Julia L. Kelly

Health status assessment in routine clinical practice: the chronic obstructive pulmonary disease assessment test score in outpatients.

Background: The chronic obstructive pulmonary disease (COPD) assessment test (CAT) is a simple, self-completion questionnaire developed to measure health status in patients with COPD, which is potentially suitable for routine clinical use. Objectives: The purpose of this study was to establish the determinants of the CAT score in routine clinical practice. Methods: Patients attending the clinic completed the CAT score before being seen. Clinical data, including, where available, plethysmographic lung volumes, transfer factor and arterial blood gas analysis, were recorded on a pro forma in the clinic. Results: In 224 patients (36% female), mean forced expiratory volume in 1 s (FEV1) was 40.1% (17.9) of predicted (%pred); CAT score was associated with exacerbation frequency [0–1/year 20.1 (7.6); 2–4/year 23.5 (7.8); >4/year 28.5 (7.3), p < 0.0001; 41/40/19% in each category] and with Medical Research Council (MRC) dyspnoea score (r2 = 0.26, p < 0.0001) rising approximately 4 points with each grade. FEV1 %pred had only a weak influence. Using stepwise regression, CAT score = 2.48 + 4.12 [MRC (1–5) dyspnoea score] + 0.08 (FEV1 %pred) + 1.06 (exacerbation rate/year)] (r2 = 0.36, p < 0.0001). The CAT score was higher in patients (n = 54) with daily sputum production [25.9 (7.5) vs. 22.2 (8.2); p = 0.004]. Detailed lung function (plethysmography and gas transfer) was available in 151 patients but had little influence on the CAT score. Conclusion: The CAT score is associated with clinically important variables in patients with COPD and enables health status measurement to be performed in routine clinical practice.

Lung function indices for predicting mortality in COPD

Chronic obstructive pulmonary disease (COPD) is characterised by high morbidity and mortality. It remains unknown which aspect of lung function carries the most prognostic information and if simple spirometry is sufficient. Survival was assessed in COPD outpatients whose data had been added prospectively to a clinical audit database from the point of first full lung function testing including spirometry, lung volumes, gas transfer and arterial blood gases. Variables univariately associated with survival were entered into a multivariate Cox proportional hazard model. 604 patients were included (mean±sd age 61.9±9.7 years; forced expiratory volume in 1 s 37±18.1% predicted; 62.9% males); 229 (37.9%) died during a median follow-up of 83 months. Median survival was 91.9 (95% CI 80.8–103) months with survival rates at 3 and 5 years 0.83 and 0.66, respectively. Carbon monoxide transfer factor % pred quartiles (best quartile (>51%): HR 0.33, 95% CI 0.172–0.639; and second quartile (51–37.3%): HR 0.52, 95% CI 0.322–0.825; versus lowest quartile (<27.9%)), age (HR 1.04, 95% CI 1.02–1.06) and arterial oxygen partial pressure (HR 0.85, 95% CI 0.77–0.94) were the only parameters independently associated with mortality. Measurement of gas transfer provides additional prognostic information compared to spirometry in patients under hospital follow-up and could be considered routinely. Transfer factor not GOLD stage is the most powerful predictor of survival in patients with COPD http://ow.ly/mGmjG

Singing classes for chronic obstructive pulmonary disease: a randomized controlled trial

BackgroundThere is some evidence that singing lessons may be of benefit to patients with chronic obstructive pulmonary disease (COPD). It is not clear how much of this benefit is specific to singing and how much relates to the classes being a group activity that addresses social isolation.MethodsPatients were randomised to either singing classes or a film club for eight weeks. Response was assessed quantitatively through health status questionnaires, measures of breathing control, exercise capacity and physical activity and qualitatively, through structured interviews with a clinical psychologist.ResultsThe singing group (n=13 mean(SD) FEV1 44.4(14.4)% predicted) and film group (n=11 FEV1 63.5(25.5)%predicted) did not differ significantly at baseline. There was a significant difference between the response of the physical component score of the SF-36, favouring the singing group +12.9(19.0) vs -0.25(11.9) (p=0.02), but no difference in response of the mental component score of the SF-36, breathing control measures, exercise capacity or daily physical activity. In the qualitative element, positive effects on physical well-being were reported in the singing group but not the film group.ConclusionSinging classes have an impact on health status distinct from that achieved simply by taking part in a group activity.Trials registrationRegistration Current Controlled Trials - ISRCTN17544114

Randomized trial of 'intelligent' autotitrating ventilation versus standard pressure support non-invasive ventilation: impact on adherence and physiological outcomes.

