Acute Exacerbations of Chronic Obstructive Pulmonary Disease; Nikos M. Siafakes, Nicholas R. Anthoniesen, Dimitris Georgopoulos, ed.; New York, Marcel Dekker Inc., 2003
Chronic obstructive pulmonary disease (COPD) represents the fourth leading cause of death and the second in number of days missed from work. COPD is complicated by frequent and recurrent acute exacerbations (AECOPD) which is associated with high morbidity and enormous health care expenditures. Although there is much debate in the literature about the appropriate treatment and prevention of AECOPD, it is evident that both patients and physicians underestimate the impact of morbidity and mortality associated with these episodes. Over the years we have accepted the fact that exacerbations are part of COPD's natural history and our therapies are limited to reduction in symptoms. Thus, this book is an ambitious and urgently needed comprehensive review to summarize our knowledge of this disease process.
The interpretation of data in the literature is confusing and difficult to generalize due to the many differences in patients with AECOPD. Most of the early clinical studies included patients of all ages, mainly those with “chronic bronchitis”. There was no requirement of a minimum age or smoking history in many of the studies. In addition, many of the studies did not require patients to have an obstruction pattern on pulmonary function tests. Since many patients included in these studies were 20–30 years old and had normal lung function, the results can not be generalized to most COPD patients that are treated for acute exacerbations today. In the first part of this book chapters deal with basic concepts, such as: definition, natural history and epidemiology. How we define AECOPD is basic to the understanding of the impact of this disease process and determining the appropriate treatments. A subsequent chapter points out the impact of AECOPD to the natural history of COPD. It reminds us that relapses (treatment failures requiring return visit or hospitalization) occur in a large number of patients (up to 35%) and are associated with high morbidity and even mortality.
In AECOPD, as a consequence of the high morbidity and mortality, the economic impact is enormous. The last chapter in this section describes the economic impact on our health care system. It points out what makes this condition different is the fact that patients have several exacerbations during a single year and multiple in the course of their disease. As a consequence, AECOPD is associated with increased number of visits to doctors' offices, emergency departments and hospitalizations. A large proportion of the estimated annually direct medical costs of COPD is known to be related to the management of acute exacerbations. Furthermore, there is also a significant impact in non‐quantifiable expenses such as loss in patient's productivity.
The pathophysiology of AECOPD is extensively discussed in this book. It points out the different cellular mechanisms that are involved. Chapter 7 describes the various biomarkers of AECOPD and the potential clinical utility and impact in patient management.
Acute exacerbation of COPD is the term that is used in the literature to describe a heterogeneous group of patients and involves a wide variety of causes. Part III of the book examines the causes of AECOPD including extensive discussion of causes of infections. In addition, there has been no consensus in the literature of the symptoms and signs of AECOPD. Patients are currently classified as having a severe exacerbation if they have all of the following clinical symptoms: increased shortness of breath, increased sputum production, and a change in sputum purulence. There is a chapter in the book that has an extensive description of the literature of symptoms and signs of the exacerbations. A subsequent chapter discusses the utility of radiologic procedures. These chapters concluded that data on the utility of most diagnostic tests are limited. However, chest radiography and arterial blood gas sampling seem useful while acute spirometry does not.
Subsequent chapters provide a critical analysis of the pathophysiology including the changes in pulmonary gas exchange, cardiopulmonary interactions, and impact in respiratory muscles, electrolyte imbalance, nutritional status and sleep. This book offers to the reader several chapters that provide a comprehensive assessment of the severity of exacerbation and when we are dealing with end‐stage disease.
I found the chapters related to treatment (including the use of antibiotics, bronchodilators, corticosteroids, supplemental oxygen, invasive and non‐invasive ventilation) outstanding. In addition, these chapters provide the reader with an up‐to‐date review of the treatment alternatives with practical recommendations. These chapters also emphasized that the treatment of AECOPD patients requires the combination of different therapies. Furthermore, they indicate that these therapies have to be adjusted based on the patient's clinical symptoms, signs and demographic factors including age, severity of lung disease, co‐morbidities, etc.
The final chapter tries to tie things together and make appropriate recommendations related to home or hospital management. The strength of this book to the readers is the manner in which the authors bring their knowledge of the literature and combine it with their experience. This book will help to better understand AECOPD, a condition that until recently has been ignored.
Antonio Anzueto, M.D.
University of Texas Health
Science Center at San Antonio
San Antonio, Texas
Hansel, Trevor T., Barnes, Peter J., An Atlas of Chronic Obstructive Pulmonary Disease COPD, New York, Parthenon Publishing Group Inc., 2004.
