hong Kong
The contribution of pulmonary tuberculosis (TB) to chronic obstructive pulmonary disease (COPD) and its interaction with smoking remains unclear. Participants in the Guangzhou Biobank Cohort Study undertook spirometry, chest radiography, and an interview. COPD was defined as FEV1/FVC < 0.7 without asthma. The presence of previous TB was based on either self-report or changes consistent with TB on X-ray. The prevalence of previous TB in this sample (n = 8076, mean age 61.9) was 25.2% (men: 35.2%; women: 21.5%). Past TB and smoking (adjusted for age and sex) both independently increased the risk of COPD. The interaction between the two caused an additional 23.6% increase in risk (). Adjustment for exposure to passive smoking, dust, and biomass fuel did not alter the relationship. TB is an independent risk factor for COPD, which may partly explain the higher prevalence of COPD in China. As TB is now renascent, clinicians should be aware of this long-term risk in people who have had TB, irrespective of smoking status.
Table 1 Separate and joint risk of COPD by TB and smoking status
USE OF RELIEF MEDICATION IN SEVERE COPD PATIENTS: RESULTS FROM THE INSPIRE STUDY (INVESTIGATING NEW STANDARDS FOR PROPHYLAXIS IN REDUCTION OF EXACERBATIONS, SCO40036; NCT00361959)
Robert Stockley, Terence Seemungal, Peter Calverley, Lisa Willits, John Riley, and Jadwiga Wedzicha University Hospital Birmingham NHS Foundation Trust. Department of Medicine, University Hospital Birmingham NHS Foundation Trust, Birmingham, UK
Inspire compared salmeterol/fluticasone propionate (SFC) 50/500 mcg BD with tiotropium (Tio) 18 mcg OD in 1323 individuals (mean age 64 years, 39% postbronchodilator FEV1) in a randomized, double-blind, parallel 2-year study. The primary end point was health care utilization (HCU) exacerbation rate. Use of Ventolin as a relief medication was an additional efficacy end point. There were no differences in HCU exacerbation rate between treatment groups. Compared with SFC, subjects on Tio were more likely to withdraw from the study, used more oral steroids for exacerbations, and were more likely to die during the study. On the other hand, antibiotic use for exacerbations and pneumonia reporting was higher in the SFC treatment arm. (Wedzicha J, AJRCCM 2008; 177: 19–26). Subjects on Tio used more relief medication than those on SFC. The difference in average relief medication usage was 0.33 uses/day in weeks 1–12 (95% CI: 0.21–0.46, p < 0.001) and 0.74 uses/day in weeks 85 to 104 (95% CI: 0.51–0.98, p < 0.001); the difference was also statistically significant at all other time intervals (p < 0.001). SFC subjects also had significantly more relief medication-free days than Tio subjects. The higher use of relief medication on Tio was maintained during exacerbations.