Effective non‐invasive ventilation (NIV) therapy is dependent on optimal ventilator settings to maximize clinical benefit and patient tolerance. Intelligent volume‐assured pressure support (iVAPS) is a hybrid mode of servoventilation, providing constant automatic adjustment of pressure support (PS) to achieve a target ventilation determined by the patients requirements. In a randomized crossover trial, we tested the hypothesis that iVAPS, with automated selection of ventilator settings, was non‐inferior to standard PS ventilation, with settings determined by an experienced health‐care professional, for controlling nocturnal hypoventilation in patients naive to NIV.

Breathlessness and Skeletal Muscle Weakness in Patients Undergoing Lung Health Screening in Primary Care

Abstract Earlier diagnosis of COPD is a major public health challenge as symptoms may be attributed to the normal consequences of aging. The optimum strategy for identifying patients with COPD remains to be determined. People aged 35 and over (n = 1896) on a GP practice register were randomised to either invitation or an opportunistic lung health check which included spirometry, quadriceps strength and MRC dyspnoea score. Then, 101 participants subsequently completed the General Practice Physical Activity Questionnaire. A total of 335 attended over a 15-week period; 156 were in the invitation group and 179 from the opportunist group. In 25 persons, spirometry was unsatisfactory or contraindicated. Spirometry was normal in 204(65.8%) and restrictive in 36(11.6%). 70(22.6%) had airflow obstruction, corresponding to Global Initiative for Chronic Lung Disease (GOLD) stages I-IV in 18(5.8%), 35(11.3%), 14(4.5%) and 3(1.0%), respectively. The opportunist group were significantly more likely to have airflow obstruction 30.1% vs 14.3% (p = 0.001). Breathlessness was reported commonly (40.5%) and quadriceps strength correlated significantly with MRC dyspnoea score independent of age, sex, pack-years smoked, fat-free mass and FEV1 percent predicted. This relationship was also present in the subgroup of healthy participants (n = 143). 51.5% of participants screened were classified as “inactive” and this group were weaker and more breathless than those who were more active. Airflow obstruction was more common in those screened opportunistically. Breathlessness and inactivity are common in patients taking part in spirometry screening. Breathlessness is significantly associated with leg strength independent of spirometry and should be amenable to interventions to increase physical activity.

Effect of acute exacerbations on skeletal muscle strength and physical activity in cystic fibrosis

BACKGROUND Skeletal muscle weakness is an important complication of chronic respiratory disease. The effect of acute exacerbations on strength in patients with cystic fibrosis is not known. METHODS Quadriceps (QMVC) and respiratory muscle strength were measured in patients at the time of acute admission, at discharge and one month later. Patients wore an activity monitor during admission and at one month. Convalescent values were compared to the stable clinic population. RESULTS Data were available for 13 acute admissions and 25 stable CF outpatients. Strength and other parameters including daily step count did not differ significantly between the stable and one month post-admission groups. At admission, QMVC was 16.7 (8.3)% lower than at convalescence, whereas inspiratory muscle strength did not change significantly. Reduction in QMVC did not correlate with activity levels or with markers of systemic inflammation. CONCLUSION Further research is needed to identify the mechanisms responsible for the reduction in QMVC.

Respiratory Muscle Fatigue following Exercise in Patients with Interstitial Lung Disease

Background: It is not known whether respiratory muscle fatigue occurs as a consequence of exercise in patients with interstitial lung disease (ILD) and, if so, to what extent it is related to changes in dynamic lung volumes. Objectives: To assess the development of respiratory muscle fatigue in patients with ILD and relate it to the respiratory pattern during exercise. Methods: Sixteen ILD patients (11 women) performed incremental, symptom-limited cycle ergometry with inspiratory capacity manoeuvres used to measure changes in end-expiratory lung volume (EELV). Twitch transdia-phragmatic pressure (TwPdi) and twitch gastric pressure (TwT10Pga), in response to magnetic stimulation, were used to assess the development of fatigue. Results: TwPdi did not differ significantly before and after exercise (21.8 ± 8 vs. 20.2 ± 8 cm H2O; p = 0.10), while TwT10Pga fell from 28.6 ± 18 to 25.2 ± 14 cm H2O (p = 0.02). EELV fell from 2.18 ± 0.65 to 1.91 ± 0.59 liters following exercise (p = 0.04). The fall in TwT10Pga correlated with peak oxygen uptake at peak of exercise (r = -0.52, p = 0.041), increase in heart rate (r = 0.53, p = 0.032) and with the decrease of EELV during exercise (r = 0.57, p = 0.021). Abdominal muscle fatiguers (n = 9, 56%), defined as having a ≥10% fall in TwT10Pga, had a fall in EELV of 22 ± 22% compared to 0.7 ± 8% in non-fatiguers (p = 0.016). Conclusion: Abdominal muscle fatigue develops during exercise in some ILD patients in association with increased expiratory muscle activity manifested by reduced EELV.