It is rare for a modern textbook to be considered complete and up to date as the pace of medical discovery often renders such efforts obsolete at the time of their publication. In their book, An Atlas of Chronic Obstructive Pulmonary Disease COPD, Trevor Hansel and Peter Barnes have not only defied this conventional wisdom but have produced a succinct and easy to read resource that will be valuable to physicians‐in‐training as well as experienced clinicians.
This atlas comes at a time when COPD demands additional attention. COPD is already a major public health problem, affecting more than 10 million Americans, and its impact is expected only to increase over the next several decades. It is the only major illness (other than AIDS) for which mortality continues to increase and by 2020, the WHO estimates that it will be the 3rd leading cause of death worldwide. The financial burden of COPD is also significant, costing more than ∖30 billion annually in the US alone. Despite these staggering estimates, the disease remains largely unknown to most of the US population and is under‐diagnosed by physicians. Unlike cancer or heart disease, COPD is not viewed as an urgent problem and has been stigmatized as a smokers' disease by laymen and as uninteresting by the medical profession. This dynamic textbook will hopefully help reverse these unfortunate misconceptions.
Although the book is relatively short (290 pages), it is quite comprehensive. The atlas is divided into eight chapters covering the epidemiology and pathophysiology of COPD as well as the pharmacologic and non‐pharmacologic management of the disease. There are also separate chapters devoted to smoking cessation, emphasizing its importance and feasibility, and to the management of exacerbations of COPD, an underappreciated cause of impaired quality of life in these patients. Throughout the book, the authors take time to present both the cellular and biochemical underpinnings of the disease and its management and to provide practical information for the busy physician. Each chapter is well referenced and includes many key articles that have only become available in the last year including the findings of the National Emphysema Treatment Trial and the Tristan Study. Chapters devoted to pathophysiology and to new drugs also highlight many of the fascinating ongoing and future research endeavors in COPD. These chapters will force readers to reconsider their nihilism towards COPD and hopefully stimulate both research interest and a renewed enthusiasm for treating those who are afflicted.
Importantly, the text is accompanied by numerous well‐designed figures that complement the reading as well as summary tables at the beginning of each chapter that highlight the key information. These visual tools help maximize the readers' retention of the material and are in sharp contrast to the endless droning of most textbooks. As a result, the atlas is a pleasure to read and easy to digest.
Lastly, the authors discuss the pathophysiology, clinical features, and management of COPD in the context of the recent GOLD guidelines. This strategy is important as it not only helps the reader better understand the COPD phenotype but also helps publicize the guidelines—currently our best effort to outline the state of the art in COPD. By framing their atlas around the GOLD guidelines, the authors help those of us who work in the field present a clear, unambiguous message about the immediate need to better identify and treat patients with COPD.
Mark Dransfield, M.D.
Division of Pulmonary, Allergy and Critical Care Medicine
University of Alabama at Birmingham
215 THT
1900 University Blvd.
Birmingham, AL 35294
Tel.: 205‐934‐7557
Fax: 205‐934‐6229
Email: [email protected]
William C. Bailey, M.D.
Division of Pulmonary, Allergy and Critical Care Medicine
University of Alabama at Birmingham
Pharmacotherapy in Chronic Obstructive Pulmonary Disease. Celli BR, editor. Lung Biology in Health and Disease Series, Volume 182. New York: Marcel Dekker, 2004.
The central theme of this book is that COPD is a modifiable disease, contrary to popular perception. For too long, editor Bartolome Celli argues, defining COPD as a disease in which FEV1 “fails” to fully improve after a bronchodilator has helped to stigmatize COPD as a condition largely unresponsive to pharmacological intervention. A growing body of evidence, thoughtfully explored in this book, shows that drug therapy can improve clinically important outcomes in COPD, such as dyspnea and functional status, even though effects on FEV1 may be relatively small. The time has come, Celli asserts, to shift our focus from changes in FEV1 to a broader range of relevant outcomes when evaluating therapies for COPD.
Written for “busy practitioners” (pulmonologists and primary care providers), the text is divided into two parts. The first half of the book reviews the assessment of outcomes that are increasingly important to patients, practitioners, and society. These outcomes include respiratory physiology, exercise performance, sleep quality, dyspnea, exacerbation severity and frequency, health status (quality of life), and health resource utilization, all of which can be improved with drugs currently on the market. Each outcome is explored in a separate chapter, with a logical progression from respiratory physiology to health resource utilization. The second half of the book focuses on specific drug classes (anticholinergics, β2‐agonists, phosphodiesterase inhibitors, corticosteroids, antioxidants and protease inhibitors), their pharmacology, and their impact on the outcomes described in the first portion of the book. The volume concludes with an overview of how pharmacological therapy is integrated into a comprehensive approach to the patient with COPD.