Patent Foramen Ovale Is Not Associated with Hypoxemia in Severe Chronic Obstructive Pulmonary Disease and Does Not Impair Exercise Performance

RATIONALE Patent foramen ovale (PFO) may be disadvantageous in chronic obstructive pulmonary disease (COPD). It is unknown whether right-to-left shunting through PFO increases during exercise impairing exercise performance. OBJECTIVES To determine whether (1) PFO prevalence is greater in hypoxemic versus less hypoxemic patients with COPD, (2) PFO is associated with clinically relevant impairment, and (3) right-to-left shunting increases during exercise and impairs exercise performance. METHODS Patients with COPD and age-matched control subjects underwent contrast transthoracic echocardiography and transcranial Doppler to identify PFO. Patients with COPD with no shunt and patients with large PFO underwent cardiopulmonary exercise tests with contrast transcranial Doppler, esophageal, and gastric balloon catheters. MEASUREMENTS AND MAIN RESULTS PFO prevalence was similar in 50 patients with COPD and 50 healthy control subjects (46% vs. 30%; P = 0.15). Large shunts were more common in patients with COPD (26% vs. 6%; P = 0.01). In an expanded COPD cohort, PFO prevalence was similar in 31 hypoxemic (Pao2 ≤ 7.3 kPa) and 63 less hypoxemic (Pao2 > 8.0 kPa) patients with COPD (39% vs. 52%; P = 0.27). Patients with intrapulmonary shunting had lower Pao2 than both patients with PFO and those with no right-to-left shunt (7.7 vs. 8.6 vs. 9.3 kPa, respectively; P = 0.002). Shunting significantly increased during exercise in patients with COPD with PFO. Endurance time at 60% Vo2max was 574 (178) seconds for patients with PFO and 534 (279) seconds for those without (P = ns). CONCLUSIONS Hypoxemic patients with COPD do not have a higher prevalence of PFO. Patients with COPD with PFO do not perform less well either on a 6-minute walk or submaximal exercise testing despite increased right-to-left shunting during exercise.

Can financial incentives for improvements in healthcare quality enhance identification of COPD in primary care

Undiagnosed chronic obstructive pulmonary disease (COPD) is a major public health issue, as it leads to patients missing out on appropriate preventive and therapeutic interventions.1–3 The ratio of diagnosed/predicted COPD prevalence differs widely between Primary Care Trusts (PCTs), suggesting that there are unacceptable variations in care.4 A National Clinical Strategy for COPD is to be launched in the UK in 2010 and there is an urgent need for evidence to support strategies to increase the identification of patients, particularly those with early disease. In 2008 a locally enhanced service (LES) for COPD …

P220 Transfer factor and arterial oxygen partial pressure are predictors of survival in hospital outpatients with COPD

Introduction COPD is a disorder characterised by high morbidity and mortality. Although several parameters have been used to predict survival among COPD patients, most of the information on the prognostic value of pulmonary function comes from studies, either conducted in selected COPD populations or where only simple spirometry was measured. Few studies have comprehensively assessed lung function parameters and investigated their impact on survival; a prior smaller study from our group suggested carbon monoxide gas transfer may have prognostic value.1 Objective The study aimed to identify potential predictors of survival in a cohort of stable COPD outpatients. Methods Data from patients, who had their first full lung function tests including blood gas analysis between February 1996 and May 2010 were extracted from the hospitals clinical COPD database. Patients with major co morbidities, such as malignancy, chronic renal failure and chronic heart failure were excluded. Survival data were available for all patients, until May 2011. Demographic data, PaO2 and PaCO2, transfer factor, and plethysmographic lung volumes were initially entered in a univariate regression model. Age, Body Mass Index (BMI), FEV1% predicted, FEV1/FVC, TLC% predicted, TLCOc% predicted, KCOc% predicted, RV% predicted, IC/TLC, PaCO2 and PaO2, were found to be univariately associated with survival and then entered in a stepwise Cox regression analysis model. Corresponding HRs and 95% CI were calculated for each independent predictor. Results Data were available for 641 patients (62.2% male); mean age 61.9±10.2 years, FEV1 38.4±19.7% and BMI 24.3±5.3 kg/m2. Median survival was 92.9 months. Survival rates at 3 and 5 years (all cause mortality) were 0.88 and 0.62. In the total population, age (HR 1.05, 95% CI 1.03 to 1.07), PaO2 (HR 0.843, 95% CI 0.76 to 0.934) and TLCOc% (HR 0.975, 95%CI to 0.965 to 0.986) independently predicted survival. Abstract P220 Figure 1 presents the Kaplan–Meier survival curves, adjusted for age and PO2, for the two population groups, separated using the TLCOc% median value as a cut-off point (>38.0 and =38.0% predicted).Abstract P220 Figure 1 Survival curves adjusted for PO2 and age for the two patient groups, separated according to TLCOc% predicted value. Conclusions Gas transfer measurement provides additional prognostic information compared to spirometry.