The highlights of this book lie primarily in the chapters covering outcomes and how they are evaluated in clinical research. Particularly strong are the chapters on pulmonary function and exercise testing, because they explain concisely how static and dynamic hyperinflation are measured and how they contribute to the dyspnea and limit exercise. Other standout chapters include those on β2‐agonists and phosphodiesterase inhibitors, which describe the multiple effects of these medications not only on airway smooth muscle, but also on airway inflammation. The basic and clinical pharmacology of the long‐acting drug tiotropium is the main focus of the chapter on anticholinergics. The chapter on corticosteroids (oral and inhaled) is a succinct and useful summary of the research in this controversial area. Although the chapters are balanced in their coverage of the data, the volume could have been enhanced by disclosure of the authors' affiliations with pharmaceutical companies.
Those hoping to discover detailed information about novel classes of drugs for COPD will not find it here. Two chapters, however, one on the genetics of COPD and the other on antioxidants and protease inhibitors, provide a glimpse of some of the basic and translational research that will hopefully give rise to new pharmacological therapies. Overall, this book is a well‐written review of how far we've come in developing drugs to treat COPD. It's also a reminder of how far we have to go.
Esther L. Langmack, M.D.
Assistant Professor of Medicine
National Jewish Medical and Research Center
University of Colorado Health Sciences
1400 Jackson Street, J208
Denver, CO 80206
Tel.: (303) 398‐1903
Fax: (303) 398‐1476
Email: [email protected]
Lung Volume Reduction Surgery for Emphysema. Lung Biology in Health and Disease, volume 184. Edited by Henry E. Fessler, John J. Reilly, Jr., David J. Sugarbaker, pp. 507. Marcel Dekker, Inc., 270 Madison Ave, New York, NY 10016; 2004.
The prospect of a surgical therapy for emphysema which is both feasible and effective has had the attention of chest physicians and surgeons for nearly a decade. Cooper's initial report of bilateral pneumectomy inaugurated an intense wave of investigation into determining the efficacy, optimal technique, patient selection, and overall impact of this surgery, and numerous reports, clinical trials, and renewed discussions about respiratory physiology ensued.
Lung Volume Reduction Surgery for Emphysema culls together what is currently known about this procedure, and what has been learned about emphysema in light of it. This volume brings together a practical, informative, and readable collection of various aspects of lung volume reduction surgery (LVRS), some of which heretofore have not been fully discussed. Moreover, it serves as a basic primer for the epidemiology, pathology, and physiology of advanced emphysema.
The textbook involves 29 authors, who are at the forefront of not only LVRS, but emphysema and COPD research. The chapters are well written with sufficient detail to provide the reader with information that can be considered as a primary source to answer additional questions regarding the pathobiologic effects of LVRS. With the focus on more than just LVRS (e.g., epidemiology, physiology, pathology, and medical treatment of chronic obstructive pulmonary disease), a cohesive quality is projected by the book. As a result, it provides an effective format to better understand the purpose and results of LVRS by the content presented in the nonsurgical chapters. The chapters that deal with LVRS are complete, and cover issues regarding patient selection, both by clinical and radiographic criteria, important aspects of the operative technique, and the short and long‐term outcomes of LVRS. Importantly, the proposed mechanisms of LVRS improvement and application of LVRS in select patient groups are also reviewed.
The final chapter details the outcomes reported in the National Emphysema Treatment Trial, and provides a useful, complete, up‐to‐date feel to the book. This aspect provides the reader with the most current information in a rapidly evolving new therapy.
Lung Volume Reduction Surgery for Emphysema is almost certainly not the definitive text on LVRS, and as such appropriately appears as simply one volume in a long series of work concerning lung biology in health and disease. However, in the early post‐NETT era, Lung Volume Reduction Surgery for Emphysema emerges as one of the “must‐haves” in the collection of reference texts for those interested in LVRS, or in the clinical care of the emphysema patient.
John M. Travaline, M.D.
Temple University Hospital
Temple University School of Medicine
Temple Lung Center
3401 N Broad St.
Philadelphia, Pennsylvania 19140‐5103
Tel.: (215) 793‐3323
Email: [email protected]